Pandemic broadens use of telemedicine in Indian Country and beyond
The COVID-19 pandemic has prompted countless changes. One that’s likely to stick is the more common use of telecommunications in the health field.
Both telemedicine, or the delivery of clinical care by telephone or the internet; and telehealth, which includes training, education and other communications; already play a bigger role than before the pandemic.
"In our practice, we never used telehealth before two months ago, and now I feel like I'm almost a mini expert in telehealth,” said Dr. Joseph Bell, Lummi, a pediatrician with the Spartanburg Regional Medical Center in South Carolina.
Bell spoke at a May 6th American Indian Physicians Association and National Indian Health Board virtual town hall, where a caller said half her patient visits on the Fond du Lac reservation in Wisconsin now are by telephone.
And, Bell said, “If COVID ended tomorrow, I think that telehealth's going to be an increasing part of healthcare in the United States moving forward … I think it's going to be a very integral part of how we move forward with medicine.”
Bad weather, great distances, few people
Alaska’s weather, terrain and demographics had already pushed the state's tribal health system to become a telemedicine leader and innovator.
It had to find a cost-effective way to maintain access and quality while providing services to more than 100,000 Alaska Natives when half of them live in communities of fewer than a thousand people. And three-quarters of Alaskan communities are not connected by road to a hospital. The system includes more than 200 village and subregional clinics, health centers and regional hospitals.
In reports and presentations, Chief Technology Officer Stewart Ferguson, PhD, with the Alaska Native Tribal Health Consortium, also notes that Alaska is nearly last in the nation for the number of doctors per resident. And 65 percent of its doctors are in Anchorage. The state’s largest city is about $1,000 round-trip flight from most villages. Fast-moving storms add sometimes frightening uncertainty to the high cost of travel.
Ferguson heads the consortium’s program known as AFHCAN, after the name it was given when it was started in 1998, the Alaska Federal Health Care Access Network. It provides equipment, software, and technical support to 44 tribal, state, federal, and other health care providers serving 248 sites across Alaska.
The program developed a telemedicine cart with attachments such as digital and dental cameras and devices that measure lung capacity and look inside the ear. Using a “store and forward” system, rural care providers can transmit data such as images and medical records.
And patients have live video interactions with physicians and specialists in regional hubs and Anchorage. They receive care for everything from medications management, monitoring of chronic conditions, and speech or physical therapy to post-surgical follow up and trauma.
‘We’d like to think that the things we do in an exam are so important’
Dr. Matthew Schnellbaecher, a cardiologist with the Alaska Native Medical Center in Anchorage, said travel has always been a part of his job.
“[Care providers] realized long ago how difficult it was for patients to get all the way in to see us in Anchorage, both time- and inconvenience-wise and elders trying to step up on, you know, four-seater airplane wings and kind of scrunch down and make their way into the plane. That's hard enough for kind of able-bodied people. It's really a struggle for our elders with arthritis and congestive heart failure and such.”
Schnellbaecher said some care, such as high-tech tests, has to be provided in person.
But doctors and nurse practitioners in the Native medical center’s cardiology department all set aside one afternoon or morning a week for telemedicine. Telemedicine saves so much money for the providers and hassle for patients, “It’s a no-brainer, really,” said Schnellbaecher. And, he says, “I think it provides excellent care.”
“We’d like to think that the things we do in an exam are so important. But in a relatively stable patient who we’ve known for many years that really doesn't add much, like, you know, very little.”
He said he gets most of the information he needs from talking with the patient, and less than 10 percent of it from “me actually putting my stethoscope to their lungs, listening to their heart, and pressing my finger into their ankles to see if they have any edema.”
“So you can get a lot just by telling people with congestive heart failure, ‘how's your breath? Are you able to lay flat or are you waking up at night? ... How far can you walk before getting short of breath? Can you carry your firewood into the house? Can you chop wood? Can you go berry picking without getting short of breath?’ said Schnelbaecher. “You can get all kinds of information and have a pretty darn good idea how their heart failure is going just by what they're telling you.”
