|By the Innovations Exchange Team|
Alaska’s Tribal Health System (ATHS) is a coalition of more than 30 tribal organizations that provide health care services to 229 federally recognized tribes and approximately 140,000 Alaska Natives, more than one-half of whom live in rural and frontier Alaska. The Alaska Federal Health Care Access Network (AFHCAN) was established in 1998 to provide telehealth services for Federal beneficiaries in Alaska, including Alaska Natives. The Alaska Native Tribal Health Care Consortium (ANTHC) manages the telehealth program and provides statewide health and information technology services to Alaska Natives and American Indians, in addition to supporting local tribal health organizations.
The Innovations Exchange interviewed Stewart Ferguson, PhD, Chief Information Officer for the ANTHC, and John Kokesh, MD, Medical Director of the Department of Otolaryngology at the Alaska Native Medical Center (ANMC), which serves as the tertiary and specialty hospital for the ATHS.
The Innovations Exchange: How does the telehealth system work in Alaska?
Dr. Stewart Ferguson: The AFHCAN program developed a store-and-forward technology, which enables text, data from biomedical equipment, and images to be sent securely from one provider to another. Health care professionals view each patient’s case and respond using a standard PC (or Mac) workstation, including laptops. We also have continued to expand our videoconference-based telehealth capability to support specialty services, including mental health, cardiology, pediatrics, and oncology. Health care services that rely on telehealth are reimbursed by Medicare and Medicaid as well as private payers.
How does the ATHS use telehealth?
Telehealth connects approximately 180 Alaska Native community village clinics, 25 subregional clinics, 4 multiphysician health centers, 6 regional hospitals, and the ANMC in Anchorage. The clinics, health centers, and regional hospitals are operated by tribal health organizations or foundations. The ANMC is jointly managed by the ANTHC and the Southcentral Foundation, both based in Anchorage.
Why was telehealth needed to reach Alaska Natives?
This population faces unique challenges in gaining access to high-quality care:
Air travel, which is expensive and weather-dependent, is required for most village inhabitants to reach a clinic, health center, or hospital outside their village. Roads simply do not exist between most villages. Patients would typically fly on a small airplane to a regional location to connect with a jet airplane to fly to Anchorage to receive treatment at the ANMC.
Approximately 60 percent of Alaska Natives live outside the Anchorage area, and many live in federally recognized medically underserved areas. Alaska has one of the lowest rates of medical specialists in the country.
Patients face long waiting times to be seen by specialists who fly out to regional hospitals to conduct field clinics every few months.
Who pays for the statewide telehealth program?
The AFHCAN was initially funded in 1999 by multiple Federal agencies, including the Indian Health Service (IHS), the Department of Health and Human Services, the Department of Defense, and the Department of Veterans Affairs. Since 2004, IHS has been the primary funder of AFHCAN to support core services such as technology development, clinical program development, training, and support.
Tribal partners and other AFHCAN participants pay for their costs, including equipment, provider training, and connectivity. Telehealth cannot function without reliable connectivity. Rural Alaska sites depend heavily on the Federal Communications Commission’s Universal Services Fund to subsidize the cost of a satellite-based T1 link. Without that subsidy, many tribal organizations that manage multiple clinics could not afford these linkages.
Which health care professionals use telehealth?
Approximately 75 percent of the AFHCAN’s telehealth usage is for primary care services. Typically, community health aides and practitioners in village clinics use telehealth to consult with family physicians at regional hospitals or at the ANMC when they have to make decisions about the diagnosis, treatment planning, or urgency of a case. They also may use telehealth to follow up on patients with medical conditions or trauma. Nurses and nurse practitioners also use telehealth extensively.
The other 25 percent of our telehealth services are for specialty care services, ranging from psychiatry to radiology. Behavioral health aides and dental health aide therapists, along with community health aides and practitioners, are trained during their formal coursework to use telehealth.
What initial concerns did providers have about using telehealth?
Dr. John Kokesh: I was concerned about the connectivity in the state and the reliability of broadband, how easily we could train people at distant sites to use it, and how well patients and providers would accept it. Nonetheless, I also saw that we were unable to meet the needs of rural Alaska Natives, so I was open to new ways of addressing the need. We saw only a fraction of the patients who needed to be seen at the specialty clinics that we held at regional hospitals or health centers.
Have providers become more accepting of telehealth?
Kokesh: I like using it and appreciate the benefits it offers. We can do more patient encounters in 1 hour using telehealth than if we saw patients in person or conducted video consultations. New practitioners on our team are expected to use telehealth routinely and to undergo training and mentoring in the use of the technology.
Ferguson: We have been doing this long enough now that some organizations have mandated telehealth in their policies, and other organizations such as the ANTHC have built strategic plans around telehealth. Our current challenge is keeping up with the rapidly increasing demand. We expect to see a 100 percent growth in telehealth usage at the ANMC in 2014, and we will likely experience an overall 509 percent growth in primary care usage of telehealth throughout the state.
How has telehealth changed the way that a specialty such as otolaryngology is practiced?
