Telehealth and Indian Healthcare: Moving to Scale and Sustainability

Introduction

An operational division of the Department of Health and Human Services, the Indian Health Service (IHS) provides comprehensive healthcare for 2.0 million American Indian and Alaska Natives from 566 federally recognized Tribes. Partnership with Tribes is vital to service delivery and health advocacy; a growing percentage of service operations are administered and governed by Tribes and Native corporations. Through a network of more than 600 facilities located in 35 states, IHS and Tribal partners deliver 12.7 million outpatient visits, 3.7 million dental visits, and 48,000 admissions annually. ¹ Most Indian health facilities are ambulatory and are located in rural and remote communities. All IHS-governed hospitals are accredited by the Joint Commission.

Telehealth and Indian Health

There is a long history of telehealth innovation in Indian health. For example, the National Aeronautics and Space Administration's Space Technology Applied to Rural Papago Advanced Healthcare program represented one of the first telemedicine collaborations for remote and mobile primary care service delivery in the United States. Services were provided from 1973 to 1975. In the decades that followed, the use of telehealth in Indian health fluctuated, mirroring general trends in U.S. healthcare delivery. Over the past 15 years, the use of telehealth has grown significantly. Today, telehealth tools support a diverse range of services for American Indian and Alaska Native communities, including direct care, specialist consultation, image interpretation, and care coordination. This expanding experience catalyzes change in access and quality for Indian healthcare. It also informs strategic planning activities and service development, bringing a vital perspective on innovative care models designed to improve access, quality, and value in healthcare delivery for American Indians and Alaska Natives.

Just as the type of telehealth innovation is varied, so is the scale of that innovation's use. Select programs and services have demonstrated successful diffusion. Examples include the IHS Joslin Vision Network Tele-Ophthalmology Program and the Alaska Federal Healthcare Access Network. But many other types of telehealth innovation have not experienced similar growth or expansion. Indeed, despite important service development in direct care and consultation via telehealth for clinical disciplines such as nephrology, cardiology, and nutrition, most telehealth innovations in Indian healthcare remain local or regional in nature.

Challenges to Diffusion

The challenges to the diffusion of telehealth are not unique to Indian healthcare. Uneven implementation of telehealth capability across U.S. healthcare is more the rule than the exception. Telecommunication infrastructure, business processes, and operational uncertainties—similar obstacles to sustained telehealth use and spread—confront many healthcare organizations. However, the relative impact of such obstacles, even in rural environments, is evolving. Whereas telecommunications (e.g., the “digital divide”) and operational barriers (e.g., credentialing and privileging) once offered the most significant hurdles for further development of this field, now business and care model challenges rank highest. This is not to diminish the difficulty that some rural and underserved communities still experience in accessing broadband service, technology infrastructure, and timely support; work on critical infrastructure in many communities and geographies must continue. But the primary challenges facing scale and sustainability are now different than they were a decade ago. Enhanced alignments among technology, care models, and reimbursement policy are increasingly critical to effective telehealth integration and diffusion.

Nephrology offers an important example. Although many Native Americans experience kidney disease, there are few nephrologists working in or near Indian communities who can provide timely and culturally sensitive consultation. Telehealth becomes meaningful for patients and care teams when such consultation is consistently available. This has been the experience at the Zuni Indian Hospital in New Mexico. For many years, an IHS-employed nephrologist stationed in the region provided on-site care. When the nephrologist accepted a position in another agency, continued consultative service for Zuni Indian Hospital care teams was possible only through videoconferencing. The value of the nephrologist's ongoing expertise has been readily understood by patients, families, and local primary care clinicians. Nonetheless, absent facilitating change in reimbursement policy, it has not been possible to replicate that model across Indian healthcare. From the patient perspective, the ready availability of a nephrologist and a care team via telehealth technology is very significant. From the system perspective, this availability cannot be effectively expanded without payment for those services.

To be sure, there are additional factors affecting the diffusion of telehealth. The healthcare ecosystem is complex. “One size does not fit all” for the various types of telehealth innovations available. Business and operational practices vital for improved care coordination of chronic conditions (e.g., congestive heart failure) are quite different for those that support videoconferencing-based direct service (e.g., psychiatry) and store-and-forward specialist consultation (e.g., dermatology). Each may bring measurable value for patient access to quality care. But each also brings specific change requirements to operational and financial processes that must be addressed before sustainability can occur.