He said patients with blood pressure monitors and smartwatches can measure vital signs and heart function and provide that information from their homes. Others might be hooked up to a telemedicine cart in a village clinic.
He said patients nowadays appreciate telemedicine even more than before the pandemic. “They really want it for their own safety and their fear of getting sick themselves but also the fear of bringing COVID to a village that thus far has been spared any cases,” Schnelbaecher said.
Schnelbaecher said as terrible as the pandemic is, it will let people and medical providers realize that providing care to people in their home or a clinic close to home, “is a great way to take care of them as they're very happy with it.”
So telemedicine has the potential to improve access and reduce the cost of medical services. But putting it to use in rural areas and for many Native Americans is hindered by a lack of fast, affordable Internet service.
“Yeah, we have internet,” said Tribal Administrator Millie Frankson, Inupiaq, of the North Slope village of Atqasuk but, “lately it's been slow now that school is out, people are having to stay home. The jobs are getting suspended, cut. And, you know, all the non-essential employees are staying home now and everybody's on the computer. And with our school children on the computer doing homework and stuff, it's been slow.”
That’s also the case in the village of Platinum, on the west coast of Alaska, said tribal administrator Clara Martin, Yup’ik.
Gerad Godfrey, Alutiiq, serves on the tribal working group of FirstNet, which was set up after 9/11 to ensure first responders have top priority for telecommunications during emergencies. He was also a senior advisor on rural business and intergovernmental affairs to former Alaska governor Bill Walker.
He said villagers’ complaints about inadequate or a complete lack of internet service are common in many parts of the country.
“If you live in a farm or ranch somewhere in rural America, middle America, you don't have connectivity or you don't have good connectivity.”
Too often rural internet coverage, he said, is spotty, inconsistent, and slow. There may be “times of the day when it's better than other times and there's challenges when rain is falling at a certain angle because the wind is blowing,” Godfrey said.
Indian country, rural, western states affected
Researchers compared access, speed, and cost to rank the quality of Internet services across the United States. Alaska, New Mexico, Wyoming and Montana were ranked the lowest. They happen to also have the largest percentage of American Indian and Alaska Native residents. Other states with significant Native American populations, such as North Dakota and South Dakota, Arizona, and Oklahoma, are in the middle of the ratings.
BroadbandNow, which analyzes governmental and other studies, has found that only half of Americans have access to adequate affordable Internet (defined as $40 a month or less for basic service).
And the pandemic is straining the system. In the first quarter of 2020, BroadbandNow said, “16 states recorded lows in internet speeds in March (compared to the previous five months of speed test data) as the coronavirus continues to spread and more residents are relegated to staying at home.”
“Telehealth is being touted as a potential solution for overwhelmed healthcare systems in many states, but as many as 42 million Americans may not have the broadband connection to support this emerging service. Despite this, a recent survey showed that 75% of American adults were open to a virtual visitation as an alternative to an in-person appointment” said BroadbandNow authors.
The Federal Communications Commission, other agencies, and Congress are working to rectify the problem. For instance, the Health Resources and Services Administration in the US Department of Health and Human Services, recently awarded nearly $165 million to combat the COVID-19 pandemic in rural communities. Some of that money will go to 14 HRSA-funded Telehealth Resource Centers.
“It is obviously a huge windfall for all of us,” said Elizabeth Krupinski, PhD, co-director of the Southwest telehealth resource center. “It's more than double what we normally get on an annual basis.” She said the money comes with a number of restrictions but will help with a big jump in interest in telehealth.
She said the pandemic boosted awareness of telemedicine to making it a key option for many institutions. “A lot of people suddenly became very interested in doing it just to survive. And so we had a huge increase in our request for technical assistance.” She said people call with questions about everything from regulations, billing, and patient consent, to how to do a physical exam, and technology.
The funding will allow the center to expand its technical assistance, to continue to provide materials, pay for website upkeep, and boost training. “We've just been kind of putting a lot of materials out there for people,” said Krupinski. “Now it's going to allow us to organize things better and curate things better.