Kokesh: We review patient cases that are sent to us and make informed decisions about them based on these questions:
Is it a problem that can be treated by local providers, with our input and direction?
Is it a problem that requires the attention of an ear, nose, and throat specialist?
If so, how severe is it? Can it wait until specialists conduct the next clinic in the region, or should the patient be flown immediately for treatment at the ANMC in Anchorage?
Finally, is it a problem that can be addressed only at the ANMC in Anchorage, such as an elective surgery?
Given our ability to triage patients this way, we can direct or redirect treatment for more patients than we could possibly do at the regional clinics.
Describe a few cases in which telehealth improved patient care.
Kokesh: A local provider sent us images of an 18-year-old female with a ruptured eardrum and ear pain. He described treating her with ear drops to protect against a possible ear infection. We could see from the image that she had a hole in the ear drum but no infection. We also knew that the medication was ototoxic, which could cause irreversible hearing loss. We told the provider to stop using the ear drops and made recommendations for treatment and followup.
Another case involved a request for assessment of a 50-year-old female in a remote village with an unusual ear examination. Using the images, we diagnosed the condition as cholesteatoma, a skin cyst growing into the ear, which can damage the hearing bones. We contacted the patient immediately to come in for surgery at the ANMC, and we arranged for her flight transportation. The timely surgery saved her hearing.
I recently received a call about a 3-year-old child who was thrown off a snowmobile and had a lacerated face. Rather than flying the child to the regional hospital, the health aide sent a picture to the doctor in the regional hospital. He contacted us and said the laceration was too complex to treat there, so we arranged for a Medevac to transport the child directly to Anchorage. This saved at least 12 hours, which is critical when repairing an open wound.
What cost savings has telehealth achieved?
Ferguson: More than 3,000 providers have engaged in 160,000 telehealth clinical consultations since 2001. We estimate that, in 2012, the telehealth program saved the state of Alaska $8.5 million in travel costs for Medicaid patients alone. Cumulatively, for all patients, we have a conservative estimate that telehealth has saved the state a total of $38 million since 2003. The need to travel was eliminated in 75 percent of patients involved in specialty telehealth consultations and in 25 percent of patients involved in primary care telehealth consultations.
On the other hand, there was a 10-percent increase in travel for patients involved in primary care or specialty telehealth consultations. Telehealth is facilitating early detection of medical conditions, which can prevent later complications and more costly treatment.
Have you integrated electronic health records (EHRs) with telehealth?
This is a strong area of focus for the AFHCAN, as we are also involved in other integration efforts such as our statewide health information exchange (HIE) and linking the telehealth system with organizational EHRs. The telehealth system is now integrated with EHRs in several ways. At the basic level, we can pull patient information, demographics, and insurance information from the organization’s EHR system to document a telehealth case. We can receive discharge notes and other notes from an EHR system and automate the routing of that information to other providers and organizations. We are working with an EHR vendor to “visually” integrate the telehealth system within the EHR system, and we plan to work with the statewide HIE to integrate telehealth with a master patient index to enhance the ability to integrate telehealth data into patient records and billing systems.
Are you planning to implement other health technologies in 2013?
We are now starting to use video technology, which will be fully integrated into the store-and-forward system this summer. A community health aide in a village who wants to discuss a case with a doctor will quickly be able to determine who is on line, select the doctor, have a live conversation using the video capability, and integrate the available medical devices into that communication. This will be a dramatic change from how we currently use our telehealth system.
Our current goal is to increase the availability of video throughout the ATHS, to support 24-hour-a-day, 7-days-a-week care delivery models, and to expand into newer models that improve access and quality of care for our patients. The new models will enable more urgent care to be provided to patients following a stroke, trauma, or critical illness. We also plan to extend the video capability into the homes for our patients and to provide new models of home telehealth monitoring. Video services also can support chronically ill patients in their medical homes, enable the elderly to stay in their villages, and help prevent hospitalizations and readmissions.
About Stewart Ferguson, PhD
Dr. Ferguson is Chief Information Officer for the ANTHC in Anchorage, Alaska. He has the primary responsibility for information technology and clinical informatics operations for the ANMC, the largest Native hospital in the United States and the only level II trauma center in Alaska. Dr. Ferguson, who was previously Director of the AFHCAN in Anchorage, serves as President of the American Telemedicine Association.
About John Kokesh, MD
Dr. Kokesh is Medical Director of the Department of Otolaryngology at the ANMC, where he has worked for the past 18 years. The department’s 9 physicians provide comprehensive otolaryngology care for approximately 150,000 Native Alaskan and Federal beneficiaries. Dr. Kokesh has worked closely with the AFHCAN telemedicine project since its inception in 1998. His focus has been in developing clinical applications, clinical outcomes research, education, and business processes that support store-and-forward telemedicine services.
Dr. Stewart Ferguson reported that the ANTHC received funding from the Health Resources and Services Administration’s Office for the Advancement of Telehealth and the American Recovery and Reinvestment Act to support telehealth training programs.
Dr. John Kokesh reported having no financial interests or business/professional affiliations relevant to the work described in this article.