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August 21, 2006
Telemedicine on Native American reservations is being discussed in the Senate while it is making great strides in providing healthcare access to populations without the most basic comforts. Through Internet use, healthcare has evolved into a sophisticated tool that can provide access to medical resources otherwise not available to certain populations. Telemedicine, or telehealth, consists of Internet capability, industry-specific software programs, and healthcare personnel working to improve healthcare access. Native American reservations across the country are the ideal candidates for telehealth as a great number of this population is still without electricity and paved roads and must travel great distances to access healthcare. “There are 562 tribal governments in the United States with 225 of them located in Alaska,” explains Paul G. Moorehead, a Federal Indian law and policy attorney with the Indian Tribal Governments Practice Group at Gardner, Carton & Douglas in Washington, D.C. Much of the geography in Alaska is roadless and to access a healthcare provider the patient must take a flight. Similarly, the Navajo Nation, which consists of 110 Navajo Nation chapters with 300,000 tribal members covering 27,000 square miles—roughly the size of West Virginia—is what some consider a “have-not” tribe, he says. Telehealth has the ability to connect people in remote locations to specialists in urban locations, explains Moorehead. It’s being used extensively in both Alaska and the Navajo Nation to provide health screenings, medical analysis, and health services. Clinical telehealth services are available in all 12 administrative areas of the Indian Health Service (IHS), with 281 of 431 Indian health facilities reporting information on telehealth clinical activity, according to the IHS. There are numerous telehealth programs currently in operation on Native American reservations, performing everything from screening and diagnosing diabetic retinopathy to surgical services. Telemedicine Programs Detecting Diabetic Retinopathy
From Afar To date there are more than 50 sites—most of which are concentrated in the Southwest—employing the JVN camera, says Sven Erik Bursell, PhD, director of the JVN in Boston. In addition to detecting diabetic retinopathy, the system can be used for other diagnoses such as glaucoma, cataract, and age-related macular degeneration. “Since the inception of the program, we have seen an 80% increase in the number of patients with annual eye exams and have increased the number of those with saved sight by 50%,” says Bursell. “The reason that the JVN system has been so easily adopted on the reservation is that the test is quick and noninvasive,” says Horton. The test can be combined with other appointments because the camera is accessible in most hospital waiting areas, he adds. Once the image has been received at the urban reading center, the technician categorizes the level of diabetic retinopathy from zero—meaning no disease—to “proliferative,” which would suggest the need for immediate laser surgery. The turnaround time for a response from the reader is generally 48 hours for nonemergent care, but if the reader sees anything that would require emergency care, he or she can call the testing site directly to ensure that the patient is referred out for care immediately, says Bursell. The screening, paid for by the IHS, is not intended to replace live exams by an ophthalmologist but rather to identify those at risk and recommend referrals, says Horton. Reducing Cancer Mortality Rate
The difficult terrain, the burden of accessing healthcare, and the limited availability of providers on reservations makes telemedicine an ideal solution for not only improving the quality of health of Native Americans but also for increasing access and compliance, says Petereit. In 2005, the University of Wisconsin relocated its Telesynergy imaging system from its campus to the Pine Ridge Indian Health Services Hospital to better serve Native Americans. The PC-based videoconferencing system is linked in real time to Rapid City Regional Hospital, where oncologists read the scans for cancer presentations. The core reason for the move was to reduce the number of late-stage cancer presentations, says Petereit. A six-year National Health Institute grant has made the transition possible with the hope of reducing the number of deaths due to missed or delayed cancer diagnoses. Prior to the arrival of the Telesynergy system at Pine Ridge, too much time elapsed between a patient being diagnosed with cancer and his or her visit with an oncologist in Rapid City, some 110 miles away. “What we were seeing with this method of healthcare was that patients were presenting with late-stage cancer rates of 3 and 4, which are most often incurable,” Petereit explains. By eliminating the wait time between a cancer diagnosis and seeing an oncologist, patients are presenting with earlier, more curable stages of cancer, he adds. The IHS “The NACP was developed in 1993 as a collaboration between the Navajo, Phoenix and Tucson areas of the IHS, based at the University of Arizona. This program was developed to provide direct cardiovascular care to Native Americans on-site at reservation clinics within the Navajo, Phoenix and Tucson areas as well as to provide tertiary care for complex cardiovascular disease in Tucson,” according to the IHS Web site. The program has since evolved to include the