“In the past we've been very much focused on providers, but all of a sudden we have patients reaching out to us,” Krusinksi said. “So we're going to develop a lot of new material related to what the patient can expect from a telehealth encounter. And we're going to have those in English and Spanish and hopefully in Navajo.
Krupinski and several other people interviewed for this story said Medicare and Medicaid now allow providers to get paid for medical services delivered via the internet and telephone. And that’s promoted interest.
But the real fix to getting fast affordable internet to rural areas will take much more money, as in billions of dollars, plus a concerted effort. Laying cable, fiber and phone lines, and putting up towers, boosters, repeaters and antennas are spendy.
Godfrey said, “you're asking the private sector to go forward and take on a venture, a venture that could be 50 million, a hundred million dollars laying the infrastructure to get to a community of a hundred to 350 people. And they [telecom providers] say it won't ever pencil out.”
He said if the infrastructure were there -- say the federal government put in a hundred million dollars to provide infrastructure to three communities spread out over a hundred miles -- the next hurdle would be money for maintenance and operations.
“The problem is once we get these subscribers, if we don't get 80 or 90% of the community to subscribe, it [the project] will never even be able to pay for operation, maintenance, let alone ever make a buck. So the profit incentive still does not exist even if there's a full federal subsidy to lay the infrastructure because there's not enough subscribers in those three villages or communities” to pay for the operation and maintenance.
“It'll take a lot of money,” agrees Krupinski. She said it will take an effort similar to the 1930s era Tennessee Valley Authority and other projects that brought electricity and then telephone service to most of the country. “I mean, it takes just a lot of infrastructure and dedication of resources to make it a priority. Right now it is an expensive proposition.”
Plus, Krasinski said, someone, it doesn’t matter who, she said, but someone has to say, ‘Look, this is a necessity,” and bring together all the stakeholders -- the Indian Health Service, local leaders, legislators, tribes, the private sector, land-owners, telecommunications providers and health care providers, and the public. “It has to be a team effort.”
Then fight for it
Yet, in prepared statements and meetings, tribal leaders from across the country repeatedly say there’s an urgent need for broadband support for those working from home and for all of the essential and frontline workers. Advocates have long said, and now more urgently than ever, universal internet is needed for commerce, public safety, and emergency response as well as education and health.
Godfrey thinks it makes sense for the federal government to expand internet services to all parts of the country. But he said the federal obligation is also based on the history and the trust relationship the federal government has with tribes.
“Because you have tribes living in an area by design by Congress that was largely intended to remain desolate and was viewed as land that was not going to have much population growth around it, and so the private sector is not bringing broadband to them because it doesn't pencil out … they can't make money on it,” Godfrey said. “So the feds have to provide some creative way beyond just subsidies to allow the tribes to provide for themselves, right?
“I think it should. I think it could. I think it will,” Godfrey said. “I can't see what that looks like, but I also would say that there are some real champions on these types of things in Congress right now, so I think that's encouraging.”
“Telemedicine is a viable option for healthcare,” Krasinski said. “And if it's not available where you are, ask. Ask your providers. If you're a patient and you think telemedicine would be an option for you because you don't want to travel three hours to the next biggest city, ask them about it,” Kasinski said.
“Start to demand that they explore telemedicine options because … you can be an active member of your healthcare team making decisions about your healthcare, where you get it, how you get it, and telemedicine should be an option for everybody. But sometimes you have to go out there and fight for it and make people aware that their customer base ... want telemedicine,” Kusinski said.
Judith LeBlanc, Caddo, Director of the Native Organizers Alliance, at a recent Illuminative town hall on the Internet, agrees, “I say the time is right to break the racial digital divide and to fight and build a movement that's led by the tribes as well as urban communities, to make Internet, and wifi, broadband access as essential as water and electricity … Let's wage a fight to make broadband a right.”
Joaqlin Estus, Tlingit, is a national correspondent for Indian Country Today, and a long-time Alaska journalist.
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Visit Federal Communications Commission Office of Native Affairs and Policy for information about a 2.5 GHz rural tribal window, telehealth 5g fund for rural America, temporary spectrum access for the Navajo Nation, and other COVID telehealth programs.