Many forces and needs compete for attention. Consequently, it is no simple task for leadership of rural facilities to prioritize the focus of scarce human and organizational resources. Electronic health record implementation, meaningful use, health information exchange—an important array of information technology activities and requirements detract from the agenda of change that telehealth innovation brings. There is no obvious roadmap for moving forward with the diverse types of care model development that telehealth tools enable. Importantly, the destination is sometimes poorly described.

Systems resist change. The steady yet slow expansion of the IHS Joslin Vision Network Tele-Ophthalmology Program demonstrates that improved access and quality, even in the setting of adequate funding, do not necessarily lead to rapid adoption. Over a decade, the program has provided over 67,000 diagnostic eye screenings in a primary care setting for diabetic patients who otherwise might not have received such care. Still, the national screening rate for diabetic retinopathy in Indian healthcare has significant room for improvement. Eighty-five Indian health facilities in 23 states offer tele-ophthalmology services. Despite program expansion, the norm across Indian healthcare for retinopathy evaluation remains in-person assessment in an eye clinic. A critical threshold of change has yet to be crossed.

“Brute force”—the approach to innovation of just "making it happen"—is both unwise and unhelpful. Innovation does not occur in a vacuum. It is a means to an end. The goal is not more telehealth. Instead, the goal is an improved, efficient, and equitable healthcare delivery system. To reach that goal, sustainable telehealth implementation requires substantive care model redesign. If the care models do not evolve, then telehealth innovation cannot thrive.

Form should follow function. The mission of the IHS is to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level. How can telehealth innovation contribute to this? Can it help reduce the burden of diabetes, heart disease, and other conditions for Tribal people? Can it do so within financially sound care models? These questions must be answered convincingly before telehealth innovation will see widespread acceptance and use.

Sustainability

Because Indian health hospital and clinic operating budgets rely heavily on reimbursement from public and private insurance payers, business models for IHS and Tribal facilities more closely resemble those of the private sector than they do other federal agencies or departments. Many observers outside Indian healthcare mistakenly believe that healthcare for American Indians and Alaska Natives occurs within a single “closed” system. Dependence on third-party reimbursement, along with expanding Tribal self-governance and growing public–private sector partnerships, demonstrates that it does not. Similar to private sector budgets, cost avoidance for Indian health facilities often accrues to insurance carriers, not healthcare facility budgets. Differing information systems, nonuniform reporting requirements, and dependence on patchwork state Medicaid reimbursement policy all fragment efforts to develop standardized systems of care that facilitate the adoption of innovation for Tribal communities.

Despite the challenges, the future for innovation diffusion in Indian health is bright. Vital lessons have been learned from collaborations within Indian healthcare as well as those with non-Indian health organizations. To move forward, three key areas of focus have been identified: new service models, creative partnerships, and commitment to change. The importance of care model change cannot be overemphasized. But care model change will not occur without new types of collaboration. Demographic and performance forces buffet delivery systems such that stable system change cannot occur without the ballast of partnership. Once established, partnership must receive steadfast support. Rural facilities should not be distracted from the path of change, as sustainable specialty service in many communities is impossible without a firm commitment to new clinical and business processes. For example, impulsive local hiring of the occasional specialist or clinician for a hard-to-fill clinical vacancy only hampers efforts to establish sustainable care models across a region. The path forward must be clearly defined and proactively protected. Mixing service and staffing methodologies from different delivery eras will halt spread.

Finally, context—at the national level—cannot be ignored. National reimbursement policy can accelerate care model change. There may be no better way to stimulate access to quality care for Native American communities than to expand telemedicine reimbursement policy for culturally sensitive service to those communities. Such policy will do more than stimulate innovation within Indian healthcare. It will also provide a vital opportunity for evaluation of policy change for all underserved communities. National study of the clinical and financial impact of expanded telehealth reimbursement within Indian healthcare will provide invaluable data regarding healthcare utilization, cost, and population health, data that may otherwise be unavailable from smaller tests of reimbursement policy change. Such an evaluation will inform further policy considerations, highlighting key opportunities for permanent policy change and additional study.

The spread and sustainability of telehealth innovation within Indian health depend on our collective commitment to change. The current path of change is being worn through incremental improvements in care models and collaborations. Not surprisingly, progress along that change path has been slow. The time has come for a new perspective. National policy change supporting the integration of telehealth innovation within new models of effective and efficient quality care is a necessary part of that new perspective.