1. Project CHART Expanding Pediatric Specialty Care to Rural West Texas Communities Debbie Voyles, MBA Director, Telemedicine Programs David Lefforge, MBA, MS Focusing our imagination, our talents and our energy to improve the health and well-being of the people and communities of rural Texas.

2. Project CHART C hildren’s H ealthcare A ccess for R ural T exas

3. Texas Tech University Health Sciences Center F. Marie Hall Institute for Rural and Community Health Four Core Programs  Telemedicine – only community-based telemedicine in Texas; one of 2 correctional programs; one of longest running programs in nation; 39,000+ consultations  Health Education – West Texas Area Health Education Center (WTAHEC), Hot Jobs, Double-T Health Service Corps, region-wide community health needs assessment  Rural Research – Project FRONTIER, TARC, Alzheimer’s Disease  Electronic Health Records – West Texas Health Information Technology Regional Extension Center (WTxHITREC)

4. Today’s Discussions  Unique challenges for West Texas  Access to specialty health care in rural/frontier West Texas  Community-based program response (Project CHART)  Transition to program utilization  Program lessons

5. Texas Tech University Health Sciences Center (TTUHSC) Service Area

6. West Texas - Unique  131,459 sq. miles – 49% of Texas landmass  8 hours long X 10 hours wide  108 counties; 101 rural, over 50% frontier  2.7 million people – 12% state population  19.8 people/sq. mile (155 people/sq.mile in East Texas)  22 counties no physician  10 counties no physician, PA, NP  32 counties no hospital  28% uninsured  131,459 sq. miles – 49% of Texas landmass  8 hours long X 10 hours wide  108 counties; 101 rural, over 50% frontier  2.7 million people – 12% state population  19.8 people/sq. mile (155 people/sq.mile in East Texas)  22 counties no physician  10 counties no physician, PA, NP  32 counties no hospital  28% uninsured

9. Barriers to Pediatric Specialty Access for Rural/Frontier Communities  13.8% of Texas children live in the state’s 177 rural counties; (101 {57%} of those rural counties are in West Texas) Only 5% of general pediatricians practice in those rural counties  139 Texas counties do not have a general pediatrician  400,000 children live in counties w/out a general pediatrician  Acute shortage of pediatric subspecialists 688 pediatric subspecialists in 2006 (10.6 per 100,000 children)  Ten or fewer pediatric subspecialists in following fields: Dermatology, nephrology, orthopedics, psychiatry, rehabilitation medicine, urology, allergy Heavily concentrated in academic and urban settings

10. ACCESS Hospital: Clinics: Physicians: Nurses: P.A.s: 0101001010 (nearest 85mi.) Presidio, TX Presidio to Lubbock: 398 mi. / 7.5 hrs. Presidio to Lubbock: 398 mi. / 7.5 hrs. El Paso to Lubbock: 343 mi. / 7 hrs. El Paso to Lubbock: 343 mi. / 7 hrs. Population: Medicaid Enrolled Children: 4167 705

12. We know a need exists

13. Telemedicine Access in West Texas Response to:  Fewer physicians in rural/frontier communities  Fewer specialists throughout region  Technology advancements  Changes to state rules  Services w/out taking too much time off from work/school  Reduces escalating personal travel costs  Another way to see a health care professional; comparable to face-to-face care…  …and patients like telemedicine

14. Getting There From Here Texas Health and Human Services Commission (HHSC) Pediatric Specialty Telemedicine Network for Medicaid Clients Birth through 20 Years of Age  HHSC Objective: to enter into contracts with up to four Texas state health-related institutions to expand existing telemedicine services provided to persons under the age of 21 enrolled in Texas Medicaid  HHSC Goal: increase access to specialty care, including general pediatric care  Applicant Requirements: Expand current telemedicine services to children enrolled in Medicaid to include up to 30 additional patient sites Increase access to general pediatric and pediatric subspecialty health care Be independently sustainable once HHSC financial grants for the project ended Operate within the rules for Telemedicine  Funding period to end August 31, 2011

15. Project CHART  Contract awarded April 2009  Funding - $6.674 million  Time frame - 25 months to design and manage a delivery system resulting in sufficient volume of patients to generate sufficient reimbursement to sustain telemedicine sites  30 operational sites At least one telemedicine patient site operational by August 31, 2009 (Stratford, TX) A total of 20 telemedicine patient sites operational sites by August 31, 2010 10 additional telemedicine patient sites operational by August 31, 2011

