they think it's like star trek': set up and initial ......funded by aids united, social...
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"They think it's like Star Trek": Set up and initial patient outcomes in the innovative Alabama ehealthtelemedicine program.KRITI M. JAIN, MSPH, PHD(C)[email protected] 28, 2018
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Learning ObjectivesDescribe the steps in setting up a telemedicine program.
Describe the associated barriers and their solutions; describe facilitating or necessary factors for the telemedicine program.
Explore initial patient health outcomes.
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AbbreviationsEMR: electronic medical record
MoU: memorandum of understanding
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OutlineBrief introductionEvaluation set-up and methods
Steps to setting up the Alabama eHealth telemedicine program
Initial patient outcomes
Discussion
Q&A
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HIV in the U.S. Southeast
Image location: https://www.cdc.gov/hiv/images/statistics/HIV-Diagnoses-Rates-US-map-2015.pngData source: CDC. Diagnoses of HIV infection in the United States and dependent areas, 2015. HIV Surveillance Report 2016;27. (https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html)5
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Barriers to care in rural areas
Few medical providersLittle to no public transportationLong distances to providers’ officesLack of confidentialityHigh HIV-related stigma
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Alabama eHealth program
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HIV specialistat “hub” site
Nurse and patient at “spoke” sites
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Previous research on telemedicine
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OutlineBrief introduction
Evaluation set-up and methods
Steps to setting up the Alabama eHealth telemedicine program
Initial patient outcomes
Discussion
Q&A
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Methods•In-depth interviews
•Client-facing role•Strategic or supervisory role
•Recorded and transcribed
•Analyzed using directed content analysis
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OutlineBrief introduction
Evaluation set-up and methods
Steps to setting up the Alabama eHealth telemedicine program
Initial patient outcomes
Discussion
Q&A
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Steps for establishing Alabama eHealth
Establish Memoranda of Understanding (MoUs)-sensitize partners to importance of confidentiality and stigma around HIV
Pre-implementation research
Obtain seed funding
Change from paper to electronic medical records (EMR)
Establish partnerships with potential satellite clinics
Obtain an adequate broadband connection
Hire and train staff
Incorporating patient feedback, ongoing process improvements
Offer patients the option of telemedicine care by HIV physician and nurse practitioners at new satellite clinic
Add telemedicine services :• Pharmacy
consultation• Mental health
consultation• Social work case
management
Establishing overall program Establishing individual satellite clinics
Ensure sustainability of telemedicine care through support from policymakers and health insurance companies (advocacy, broadband)
Obtain telemedicine equipment
Orientation training for partners
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Pre-implementation research •Examined telepsychiatry models
•Reviewed HIV epidemiology in Alabama
•Researched telemedicine technology
“We look at minute basics, including what should be the background color to what could be the instruments, what should be the voice and sound quality… We used the Emory University’s AIDSVumap to look at what areas in Alabama have the highest HIV burden and lack of resources.”
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Steps for establishing Alabama eHealth
Establish Memoranda of Understanding (MoUs)-sensitize partners to importance of confidentiality and stigma around HIV
Pre-implementation research
Obtain seed funding
Change from paper to electronic medical records (EMR)
Establish partnerships with potential satellite clinics
Obtain an adequate broadband connection
Hire and train staff
Incorporating patient feedback, ongoing process improvements
Offer patients the option of telemedicine care by HIV physician and nurse practitioners at new satellite clinic
Add telemedicine services :• Pharmacy
consultation• Mental health
consultation• Social work case
management
Establishing overall program Establishing individual satellite clinics
Ensure sustainability of telemedicine care through support from policymakers and health insurance companies (advocacy, broadband)
Obtain telemedicine equipment
Orientation training for partners
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“We never had an in-house IT support before, and with the
grant, we were able to hire an in-house IT manager…we could not have afforded that on our
own without the AIDS United SIF grant, and we could not have done the project without it.”
Obtaining seed funding•AIDS United and the Corporation for National and Community Service’s Social Innovation Fund
•Funded telemedicine equipment, electronic medical records, and IT staff support
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“It’s very hard for a nonprofit to get the
upfront money to put in an EMR, but we did that as part of the
[AIDS United-funded] telemed grant.”
