An emergency room nurse at Lame Deer Health Center turned to a red box on the wall and pushed a button to call for backup.
With that, a silver web camera pointed to the top corner of the room swiveled around and down to look toward the patient’s bed, and a nearby television flickered on to show a woman in scrubs sitting at a desk in Sioux Falls, S.D.
“Avera ER, this is Carol,” the distant nurse answered one recent April morning. She was ready to bring over a doctor to assist with diagnosis and monitoring, or to make calls and do paperwork so on-site staff would not have to leave a patient alone.
The clinic in Lame Deer is the first Indian Health Service facility in the country to bring board-certified specialists into its emergency room via teleconference. The model on the Northern Cheyenne reservation is planned to expand to other reservation health centers in Montana and Wyoming starting early this summer once the Billings-area office finalizes a contract.
The program reflects a broader strategy of the federal agency, which was created to fulfill the United States’ treaty promises to provide health care to more than 560 tribal nations in exchange for ceding most of their land. The Indian Health Service sees telemedicine as a cost-effective way to bring specialists into its hospitals and to fill gaps at rural facilities that often struggle to recruit enough medical professionals to operate at full staff.
“Telemedicine is part of the future,” said Dr. Jonathan Gilbert, clinical director for the Billings-area IHS office. “It’s a fantastic way to bring board-certified specialists to a frontier community and to raise the bar.”
Telemedicine is not new to Montana or the Indian Health Service, but technology improvements, shifting health care demands and new, more permissive laws have spurred increasing use nationwide.
For decades the costs and quality of teleconferencing often were prohibitive, particularly in a medical setting where communication must be clear, secure and reliable.
Among the first telehealth projects was a partnership between the Indian Health Service, NASA and others. From 1972 to 1975, a van packed with medical instruments and equipped with a satellite connected on-site paramedics with specialist doctors at a distant hospital using a two-way microwave radio transmission. In the early 1990s, several federal programs offered grants for hospitals to research telemedicine or to pay for the needed connectivity improvements in rural areas.
By the early 2000s, the Indian Health Service began rolling out telemedicine specialty programs and support services for some of its hospitals that are still used today. Echocardiograms, X-Rays and retinal images could be sent from isolated communities to specialists in the Phoenix-area office to be interpreted, reducing or eliminating the need to pay for those staff locally.
In 2009, the agency received $85 million to improve electronic and telehealth capabilities, including the purchase of several video conferencing units that cost more than $15,000 each.
“Nowadays, other solutions are available that are software-based and can be used on existing computers, so with a nice web camera for $80 we can lower that cost bar to maybe $100,” said Dr. Chris Fore, director of the IHS TeleBehavioral Health Center of Excellence, remarking on the pace of technological innovation. 'We’re spending hundreds instead of thousands."
Some technical challenges remain.
Unlike a Skype chat with distant relatives, doctors must be certain their digital communications are secure enough to transmit confidential patient information. File transfers became easier once federal law required hospitals to implement electronic patient records, variations of which had been tested years earlier at some IHS facilities. Services that require video conferencing, such as psychiatric appointments, must have reliable Internet connections with sufficient bandwidth. Those improvements can be costly for rural reservations like those in Montana, but Fore, a clinical psychologist, said it is a quality benchmark that should not be compromised.
“You don’t want to be in the middle of a patient disclosing a sensitive, painful event and have the connection drop,” he said.
Additionally, many hospitals delayed implementation of telehealth technologies because it is more difficult or impossible to bill for those services as is done for the same treatments provided in-person. Twenty states still do not have parity laws that outline rules for billing telehealth services, according to the American Telemedicine Association. Montana passed its law only three years ago.
Although the ability to bill insurance will help reduce program costs paid with federal funding, the Indian Health Service must provide care regardless of whether a patient has insurance. For decades, critics have argued that Congress has shortchanged the system, leading some IHS hospitals to limit services, prioritize referrals or delay care that would be routine in private hospitals.
Federal leaders spend less per capita to fulfill treaty promises for Indian health care than they appropriate for patients accessing care through Medicare, Medicaid, veterans’ programs or serving time in federal prisons, according to a periodic review of federal records by the National Congress for American Indians. In 2012, the latest year available across all programs, Congress spent an average of $2,896 per capita on IHS patients compared to $12,042 for Medicare and $6,206 for Medicaid. And that level is nearly double the amount that had been spent before a series of increases advocated by President Barack Obama and approved by Congress.
Telemedicine has been one way local IHS leaders can stretch their funding. But first, the money must be available for the initial investment.
"The truth is I don't know if they have the resources to set it up (in more facilities)," said Sen. Jon Tester, the Montana Democrat who serves as vice chair of the Indian Affairs Committee. "I see plenty of examples where it's used in rural hospitals, in emergency rooms, used in the VA for mental health treatment and they're very successful, but you've got to have the infrastructure to support it. You've got to have the fiber going in and then you've got to have the people to do it and you've got to pay for the training on how to use it. All of that costs money. But it's a one-time expense."
