Hawaii and Pacific Island Telehealth

Experiences

Christina Higa Co-Director, Pacific Basin Telehealth Resource Center

Social Science Research Institute University of Hawai’i

Brisbane April 3-4, 2019

Innovations in

Policy, Technology and Applications

University of Hawaii TASI Programs

“One” (Samoan) + “Ocean” (Chomorro)

“one sea/ocean” connectivity

• Pan Pacific Education and Communication Experiments by Satellite (PEACESAT) 1969-2012

• Re-Purpose – Recycle Test/Weather Satellites (NASA’s ATS-1 & 3; NOAA’s GOES 2, 3 & 7)

• ”Free” Public Service Communication• Multi-Propose – Collaboration

✓Distance Learning✓Emergency Management✓Telehealth

• Notable: Kangaroo Network – Royal Flying Doctors - Medical Chests

Our History in the Pacific Islands

Take Away from the

PEACESAT Story

Maximize - Limited Small Island Resources

Work Together – Collaborate across multi-sectors

Innovate - Value repurposed/ recycled systems & networks

“Free” connectivity spurred innovation of applications

Take a moment to think about your initiatives…

How might your service be applied to another target community (rural/urban), health discipline; or another sector completely (disaster response, education, tourism), something else?

What added value can you share with the platform you are using – whether it is technical or human resources?

UH TASI Programs• Training: Pacific International

Training Desk

• Health Informatics: Pacific Health Informatics Data Center (PHIDC)

• Telehealth: Pacific Basin Telehealth Resource Center (PBTRC)

Pacific Islands on the World Map

https://d-maps.com/m/world/centrepacifique/

Marshall Islands

American Samoa

Federated States of Micronesia

Palau

Northern Mariana IslandsGuam

• Area larger than CONUS• 480K USAPI 1.4M HI Population• PBTRC: 1-State, 3 US Territories,

3 COFA with US

Hawaii & USAPI

State of Hawaii

State of Hawai`i

• 1.4 Million People

• 8 Islands, 7 inhabited

• O`ahu – 900K

• Honolulu – Health Specialists

• Interisland Travel by Air

Telehealth in Hawai`i

• Island State – telehealth still evolving?

• Increasing adoption

• Years of “Broken Record” Policy Challenges✓Reimbursement✓Liability✓Workflow/Workload✓Licensing

State of Hawai`i Stakeholders & Policy

Actions

• 2016 Stakeholder Summit

• US/State legislators, Providers, Administrators, Researchers, Family Advocates, Payer, Vendors

• White Paper Policy Challenges

Environment

• Tipping point in our country?

• Payment Reform: service/encounter to quality performance

• Bi-Partisan Support

Telehealth Law - Act 226 (1/2017)

• Requires telehealth parity

• Malpractice coverage

• Lifts restrictions on originating site

including patient home or work;

• Definition: store and forward, remote

monitoring, live consultation & mhealth

• Does not require presence of two

providers and a patient, appropriately;

• Permits provider-patient relationship to be

established via telehealth by referral

• (Provider must have HI Medical License)

Take Away from the Hawai`i Story

Systemic Issues -- Stuck because of Policy; need to change Policy…right environment to do it.

Law Does Not = Change…requires details, change takes time

Co-design? Proposition of value: What is in it for each stakeholder? What’s in it for provider, patients, community, law makers?

Emerging Initiatives in the US Affiliated Pacific Islands

Long Standing InfrastructureChallenges and Barriers

EnvironmentTiny Population/Markets, Poor Economies of Scale, Developing & Fragile Economies

InfrastructureVast Distances, Difficult and Expensive to Serve, High Travel Costs

Non-Communicable Disease (NCD)Among highest NCD related deathsRegional State of Health EmergencyLack of Specialty Care, Costly Referrals

TelecommunicationAccess/ Affordability/ReliableLack of Enabling Telecom RegulationMonopoly Environments

Telecommunication Cost Barriers

Site Name Connection TypeProvided

Connection SpeedCost USDPer/Mo.