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Steps for establishing Alabama eHealth
Establish Memoranda of Understanding (MoUs)-sensitize partners to importance of confidentiality and stigma around HIV
Pre-implementation research
Obtain seed funding
Change from paper to electronic medical records (EMR)
Establish partnerships with potential satellite clinics
Obtain an adequate broadband connection
Hire and train staff
Incorporating patient feedback, ongoing process improvements
Offer patients the option of telemedicine care by HIV physician and nurse practitioners at new satellite clinic
Add telemedicine services :• Pharmacy
consultation• Mental health
consultation• Social work case
management
Establishing overall program Establishing individual satellite clinics
Ensure sustainability of telemedicine care through support from policymakers and health insurance companies (advocacy, broadband)
Obtain telemedicine equipment
Orientation training for partners
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Moving to web-based electronic medical records“The [EMR] learning curve is horrific and time consuming and therefore costly. We've had it for at least two years now. We are not as efficient now in terms of provider time and visits as we were on paper [records].”
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Steps for establishing Alabama eHealth
Establish Memoranda of Understanding (MoUs)-sensitize partners to importance of confidentiality and stigma around HIV
Pre-implementation research
Obtain seed funding
Change from paper to electronic medical records (EMR)
Establish partnerships with potential satellite clinics
Obtain an adequate broadband connection
Hire and train staff
Incorporating patient feedback, ongoing process improvements
Offer patients the option of telemedicine care by HIV physician and nurse practitioners at new satellite clinic
Add telemedicine services :• Pharmacy
consultation• Mental health
consultation• Social work case
management
Establishing overall program Establishing individual satellite clinics
Ensure sustainability of telemedicine care through support from policymakers and health insurance companies (advocacy, broadband)
Obtain telemedicine equipment
Orientation training for partners
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Partnerships
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"We already had very good working relationships with
partners in our area."
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Steps for establishing Alabama eHealth
Establish Memoranda of Understanding (MoUs)-sensitize partners to importance of confidentiality and stigma around HIV
Pre-implementation research
Obtain seed funding
Change from paper to electronic medical records (EMR)
Establish partnerships with potential satellite clinics
Obtain an adequate broadband connection
Hire and train staff
Incorporating patient feedback, ongoing process improvements
Offer patients the option of telemedicine care by HIV physician and nurse practitioners at new satellite clinic
Add telemedicine services :• Pharmacy
consultation• Mental health
consultation• Social work case
management
Establishing overall program Establishing individual satellite clinics
Ensure sustainability of telemedicine care through support from policymakers and health insurance companies (advocacy, broadband)
Obtain telemedicine equipment
Orientation training for partners
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Obtaining broadband•Strong broadband necessary for telemedicine program
•Difficult to obtain sufficient broadband in rural areas
•Partnership with Alabama Department of Public Health
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“There was a cap on the amount of bandwidth they [internet companies] could provide to that town…and
so until someone cancelled service, we wouldn’t be able
to get as much bandwidth as we were requesting.”
“We have had technological
challenges…with the network, internet, not enough bandwidth or
the internet not working.”
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Steps for establishing Alabama eHealth
Establish Memoranda of Understanding (MoUs)-sensitize partners to importance of confidentiality and stigma around HIV
Pre-implementation research
Obtain seed funding
Change from paper to electronic medical records (EMR)
Establish partnerships with potential satellite clinics
Obtain an adequate broadband connection
Hire and train staff
Incorporating patient feedback, ongoing process improvements
Offer patients the option of telemedicine care by HIV physician and nurse practitioners at new satellite clinic
Add telemedicine services :• Pharmacy
consultation• Mental health
consultation• Social work case
management
Establishing overall program Establishing individual satellite clinics
Ensure sustainability of telemedicine care through support from policymakers and health insurance companies (advocacy, broadband)
Obtain telemedicine equipment
Orientation training for partners
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Challenges with telemedicine equipment
•Learning curve with telemedicine equipment
•Poor audio quality
•Larger screen requested by patients
•Establishing procedures for connecting main and satellite site
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"We have gone through two nurses...
our second telemedicine nurse
was really dedicated to our patients and was a
very experienced nurse, but she just could not grasp the
technology.”
