Hawaii and Pacific Is Island Telehealth Experiences Innovations in Policy, Technology and Applications Christina Higa Co-Director, Pacific Basin Telehealth Resource Center Social Science Research Institute University of Hawai’i Brisbane April 3-4, 2019
Univ iversity of f Hawaii TASI Programs “One” (Samoan) + “Ocean” ( Chomorro) “one sea/ocean” connectivity
Our His istory ry in in the Pacific Is Isla lands • 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
Maximize - Limited Small Island Resources Take Away Work Together – Collaborate across multi-sectors fr from the PEACESAT Innovate - Value repurposed/ Story ry 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)
Pacif ific Is Isla lands on the Worl rld Map https://d-maps.com/m/world/centrepacifique/
Northern Guam State of Hawaii Mariana Islands Palau Marshall Islands Federated States of Micronesia American Samoa Hawaii & USAPI • Area larger than CONUS • 480K USAPI 1.4M HI Population • PBTRC: 1-State, 3 US Territories, 3 COFA with US
State of Hawai`i • 1.4 Million People • 8 Islands, 7 inhabited • O`ahu – 900K • Honolulu – Health Specialists • Interisland Travel by Air
• Island State – telehealth still evolving? • Increasing adoption • Years of “Broken Record” Policy Telehealth in in Challenges Hawai`i ✓ 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
Tele lehealt lth 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)
Systemic Issues -- Stuck because of Policy; need to change Policy…right environment to do it. Take Away Law Does Not = Change…requires from the details, change takes time Hawai`i Story Co-design? Proposition of value: What is in it for each stakeholder? What’s in it for provider, patients, community, law makers?
Emerging In Initiatives in in the US Affil iliated Pacific Is Isla lands
Long Standing In Infrastructure Challe llenges and Barrie iers Environment Tiny Population/Markets, Poor Economies of Scale, Developing & Fragile Economies Infrastructure Vast Distances, Difficult and Expensive to Serve, High Travel Costs Non-Communicable Disease (NCD) Among highest NCD related deaths Regional State of Health Emergency Lack of Specialty Care, Costly Referrals Telecommunication Access/ Affordability/Reliable Lack of Enabling Telecom Regulation Monopoly Environments
Telecommunication Cost Barriers Amongst the highest Provided Cost USD worldwide Site Name Connection Type Connection Speed Per/Mo. FSM (Chuuk) T1 Internet 1.544 Mbps $ 320 Standard ADSL Internet 1 Mbps download $ 400 Mbps U/D Mo. Cost 256 Kbps upload RMI (Majuro) ADSL (Residential) 256 Kbps $50 Palau 3/1 $7,500 US 1.5 Mbps $140 Hawaii 250/250 $1,200 US ADSL (Business) 3-7 Mbps $2,100 - $4,000 FSM (Pohnpei) ADSL 1.5 Mbps $600 GDP (2017) VDSL 8 Mbps $10,192 Palau MOH Palau Telecom (Wireless on 3 Mbps download Small Is. $4,000 US island, Intranet Management) ~$7,000 US $59,000 US Off island via satellite (O3B) 1.5 Mbps upload Palau MOH PNCC (Wireless on island) - Off 4 Mbps download ~$5,000 island via satellite (O3B) -1 Mbps upload $130 American DSL (Residential) 2 Mbps Samoa DSL (Business) 10 Mbps $700 80X bandwidth for 6x cheaper 9 Mbps download CNMI ADSL Internet $325 1 Mbps 50 Mbps download 2 Mbps Guam ADSL (Residential) Internet $100 upload
• Guam - Hub • Majuro, Kwajalein, Ebeye (RMI) Infrastructure Improvements: Pohnpei (FSM) Micronesian Under Sea • Chuuk, Yap (to be operational) Fiber Optic and the Palau connection installed in late 2017
USAPI Telehealth Champion Building and Planning Workshop September 13 to 15, 2016 Honolulu * Hawai`i 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.” 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)
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 Telehealth in Pohnpei, , ✓ Attracts other local NGO FSM funding Pohnpei State: 36,000 Pop, FSM Capital, Connected to off island fiber
Telehealth in Pohnpei • Rheumatic Heart Disease • MCH Telehealth - Teleaudiology Screening: Handheld Ultrasounds • Pohnpei Hospital Telehealth Room (10 • Tele-Consultation: neurological Mbps – Excellent Connectivity, referrals to Shriners Hospital for $400/mo) Children • Hokkaido Cancer Center, Japan. Tele- • Tele-Audiology: Maternal and pathology for cancer diagnoses & life- saving interventions. Chuuk Pap Child Health Care Services Pohnpei State Hospital Tele-Pathology Smears reads in Pohnpei • Tele-Cardiology: store and forward • Shriners Hospital Consultations complicated cases • Cardiology Consultation – Dr. Mahnke • Tele-Pathology: Hokkaido Cancer (Store & Forward, Complicated Echo Institute. Tele-pathology for Studies) cancer diagnoses & life-saving • Rheumatic Heart Disease Screening interventions, Chuuk pap reads and Possible Follow-Up via Telehealth Image: Kaselehlie Press, Jan. 29, 2018
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; Pohnpei Hospital, Dr. Payne Perman • Pacific Island TB Nurses' Network Medical Education (TB Case Consultation for USAPI Mentoring Program Nurses) CDC/Australian Case Based Learning Respiratory Council Well Received in Pacific Islands
Importance of Champions, even if cliché Infrastructure / Resource Constraints Take Away Common Telehealth issues (reimbursement, from the liability, patient privacy) not yet overbearing concerns Pacific Story Severity of the resource constraints Risk Management Dire health care needs Assessment: Access to health information, consults Imperative 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.
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