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How telehealth gets to far-flung residents in Alaska

Most people know Alaska’s state nickname is “The Last Frontier,” but how many know its motto is “North to the Future”? We all may be surprised at how relevant that motto may become for health systems in the Lower 48. Odd as it may sound, Alaska could offer a future model for delivering care for all U.S. health systems, especially those focused on value-based care built upon digital health.

Telehealth has become an emphasis for even urban health systems seeking to deliver digitally enabled care and wellness programs to individuals and populations with equal ease, efficiency and quality across cities or wide regions. It has no better testing ground than Alaska. In essence, if it can play in Kodiak or Sitka, it can play anywhere.

Ranked first among the 50 states in area at just over 663,000 square miles, Alaska ranks 48th in population with about 740,000, more than a third of whom live in Anchorage. It’s like taking a medium-sized city and distributing its population over an area three and a half times the size of the Midwest.

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“Bears and other wildlife are a few of the hazards we face,” says Colin Underwood, Healthcare Program Manager at Anchorage-based Alaska Communications, a broadband and managed IT firm that was the state’s first internet service provider. “When you go out to maintain a microwave tower, for example, you have to watch your surroundings.” Distances are almost unimaginable to Lower 48ers. Traveling from Anchorage to Juneau the capital, for example, is the same as traveling from Washington, D.C. to Orlando, Fla.

Networking against nature
Alaska’s large expanse, inhospitable climate, and challenging terrain make it uniquely difficult to achieve a ubiquitous fiber-optic network. “We can’t just take a truck and wheel out some fiber. We've also got to use planes and boats,” he says. Then there’s the complicated permit process arising from Alaska’s preponderance of federal, state and tribal lands. Use of microwave towers is also expensive, requiring helicopter transport, onsite construction and continual maintenance to ensure a continuous supply of power and address the stresses of ground swells and frost heaves.

With only six months of the year with suitable weather conditions for construction and maintenance, half the year is spent planning, and then companies like Alaska Communications make a mad six-month dash to install networks. It’s expensive. As a result, he says, “We’re continually seeking new and creative ways to use technology and leverage every bit of bandwidth to deliver healthcare to remote areas of Alaska. I’ve been to villages of 50 people with a health clinic that takes 12 hours to reach.”

In other words, it’s time for telehealth.

Using network-backbone technology from Sunnyvale, Calif.-based Juniper Networks (which includes an SDN platform running Juniper’s MX series routers and SRX firewalls), Alaska Communications provides a variety of telehealth solutions for remote Alaskan villages, ranging from basic internet access service to highly sophisticated managed broadband network connections. The latter enables healthcare providers to have access to VoIP (voice over internet protocol), store and retrieve EHRs (electronic health records) and take advantage of high-speed broadband connection to the state HIE (health information exchange) to gather and access as much of a patient’s medical information as possible.

Alaska Communications’ network can also enable televideo conferencing to connect remote clinics with urban medical centers like Providence Hospital in Anchorage. Using a high-bandwidth connection, hospital specialists can evaluate patients in a village clinic that is equipped with telemonitoring capabilities including a camera-mounted cart, digital stethoscope and other diagnostic devices administered with the help of an onsite medical aide.

Using e-stroke technology, for example, a hospital-based neurologist can diagnose a patient with a suspected stroke and prescribe blood thinners to prevent the condition from worsening. In the case of trauma from an accident in a remote area, Providence Hospital ‘s e-ICU can triage the patient, determine a diagnosis and even walk a local caregiver at the clinic through procedures to treat the patient.

For Underwood, building Alaska’s telehealth capability is personal. Years earlier, he worked closely with a tribal-village elder who was a leading advocate of bringing the medical network to villages. Despite the distances and the hit-or-miss communications, the two developed a close relationship. When Underwood didn’t hear back from the elder for a month, however, he became alarmed. Ironically it turned out the man had died of a heart attack in the village because he was unable to get timely care.

AK Child & Family
Angie Rush is a fan of better connectivity. As Director of Development for AK Child & Family, one of the oldest not-for-profit social service organizations in Alaska, she is acutely aware of the organization’s historical evolution growing from an orphanage in the late 18th century to focusing on mental health in the 1980s and finally to a multidimensional family support agency today that provides inpatient residential treatment, therapeutic foster homes and home-based services. With 90 percent of its reimbursement now derived from Medicaid and commercial insurance, an EHR was critical for billing and quality care.

“Being a lifelong Alaskan, I admitted children from all over Alaska, but I didn’t really understand where many of them came from. Initially, I didn’t know what a remote village was really like. But I knew that we had technical difficulties connecting with them. For example, during an admission oftentimes children with serious mental health issues would need to be medevacked to a treatment facility in Anchorage. But often the parents were in Gambell or St. Paul or somewhere far away and didn’t even have telephone service at home,” she says.

“To admit a child, depending on the season, a parent would have to ride their snow mobile or take a boat to the grocery store to use the phone or fax and sign all the documentation. And then they’d just get back on their snow mobile and go back home. It would take a couple more days to connect with them,” says Rush. When she was finally able to visit a village and meet with elders, Rush left deeply convinced of the need to focus on any technological solutions that keep children in their home and village whenever possible.