Some telemedicine programs are in-house at the federal agency. Others operate through private contracts or partnerships with medical schools. Although in-house programs tend to operate more cheaply than contractors, Fore said all provide cost savings for participating clinics by leveraging regional wage differences and economies of scale.
Federal payroll records show that the Indian Health Service pays most physicians – from ER doctors to cardiologists – about $200,000 a year. Those salaries quickly eat up local operating funds at IHS hospitals and clinics even though they tend to be less than private sector pay.
Retina examined remotely
A health tech, paid a fraction of the salary of an ophthalmologist, sat next to a blue-and-white retinal scanner tucked in the corner of a small room at the Crow-Northern Cheyenne Hospital in Crow Agency recently. Dr. Lynelle Noisy Hawk, the hospital’s clinical director and a patient, sat in front of the blue-and-white scanner for an eye exam that is part of the facility’s comprehensive diabetes screening. The tech pushed a button and the $85,000 machine hummed louder and louder as it warmed up.
As Noisy Hawk pressed her face against the scanner, the tech touched the screen to take an orange-hued photo of blood vessels snaking through the back of the eye’s light-sensitive retina. The blood vessels here are the smallest in the body, making them the first place doctors can identify diabetic complications such as a loss of vision or hypertension. Although Noisy Hawk herself doesn’t have diabetes, she said she is considered high-risk for developing the condition because of her family health history.
“All right, lean back,” the tech directed Noisy Hawk as they finished the four-minute exam. “I’m going to send these images down to our national reading center. From there an ophthalmologist will look at it to grade it for a specific level of diabetic retinopathy. From there, a follow up will be recommended.”
That small crew of ophthalmologists at a Phoenix IHS office providing advice to local physicians and optometrists saves participating hospitals the cost of those specialty salaries.
Noisy Hawk said the technology also has made it easier to examine more patients by adding a quick scan to any visit rather than having to schedule around a doctor. Although the program is only available at about half of the agency’s facilities, internal statistics show a 20 percent increase in the rate of exams conducted nationwide since 2007.
In nearby Lame Deer, the contract with Avera Health for its teleER services costs about $72,000 a year, which is cheaper than hiring emergency medicine physicians. Nursing Director Mardell Nichols, who spearheaded the program, said it also helps solve another persistent challenge: recruitment and retention.
“The challenge with rural health care is you’re not going to find a board-certified ER doctor or emergency family practitioner to work in your ER,” Nichols said.
Rural facilities in particular struggle to recruit doctors as the number of primary care providers plummets and pay surges for those in specialty fields. If they do hire someone skilled, it is often not long before neighboring urban hospitals offer them a raise.
The next site expected to launch a teleER like the one in Lame Deer is the Blackfeet Community Hospital in Browning. CEO Dee Hutchison said the facility has struggled to bring emergency-medicine doctors to the small Hi-Line community, forcing family practitioners to take extra rotations through the ER that reduce their availability for primary care patients.
Fore said that while the cost efficiencies are critical in a cash-strapped system, the primary driver behind IHS' telehealth programs are to increase access to specialties that improve the quality of care.
“Discussions about telemedicine really have changed,” Fore said. “It used to be at conferences that we’d ask, ‘Is telehealth effective? Is it as good?’ Now, the research shows that, in some cases, it may be better than in person.”
Mental health care
Fore said some advantages of telemedicine can be surprising, listing examples from his experience with the agency’s psychiatry program.
Patients travel to the same hospitals for a counseling appointment whether it is in-person or by video conference, yet they are 2½ times less likely to skip a teleconference session, according to internal data from 2012. Likewise, initial internal reviews and anecdotal evidence suggest that the physical distance helps patients open up about difficult experiences more quickly than if they received therapy in-person, potentially speeding up treatment progress.
“Many tribal communities are small, insular, everybody knows everything going on,” Fore said of the program used at Fort Peck Indian Reservation, among others. “Patients have told us they like that they won’t see their provider at a gas station or at Wal-Mart. There’s a feeling that it’s more confidential.”
Nathan Moyer, nurse ER director at Crow-Northern Cheyenne Hospital, said he is excited about the possibility of the teleER program coming to the Crow Agency facility.
“Weird stuff happens that you don’t know what to do about. Having the ability to do a quick video consult with a specialist and ask, 'How do you manage this?'" he said. “We don’t have a lot of resources at three o’clock in the morning. When we have a multi-trauma come in, it would be great to have another set of eyes to take a look at your patient or monitor their vital signs. Simple things where you can free somebody up for 5 minutes to care for someone else.”
Even when an ambulance arrives with seriously wounded patients, Nichols agreed that it helps to have a doctor available at the push of a button to issue lifesaving medical orders.
“We have a doctor on call at night, but he’s 30 miles away,” she said, noting that delaying care even minutes can matter. “It’s a safety net for sure.”