FSM (Chuuk) T1 Internet 1.544 Mbps $ 320

Standard ADSL Internet 1 Mbps download $ 400

256 Kbps upload

RMI (Majuro) ADSL (Residential) 256 Kbps $50

1.5 Mbps $140

ADSL (Business) 3-7 Mbps $2,100 - $4,000 FSM (Pohnpei) ADSL 1.5 Mbps $600

VDSL 8 Mbps $10,192 Palau MOH Palau Telecom (Wireless on

island, Intranet Management)3 Mbps download

~$7,000Off island via satellite (O3B) 1.5 Mbps upload

Palau MOH PNCC (Wireless on island) - Off island via satellite (O3B)

4 Mbps download -1 Mbps upload ~$5,000

American Samoa

DSL (Residential)DSL (Business)

2 Mbps10 Mbps

$130$700

CNMI ADSL Internet

9 Mbps download

$325 1 Mbps

Guam ADSL (Residential) Internet

50 Mbps download 2 Mbps upload $100

Amongst the highest

worldwide

Mbps U/D Mo. Cost

Palau 3/1 $7,500 US

Hawaii 250/250 $1,200 US

GDP (2017)

Small Is. $4,000 US

US $59,000 US

80X bandwidth for 6x cheaper

• Guam - Hub

• Majuro, Kwajalein, Ebeye (RMI) Pohnpei (FSM)

• Chuuk, Yap (to be operational) and the Palau connection installed in late 2017

Infrastructure Improvements:

Micronesian Under Sea Fiber Optic

USAPI Telehealth Champion Building

and Planning WorkshopSeptember 13 to 15, 2016 Honolulu * Hawai`i

Region IX - Office of the Assistant Secretary for Health and Regional

Directors Office worked with the Office of the Assistant Secretary for

Planning and Evaluation (ASPE)

In 2010 Pohnpei was

connected to fiber but didn’t

know what to do with

it…”our eyes were opened up

to the possibilities of

telehealth and numerous

applications.”

Telehealth in Pohnpei, FSM

Telehealth Room• Pohnpei Hospital

• Negotiated: Telecom link 10Mbps $400 USD/mo. (form $5K)

• No Budget? Local NGO funding

• Room? Re-purposed

• Opening – 3 mo. after workshop

✓Demonstration of Value

✓Attracts other local NGO funding

Pohnpei State: 36,000 Pop, FSM Capital, Connected to off island fiber

• MCH Telehealth - Teleaudiology

• Pohnpei Hospital Telehealth Room (10 Mbps – Excellent Connectivity, $400/mo)

• Hokkaido Cancer Center, Japan. Tele-pathology for cancer diagnoses & life-saving interventions. Chuuk Pap Smears reads in Pohnpei

• Shriners Hospital Consultations

• Cardiology Consultation – Dr. Mahnke(Store & Forward, Complicated Echo Studies)

• Rheumatic Heart Disease Screening and Possible Follow-Up via Telehealth

Pohnpei State Hospital Tele-Pathology

Image: Kaselehlie Press, Jan. 29, 2018

Telehealth in Pohnpei

• Rheumatic Heart Disease Screening: Handheld Ultrasounds

• Tele-Consultation: neurological referrals to Shriners Hospital for Children

• Tele-Audiology: Maternal and Child Health Care Services

• Tele-Cardiology: store and forward complicated cases

• Tele-Pathology: Hokkaido Cancer Institute. Tele-pathology for cancer diagnoses & life-saving interventions, Chuuk pap reads

Regional Collaboration in Medical Training

• Pacific Islands: Gastroenterology Australian and New Zealand Gastroenterology International Training Association (ANZGITA) Dr. Chris Hair; Fiji School of Medicine, Dr. Mei Ling Perman; PohnpeiHospital, Dr. Payne Perman

• Pacific Island TB Nurses' Network (TB Case Consultation for USAPI Nurses) CDC/Australian Respiratory Council

Medical Education

Mentoring Program

Case Based Learning

Well Received in

Pacific Islands

Take Away from the Pacific Story

Importance of Champions, even if cliché

Infrastructure / Resource Constraints

Common Telehealth issues (reimbursement,

liability, patient privacy) not yet overbearing concerns

Risk Management Assessment:

Severity of the resource constraintsDire health care needsAccess to health information, consultsImperative for best care possible

Opportunities for Regional Collaboration

Final Reflections….Challenges

* What are top challenges in your initiative?

* What do the stakeholders say? How do you hear from them?

Opportunities

* How to meet Value Propositions?

* What can you do to enhance it?

* Who can you collaborate with?

Health care providers in most rural and

isolated communities are often very

innovative, creative, and willing

Mahalo!

Thank you for your Time.