University of Arizona Medical Center, the Flagstaff Medical Center, and the Southern Arizona VA Healthcare System. Through its association with the Sarver Heart Center at the University of Arizona, the services provided to off-site cardiology clinics include real-time telemedicine such as Doppler, 2-D, and color tele-echocardiography as well as dobutamine stress echocardiography, which is overseen in real time from offices in Tucson and Flagstaff, according to the IHS. Culturally Sensitive Healthcare For Native Americans, telemedicine is a nice fit, says Frances Dare, director of Cisco’s Internet Business Solutions Group Global Healthcare consulting practice. “In the Navajo culture, it is customary to not look a person directly in the eye and there are no handshakes. Because of this, telemedicine could be the perfect solution because of its interpersonal nature,” she says. Through the Navajo Nation and Cisco partnership there will be a large network of Navajo dialects to access to provide culturally sensitive care in patients’ own dialects, she adds. In approaching healthcare for Native Americans in a way that is both culturally comfortable for them and clinically comprehensive for Western physicians, telemedicine can be the perfect healthcare delivery method for this population, says Bursell. The Case for Telehealth In 2003, Cisco Systems began working with the Navajo Nation to implement an IP network. In April, the initial implementation was completed which will eventually serve 110 chapter houses in the Navajo Nation. The eventual goal of the Cisco-Navajo partnership is not only to implement a wide array of telehealth services—such as videoconferencing and teleconferencing—but also to “bring the Internet to the Hogan,” a traditional home of the Native American that typically does not have electricity or phone service, according to Dare. With Alaska and the Navajo Nation utilizing telemedicine so extensively, the Alaska Native Tribal Health Consortium and the IHS Southwest Telehealth Consortium are constantly working to refine and improve access within their respective communities. Lawmakers such as Sens John Thune (R-S.D.) and Lisa Murkowski (R-Alaska) convened for the First Annual Summit Improving Native American Health through Telehealth and Emerging Technologies. The summit was considered a success, as there was great interest in improving the quality of healthcare and improving telehealth connectivity on the reservations, says Moorehead, who served as a summit moderator. “This is a niche initiative that will require us to convince the constituency that overcoming technological barriers will improve the quality of life and healthcare for the Native American,” he says. Although this is a niche initiative, according to Moorehead, there are currently two bills in the Senate addressing telehealth and the Native American population. The first, Senate Bill No. 535, or the Native American Connectivity Act, vies to establish grant programs through the Department of Commerce for the development of telecommunications capacities in Indian country. The Indian Health Care Reauthorization Act (Senate Bill No. 1057), part of the Indian Health Care Improvement Fund, authorizes the secretary of Health and Human Services to use funds to meet the healthcare needs of Native Americans, including the use of telehealth and telemedicine. — Kim M. Norton is a freelance writer/journalist. Resources The Navajo Nation www.navajo.org The Indian Health Service
“The IHS and Mayo Clinic share a philosophy of collaboration, open communication, and commitment to respectfully serve the American Indian patient and community needs. The Mayo’s Native American Programs have a long history of working with American Indian and Alaska Native students, physicians, nurses, researchers, tribal communities, and the IHS in a way that respects tribal sovereignty and self-determination,” says Charles W. Grim, DDS, MHSA, director of the IHS. “In treating American Indian and Alaska Native patients, Mayo and the IHS have worked to integrate traditional medicine practices into their care when this has been requested. Mayo’s Native American Programs have complemented the IHS mission and we look forward to this joint effort.” Recognizing that the IHS and Mayo have different resources, functions, roles, and areas of expertise, the IHS and Mayo will work jointly in five areas to improve the health of American Indian and Alaska Native people: • Education and training: Encourage and promote training and education opportunities for American Indian students seeking healthcare careers. • Career opportunities for qualified professionals: Promote career and service opportunities for qualified American Indian and Alaska Native researchers, clinicians, and allied healthcare workers. • Research to address American Indian and Alaska Native health issues: In consultation with the tribes, identify, develop, and execute research to address American Indian and Alaska Native health needs. • Federal and foundation grant contract and funding: Identify appropriate funding resource and support research and service efforts to improve health circumstances. • Cost-effective healthcare and preventive health services for American Indian and Alaska Native communities: Develop greater access to reliable, high-quality healthcare and preventive health services that respond to the identified needs and health profiles of the communities. — Source: Mayo Clinic
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