Our Health in Our Hands, Part 4: Tribal health care in the 21st century

SPONSORED | PART 4 OF 4: For years, Alaska Native people sought to manage their own Tribal health care system. When the Alaska Native Tribal Health Consortium formed, that goal had been reached, and the work was just beginning.

With Tribal health care in Alaska no longer directed by Indian Health Service administrators in Maryland, ANTHC had the flexibility to manage services that would enable Alaska Native people to chart their own course to good health.

“We knew if we had that authority, we could move in a more agile way,” said Roald Helgesen, a Tribal health care leader from Sitka who was named CEO of ANTHC in 2011.

From the beginning, ANTHC’s leaders prioritized a proactive approach to health and health care, in ways designed specifically for Alaska Native people and the communities where they live.

Groundbreaking telehealth

Early in its existence, ANTHC joined the Alaska Federal Health Care Partnership to collaborate with other complex health systems operating in the state, including the Veterans Administration, the Department of Defense, and the Coast Guard, as well as IHS, now a partner rather than a parent organization. That partnership made possible the development of what was then the world’s largest telemedicine system.

The telehealth initiative grew out of a 1997 partnership between the University of Alaska Anchorage and the Alaska Native Health Board. Called the Village Telemedicine Project, this early tech venture deployed telemedicine equipment to four regional hospitals and 20 village clinics, providing for the first time a regular connection between rural patients and medical specialists.

Tribal health organizations asked for connections in more communities.

“A lot of our village clinics didn’t have computers,” said Chief Information Officer Stewart Ferguson, who continues to lead ANTHC’s telemedicine program today. “We didn’t have connectivity. It was very, very nascent. But clearly people saw the value.”

Buoyed by this initial success, the Alaska Federal Health Care Partnership sought and received Congressional funding to build a telehealth system that would be used throughout the Tribal health care network and at remote locations like Coast Guard stations and vessels. ANTHC eventually took on management of the collaborative, inter-agency project.

When the telemedicine program went live in 2001, dial-up internet was the best that could be hoped for in many rural communities. Live videoconferencing simply wasn’t an option. So Ferguson and his team pioneered an asynchronous approach called “store and forward.” Images and information were digitally packaged and sent like an email to providers who could then remotely review and prescribe treatment for each case. The project also included custom workstations designed to take up no more than 4 square feet of clinic space, with touch screens (ubiquitous today, but rare at the time) and a user interface designed to be easy for community health aides to operate even with limited computer literacy.

“The adoption was quite fast,” Ferguson said. “By 2003, we had the equipment out to 248 sites.”

As connectivity improved, the system expanded to include real-time videoconferencing along with store and forward. Initially used primarily for otology and cardiology, today the telemedicine system is used across multiple specialties. Double-blind studies have established its accuracy and efficacy. Now that more villages are getting broadband, Ferguson said he expects telehealth to reach even further into both clinics and homes, with expanded options for behavioral health, palliative care, post-discharge support for NICU babies and their families, and even trauma care.

“There’s a whole world here,” he said.

‘Care closer to home’

Since 2001, 370,000 telehealth cases have been reviewed by 4,000 health care providers, and Ferguson said a conservative estimate puts total travel savings somewhere north of $105 million.

What’s important to remember, Helgesen said, is that each number represents a real patient who benefited from being treated close to home.

Take, for example, someone who lives in Helgesen’s family’s hometown of Hydaburg. To travel to Anchorage for a checkup with a cardiologist, that person used to have to get up at 4 a.m., drive across Prince of Wales Island, take a ferry to Ketchikan, fly to Sitka and then Juneau, and finally land in Anchorage late in the evening, not accounting for the weather delays that are an expected part of travel in Southeast Alaska.

Now, that same patient can go to the village clinic for their initial tests. That information goes into the electronic health record that is now used across much of Alaska’s Tribal health care system.

“You walk up to your clinic two days later and you sit down in front of the telemedicine unit and you see your cardiologist that you've known for the last 15 years on the other side,” Helgesen said. “He's checking your health records. He's seeing your latest laboratory results. If (you) needed an EKG, he had that done. That follow-up didn't generate two 16-hour days of travel.

“When we talk about care closer to home, that's what it means.”

Innovation and reinvention in Tribal health

Telehealth is just one of the areas in which Tribal health care has innovated and grown over the past two decades to meet the health needs of Alaska Native people across the state.

Health infrastructure was an early focus for ANTHC. A partnership with the Denali Commission helped build more than 100 new community health centers and other facilities in the early 2000s. Water and sanitation improvements have been an ongoing effort, with new innovation necessitated by coastal erosion that complicates plumbing projects in some communities. And the “care closer to home” philosophy behind the original Tribal health care innovation -- the Community Health Aide Program -- inspired the creation of similar programs for behavioral health and dental care.

Improving access to care has meant infrastructure investments in Anchorage to meet statewide health care needs as well. When Helgesen took the helm at ANTHC, he said, the consortium was short on specialists and workspace, a deficit that meant long wait times for services and increased costs to the Tribal health care system. In the last seven years, ANTHC has tripled the physical footprint of its specialty clinics and abandoned the old IHS pay scale for physicians in order to attract more talent. Lodging and shuttles were added for patients visiting from out of town. ANTHC became its own Medicaid contractor in part to speed up authorizations and eliminate delays for patients coming from villages with limited air service.

Innovating for the whole person

While Alaska’s Tribal health care system addresses today’s health matters, it’s actively trying to prepare for what may be on the horizon. ANTHC’s Clinical and Research Services program studies issues, trends, and questions that impact the health of Alaska Native people. Recently, Helgesen said, the Consortium has been looking closely at adverse childhood experiences. Alaska Native people are more likely to experience the social factors that are increasingly linked to negative health outcomes in adulthood. More and more, research indicates that community and culture can have a meaningful impact on physical and behavioral health.

“Promoting Alaska Native traditions such as Native language, storytelling, songs and dances, traditional foods and plants are the best medicine for treating our people in a holistic manner,” said Tina Woods, senior director of community health services for ANTHC. “In a system managed by Alaska Native people for Alaska Native people, we take a culturally responsive approach to promoting wellness in a way that was not imaginable prior to self-governance.”

Today’s Alaska Native Health Campus has very little in common with the old, now-demolished Alaska Native Service Hospital. One thing has stayed the same, though: The hospital is still a gathering place. Like the contemporary Tribal health care system, today’s Alaska Native Medical Center was designed with culture and community in mind.

“Come to our gathering spot in the hospital in the evening,” Helgesen said. “You'll hear drumming and singing and dancing. Our people do that. And it's really exciting.”

This story was sponsored by Alaska Native Tribal Health Consortium, a statewide nonprofit Tribal health organization designed to meet the unique health needs of more than 175,000 Alaska Native and American Indian people living in Alaska. Read Part 1. Read Part 2. Read Part 3.

This story was produced by the creative services department of the Anchorage Daily News in collaboration with Alaska Native Tribal Health Consortium. The ADN newsroom was not involved in its production.