Necessity Was the Mother of Invention: Treating Remote Alaska Natives Via Telemedicine

Cruising the Internet might leave you with the impression that telemedicine is a 21st century invention. So, you might be surprised that telemedicine has been the state-of-the-art for healthcare in Alaska for more than 50 years.

Necessity was indeed the mother of invention when it came to figuring out how Alaska could treat 240,000 Alaska Natives, spread out over its 571,951 square miles — including many of whom live in areas accessible only by air, boat or snow machine.

Though definitions vary, telemedicine is broadly defined as sharing medical information from the point of medical treatment to the point of medical advice via electronic communications means. This includes:

  • Live Video Conferencing: the use of live two-way video conferencing to conduct virtual office calls;  
  • Asynchronous Transfer (Store-and-Forward) of electronic files (video clips, still images, X-rays, electrocardiograms (EKGs), electroencephalograms (EEGs), paper files, and audio clips) for non-real time diagnosis;  
  • Remote Patient Monitoring (RPM), the real-time collection and transfer of patient data to an urban specialist for interpretation;
  • Mobile Health (mHealth), the use of mobile devices (smartphones, tablets) that support a myriad of software applications to assist with diagnosis.

And Alaska has done it all, according to Dr. Dan Hartman, Medical Director in Primary Care at the Southcentral Foundation (SCF). The largest of CIRI’s nonprofits, SCF was incorporated in 1982 to “work together with the Native Community to achieve wellness through health and related services.” It is one of several nonprofit funding arms of Alaska Native Corporations (ANCs) that administer the U.S. Department of Health and Human Services funding obligated to Tribes for healthcare.

A remote Alaska Native clinic. (Courtesy Sarah Freeman)

“It’s been a tremendous success in terms of Tribal self-determination, too,” Hartman said.

And so it has, with 99 percent of telemedicine serving Alaska Natives today. Since its beginnings in the 1960s when healthcare workers used single sideband (ham) radios to communicate with patients in remote clinics, Alaska telemedicine has evolved to become a global model for distance medicine. The tech revolution, especially satellites, has transformed Alaska’s approach to diagnosis and treatment from presenting an individual case over the radio — weather permitting — to more reliable, real-time, face-to-face interaction with clinic patients at one of six regional reference centers, or hubs — Sitka, Bethel, Dillingham, Kotzebue, Barrow, Nome or the Alaska Native Medical Center (ANMC).

Underwriting the success of Alaska telemedicine were two, much more pragmatic, institutionalized features. One was the creation of licensed Community Health Aides, a healthcare category specific to Alaska distance medicine. The second was the early development of standalone “carts” equipped with the communications and medical technology of the day to facilitate communication between the clinics and the hubs. Supplementing these were onsite stocking of medical treatment materials and pharmaceuticals to dispense immediately to the patient, and more importantly, emergency airlift for patients to hubs or to the ANMC.

Alaska Native Medicine basic cart (Courtesy Cheryl A. Skiffington)

Prior to 2005, when computers and electronic health records became the standards for communication, and Health Insurance Portability and Accountability Act (HIPAA) for protection of patient privacy, Hartman ascribed the success of the program to the “incredibly heroic work by thousands throughout the state of all kinds of healthcare providers and IT people to capture and hold information using carts.”

The six regional hubs serve 170 rural Alaska clinics, with each clinic serving 10-12 patients per day. They are staffed by 550 Community Health Aides with other providers (doctors, nurse practitioners, physician assistants) staffing the regional hubs or the ANMC. And while the telemedicine system was developed largely for Tribal communities, when there are no other healthcare systems in remote areas, clinics cannot limit care to Tribal members. “They care for whoever, with equanimity,” Hartman said with professional pride.

In the continental United States, a change in U.S. law in 2018 should facilitate the growth of non-Tribal telemedicine by the 36 states that have expanded Medicaid. But questions regarding who pays in a non-Tribal situation have put robust use of telemedicine in the Lower 48, plus Hawaii, likely another 5 to 10 years out. But that hasn’t stopped investors who have latched onto expert predictions of a 14.3 percent market growth in non-Tribal telemedicine by 2020 — up to $36.2 billion. If, as Dr. Hartman claims, “Everything follows money,” both underserved Tribes and non-Tribal patients stand a chance of catching up.

Alaska Native Medical Center (Courtesy Alaska Native Medical Center Fact Sheet)







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