With Alaska Communications’ help, AK Child & Family was able to set up videoconferencing capability between the agency and its family clients. “We could actually see the people, support them, talk to them and work with schools to keep those children at home avoiding the trauma of separation,” she says.

“We’ve been able to work through the village elders, the natural helpers who want to support and help keep Alaska’s children safe. And we’ve been able to guide them through training to be therapeutic foster parents. Today many children no longer have to fly to Anchorage for therapy and we don’t have to send people out to the villages. Telehealth is saving a lot of money, resources and time. But, mainly, we’re able to do an immediate intervention,” Rush says.

Connecting with Tenakee Springs and beyond
Chichagoff Island is part of the dangling, archipelagic southeastern tail of Alaska. Seventy-five miles long and 50 miles wide, Chichagoff is the fifth largest island in the United States. Sprinkled with small, remote villages, the island is anchored by the city of Sitka, just across the narrow Peril Strait to the south on Baranof Island. With less than 10,000 people, Sitka and its closely coupled islands are accessible only by plane or ferry. Sitka Community Hospital, a critical access hospital with 27 beds—15 of which are long-term care—serves the islands’ inhabitants.

The use of telehealth through Alaska Communications’ network infrastructure has proven invaluable in improving the quality care to outlying villages in Sitka Hospital’s catchment area. Sitka physicians, for example, can participate in televideo consultations with remote communities like Tenakee Springs, a village of some 130 people with a bare-bones clinic and part-time nurse. Allowing doctors to consult with patients and the nurse in real time eliminates the long-distance travel previously required for patients and visiting providers alike, often in bad weather and over mountainous terrain. The telemedicine system, which previously accounted for about five video consultations a week, significantly improved patient care to Tenakee Springs and other remote locations. Currently, the funding for the program has expired and new grants are being sought for its continuation.

“Previously the internet was often down or very slow due to low bandwidth,” says Grant Turner, Sitka Community Hospital’s IT Manager, who oversees an IT department of six staffers. “It was often hit-or-miss and expensive.” Now, using Alaska Communications’ fiber optics and microwave relays, the network—supported by Juniper Networks for the past five years—complies with the “Five Nines” goal: being available 99.999 percent of the time, he says.

No more dial-up
Turner cites four key benefits of the Alaska Communications network for Sitka:

  • Continual availability. It’s always up.
  • Increased speed and bandwidth. When Turner arrived at the hospital five years ago the network operated on a 50-to-80-megabyte bandwidth using a dial-up capability from another telecommunications firm. In 2018 it was upgraded to 150 megabytes using Alaska Communications, enabling Sitka Community Hospital to transmit medical images to a radiology practice in Anchorage in as few as 15 minutes compared to two hours previously. “As a result,” says Turner, “clinicians can quickly make diagnoses, patient safety has improved, patient and staff satisfaction has jumped and care delivery is much more efficient.”
  • Improved security. While Sitka Community Hospital uses a multi-layered security approach to protect patient data, Alaska Communications adds more layered security levels through their MPLS networking of segmented and layered security levels.
  • Enhanced disaster recovery. Alaska Communications offers cloud-based backup for Sitka Community Hospital’s own IT backup processes. Physical offsite backups are also maintained by both the hospital and Alaska Communications.

Keys to success
While Sitka Community Hospital has derived great benefits from its partnership with Alaska Communications, the delivery of high quality, standardized healthcare in remote areas plagued by scarcity of financial and human resources remains a hefty challenge. Turner offers some key tips for success:

  • Develop an in-depth IT plan accounting for the hospital’s geographic and resource challenges.
  • Develop multiple contingency backup plans. Have back up plans to your back up plans to address any situation.
  • Seek increased leverage by partnering with your IT-systems provider (like Alaska Communication) as well as physicians, clinics, other hospitals and social-service agencies.
  • Seek out special funding targeted to rural healthcare and/or critical access hospitals. For example, the hospital obtains support from USAC (Universal Service Administrative Company), a federally-funded program to provide broadband capabilities in areas of acute need including rural healthcare.

Sitka Hospital’s next steps, says Turner, include moving to a Cerner/cloud hybrid EHR that will be delivered via a virtual private network (VPN). The hospital has developed a flexible five-year IT plan to expand its bandwidth using fiber optics that will enable additional care delivery options, including the wider use of televideo to service additional village sites and expanding the use of remote telemonitoring of patient vitals.

Conclusion
As America’s largest state, Alaska is home to several hundred small communities unreachable by road and unconnected to any extended electrical grid. Not only do most of these communities lack full-time physicians, they also lack access to a modern, redundant broadband transmission infrastructure. Through telehealth services supported by agencies like USAC’s Rural Healthcare Program (https://www.usac.org/rhc/), Alaska Communications helps rural caregivers provide emergency services, advanced diagnostics, specialized medical treatment, palliative care and mental health care at levels previously not possible. “In terms of telehealth,” noted FCC Commissioner Michael O’Reilly in recent testimony, “what they are able to do with very small dollars in remote parts of [Alaska is] very impressive…Other places using telehealth and telemedicine are really eating up some significant dollars, whereas Alaska has been very efficient and addressed the issue very thoughtfully.”

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