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Steps for establishing Alabama eHealth
Establish Memoranda of Understanding (MoUs)-sensitize partners to importance of confidentiality and stigma around HIV
Pre-implementation research
Obtain seed funding
Change from paper to electronic medical records (EMR)
Establish partnerships with potential satellite clinics
Obtain an adequate broadband connection
Hire and train staff
Incorporating patient feedback, ongoing process improvements
Offer patients the option of telemedicine care by HIV physician and nurse practitioners at new satellite clinic
Add telemedicine services :• Pharmacy
consultation• Mental health
consultation• Social work case
management
Establishing overall program Establishing individual satellite clinics
Ensure sustainability of telemedicine care through support from policymakers and health insurance companies (advocacy, broadband)
Obtain telemedicine equipment
Orientation training for partners
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Additional uses of telemedicine equipment
•Mental health care
•Support groups
•Social work case management
•Clinical pharmacy consultations
•Pre-exposure prophylaxis (PrEP)
•Hepatitis C care and treatment
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OutlineBrief introduction
Evaluation set-up and methods
Steps to setting up the Alabama eHealth telemedicine program
Initial patient outcomes
Discussion
Q&A
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Evaluation participantsAge range
<19 1 0.4%20-24 10 4.2%25-29 25 10.4%30-39 48 20.0%40-49 69 28.8%
50+ 87 36.3%Race and ethnicity
Black/African-American, non-Hispanic 164 68.3%White 72 30.0%
Other* 4 1.7%Gender
Male 181 75.4%Female 58 24.2%
Transgender M to F 1 0.4%28
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HIV Care Continuum Outcomes
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240 240
183210
180
57 9
13
2147
0
40
80
120
160
200
240
Enrolled Linked tocare
Retained incare
UsingHAART
Suppressedviral load
Yes No Missing
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OutlineBrief introduction
Evaluation set-up and methods
Steps to setting up the Alabama eHealth telemedicine program
Initial patient outcomes
Discussion
Q&A
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Discussion
•Study describes process of setting up a telemedicine program to provide HIV care
•Highly feasible with startup funding and strategic partnerships
•Good patient HIV care continuum outcomes
•Further research could focus on patient experiences in addition to those of staff, implementation in other contexts, and sustainability of such programs in a rapidly changing healthcare environment
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Limitations
•Participants were individuals in care
•Missing data from those who did not make appointments
•No demographic differences between those with and without data
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Dissemination
Conference presentations:
Jain KM, Bhat P, Maulsby C, Andersen A, Soto T, Holtgrave D, Riordan M, Werner M, Dill L. Extending access to care across the rural U.S. south: Steps to initiating Alabama eHealth, an innovative telemedicine program. Roundtable presentation at the annual American Public Health Association Conference. Denver, CO.
Andersen A, Jain KM, Bhat P, Maulsby C, Soto T, Holtgrave D, Riordan M, Werner M, Dill L. “They think it's like Star Trek”: Barriers and facilitators to implementing Alabama eHealth, an innovative telemedicine program. Roundtable presentation at the annual American Public Health Association Conference. Denver, CO.
Peer-reviewed publication forthcoming in the Journal of Telemedicne and Telecare.
Previous and upcoming plans for sharing this information with other practitioners.
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OutlineBrief introduction
Evaluation set-up and methods
Steps to setting up Alabama eHealth’s telemedicine program
Initial patient outcomes
Discussion
Q&A
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Thank you!With gratitude to all those interviewed, the staff at MAO and partners, Dr. Prashanth Bhat, Dr. Cathy Maulsby, Alexandria Andersen, Dr. Tomas Soto, Ashley Tarrant, Dr. David Holtgrave, Erin Nortrup, Melissa Werner, and Dr. Laurie Dill.◦ Funded by AIDS United, Social Innovation Fund (SIF), a program of the Corporation for National and
Community Service (CNCS).
Please feel free to contact me at [email protected]
Opinions or points of view expressed in this document are those of the authors and do not necessarily reflect the official position of, or a position that is endorsed by, CNCS or the Social Innovation Fund program. The Social Innovation Fund is a program of the Corporation for National and Community Service, a federal agency that engages millions of Americans in service through its AmeriCorps, Senior Corps, Social Innovation Fund, and Volunteer Generation Fund programs, and leads the President’s national call to service initiative, United We Serve. For more information, visit NationalService.gov. This project was also supported by the generous contributions of 14 private funders.
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Q&A
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Appendix: details on administering mental health care through telemedicine
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