16. Getting There From Here (continued)  Selection of potential community sites 33 potential communities 19 selected to become operational  Community contact and assessments  Equipment cart design, purchase and production  Site contracts  Equipment installation and testing  Patient site training  Patient site operation  TTUHSC network of schools of medicine campuses (Lubbock, Amarillo, El Paso, Midland/Odessa)

17. Community-Based Participatory Assessments  Communities Available health services Needed health services Demographics Sustainability Acceptance and use  Will telemedicine make a difference to the community?  Will the community embrace telemedicine?  Current health care service providers Physicians, PA, NP, RN, EMT Will they participate? Limitations (facilities, internet transmission, staffing)

18. Connecting the Community  Patient site DSL has become the West Texas “Rural Standard” T-1 cable available in West Texas, but expensive Bronte, Texas – wireless (no land-based connection beyond basic dial up) Secure, robust, HIPAA compliant Equipment design and training – simple plug and use; most sites/communities don’t have IT specialists; reduce downtime, easy to fix with call to TTUHSC  TTUHSC general and specialist pediatricians Equipment installation Physician and staff training and assistance Some specialties available at multiple campuses; several available at only one  August 31, 2009 – Stratford, Texas First operational Project CHART site; nurse practitioner; 2 ½ year old female patient

19. Project CHART Equipment  High Definition (HD) cameras, monitors, associated peripherals  Standardized Facilitates installation, training and support Polycom  TeleDoc

20. Project CHART  19 operational telemedicine sites 12 Rural Health Clinics (Ahmed Clinic – FQHC) 4 Rural Hospitals (Coon Memorial Hospital in Dalhart and Pecos County Memorial Hospital in Pecos are Critical Access Hospitals) 3 Rural School-based Health Clinics

22. Project CHART Achieving Access

23.  19 operational sites  Increased participating specialties  Exploring equipment enhancements  Improving bandwidth

24. Utilization  Access achieved – it takes a long time to set up even one site  Funding reductions  Change in focus – transition from access to utilization and sustainment  Increasing public awareness of telemedicine capabilities  Active engagement with patient sites  Increasing access to sub-specialties (Cook’s Children’s Hospital; Shannon Medical Center)

25. Challenges  Distance and travel – it takes a long time to set up even one site  Life moves at a different pace in rural/frontier communities Recognize and work with it  Rural health care professions are fragile Community lost their nurse practitioner two days after site opening Physician elects to spend majority of time on adults – children suffer PA moves away from frontier community  Some communities not interested (community assessment)

26. Challenges (continued)  Internet quality  Rural IT not available  Rural legal assistance not available  Medicaid rules allowing travel reimbursement  Some pediatric specialties more suitable than others  State medical association rules changes

27. Unique Successes  Bronte, Texas (Coke County) No MD/DO, PA or NP in county No land based internet connection beyond dial-up  School science teacher practicing Physician Assistant once/month in San Angelo (48 miles) Volunteered to be Bronte school-based telemedicine presenter Arranged physician oversight from San Angelo  Opened Bronte clinic – first in-community health care service since 2002

28. Testimonials  “Telemedicine is a good thing for access to care. I have many patients that do not have the resources to travel for a second opinion. Unless the visit would require a surgical procedure or special testing then there is no reason that the patient could not be seen by telemedicine. In addition if parents have to travel then they will not get paid for missing that day of work.” Steve Ahmed, MD (Big Spring, Texas)  “We love the fact that telemedicine offers specialized care in our small community. It is such a life saver for our family to not have to travel to Lubbock”. Parent of a 13 year old female patient.

29. Testimonials  70% of the residents of Big Spring, Texas, live below poverty level. The national average is 19%. Half of these residents are 21 and under and are giving birth. No jobs, no car. It’s hard for them to make their way to my clinic here in Big Spring much less travel anywhere else. Telemedicine is absolutely essential to us. Steve Ahmed, MD (Big Spring, Texas)  “This will be a great benefit to our students, athletes and staff. It will greatly reduce our number of absences” Alan Richey, Superintendent – Bronte ISD  “After having used telemedicine as a health delivery method, I want to use it for most of my patients.” Comment from TTUHSC physician to her administrator.

30. Summary  Contract with HHSC to increase access for Medicaid-enrolled children  Project CHART achieved 19 sites in 12 months  Transition from access to utilization  Preparations for sustainment  2011 evaluations and reports

31. Debbie Voyles, Director of Telemedicine Phone: 806-743-4440 Cell: 806-778-3318 debbie.voyles@ttuhsc.edu

32. Questions and Discussions