Tele-survival

For nearly 200 remote Alaskan villages, the front line for health care contains community health aides instead of doctors or nurses. But because of advances in telehealth technology in the past decade, the community aides are only a satellite hop away from doctors offering expert advice in Anchorage or Fairbanks.

Coast Guard technicians stationed aboard cutters in Alaskan waters and community health practitioners in Arizona’s Navajo nation also depend on telehealth technology to consult with medical professionals.

By the end of the summer, all three groups will be able to tap into the Alaska Federal Health Care Access Network (AFHCAN). The Alaska Native Tribal Health Consortium (ANTHC) will manage the AFHCAN, which the Alaska Federal Health Care Partnership (AFHCP) developed. ANTHC, the Indian Health Service (IHS), the Army, the Air Force, the Department of Homeland Security, and the Department of Veterans Affairs are partners in AFHCP.

Richard Hall, director of information technology at the ANTHC, said that although disparate organizations inside the Beltway are often reluctant to work together, necessity and remoteness in Alaska quickly erase barriers and help forge partnerships. The ANTHC is an umbrella group for 39 tribal health organizations that serves more than 200 sovereign tribes in Alaska.

Alaska’s population of about 626,000 lives on a 586,000-square-mile land mass, meaning that on average, about one person occupies each square mile. So medical specialists, such as radiologists, are rare and valuable.“For a while, there was only one dermatologist in the state, at Elmendorf Air Force Base,” Hall said. “So we all had to share him.”

The ANTHC and AFHCP develop and manage telehealth systems that enable Alaska communities to share scarce medical resources. For example, a mostly satellite-based AFHCP wide-area network supports the AFHCAN and other telehealth systems.

The AFHCAN’s success rests on the Universal Services Fund, which makes telecommunications costs affordable for even the smallest Alaska village,Hall said. At commercial rates, Hall said, a T1 line could cost as much as $10,000 a month. The Universal Services Fund drops that cost to $198.20 a month.

Health care a la Cart
The core of the AFHCAN system is the Telehealth Cart, a mobile workstation deployed to about 250 tribal sites, eight Coast Guard cutters and six Coast Guard shore sites, including a Loran station on remote Attu Island at the far western end of the Aleutian Islands.

Lori Eussen, AFHCAN’s telehealth sales and marketing director, said the ANTHC-developed Cart features a PC, monitor and peripherals such as an electrocardiogram, dental camera, digital camera and a vital signs monitor that can measure temperature, blood pressure and heart rate.

The Fort Greeley, Alaska,Army base, home of a Missile Defense Agency base, will link to the network later this year, Eussen said. All stations on the network use it to transmit information from the AFHCAN Cart to hospitals or clinics, including the Alaska Native Medical Center in Anchorage, the Bassett Army Community Hospital at Fort Wainwright and the Air Force 3rd Medical Group at Elmendorf Air Force Base.

Once a community health aide creates a patient case using this equipment, the network routes the information to the appropriate specialist. Clinicians can then examine the information, provide guidance to the health aide and, in many cases, avoid the need to medevac the patient to a hospital, Eussen said.

The ANTHC has set up centers of excellence that handle specific medical problems. For example, an ears, nose and throat (ENT) center at the Anchorage Alaska Native Medical Center receives cases from all parts of Alaska and other AFHCAN partners.

Navajo telehealth
IHS has started to use the AFHCAN Cart, said Dr.Mark Carroll, the service’s telehealth program director. IHS has already deployed a cart at its Yakima Indian Health Care facility in eastern Washington state and plans to deploy a second one at a South Carolina facility, he said.

The Tuba City, Ariz., Indian Medical Center has purchased small, portable versions of the AFHCAN Cart for use in local communities. Carroll said he is excited about the support that the AFHCAN Cart can provide to IHS community outreach teams, particularly in remote areas of Navajo land that lack a solid health care infrastructure.

In places such as the Navajos’ land in Utah, Arizona and New Mexico, telehealth makes a lot of sense because recruiting and retaining health specialists such as radiologists is difficult. Carroll said he thinks that deploying the AFHCAN Cart to all 110 Navajo nation chapter houses will help plug this health care gap. A chapter house is equivalent to a county seat.

IHS has started to tap into the ANTHC Anchorage hospital’s ENT expertise from service facilities in eastern Washington state, Carroll said.And IHS may set up a tele-cardiology center of excellence in the Phoenix area and develop a multifacility system that would provide economies of scale for the IHS and ANTHC.

Meanwhile, the Coast Guard has deployed the AFHCAN technology in Alaska for the same reason that tribal villages use the system: to give their health services technicians a way to access remote medical expertise, said Coast Guard Chief Warrant Officer Jay Brudzinski, managed care officer and telehealth program officer for the Coast Guard in Alaska.

The Coast Guard uses the same hardware deployed on the AFHCAN Cart. But on some smaller cutters, the packaging has been reconfigured to fit in a small sick bay. The Coast Guard uses a satellite system to send readings from onboard medical diagnostic equipment across its network to a dedicated medical officer, who works with each health technician, Brudzinski said.

This provides faster feedback than before when remote technicians submitted quarterly reports. Because of a telehealth system that runs on 64 kilobits/sec to 128 kilobits/sec satellite links, Brudzinski said, health technicians can now get feedback from a medical officer in a day — or faster, if necessary, via a phone call to the cutter.

If the dedicated medical officer cannot answer a query from a remote health technician, the AFCHP wide-area network can forward the information to a specialist at Elmendorf. The telehealth system has helped improve regular communications between deployed health technicians and their medical officers, Brudzinski said. It has also improved prescription safety because medical officers can warn technicians about the potential dangers of drug interactions.

Although the Coast Guard program is still in its infancy, Brudzinski said, ANTHC studies show telemedicine can cut the need to medevac patients by as much as 40 percent, which is significant for people onboard cutters that operate on the often violent Bering Sea.

The AFHCAN’s success shows that voluntary federal, state and tribal partnerships can work, especially when necessity, remoteness and geography break down bureaucratic barriers, Hall said. The AFHCAN and growing number of partners prove that American Indian heath care can overcome those obstacles. In his view, “Indian health care has come of age in Alaska.”