“We have a telemedicine cart: a physical cart [at more than 200 health clinics throughout the state] that may contain up to thirteen medical devices,” Ferguson says. He explains these carts may have digital cameras, an otoscope (to take images of the eardrum), a tympanometer (to measure flexibility and pressure on the eardrum), a dental camera, an audiometer (for hearing tests), an EKG, and a number of other devices, noting that Alaska historically has one of highest rates of ear disease in the world. “Every one of these devices goes through a thorough review so we can make sure we get the right devices.”

When testing out these devices for telehealth uses, the TTAC team considers diagnostic effectiveness, durability, reliability, ease of use, and price.

“It’s best when it’s easy to use, as that simplifies the training at the many sites throughout Alaska. And it has to be reliable because, if it breaks, it’s very expensive to get out to a village to replace or fix it,” Ferguson says. “We work months at a time to review devices before we’ll pick one that we will buy in large volume and deploy throughout Alaska.”

Due to increased demand from the pandemic, one of the most significant advancements in telemedicine is a shift toward providing significant telehealth services not only in clinics and hospitals but also in patients’ homes.

ANTHC and the Alaska Tribal Health System was an early adopter of telehealth, getting on board with the system in the ’90s.

“That was not live audio or video. We did not have sufficient bandwidth to support that. We relied initially on ‘store-and-forward’ telehealth. You can think of it as a kind of email or texting kind of concept. We’ve done that for twenty years, and we’ve done almost half a million encounters,” Ferguson says.

In 2013, the Alaska Tribal Health System moved toward a statewide video conferencing-based telehealth system, providing live audio and video visits in clinics. However, it was the COVID-19 pandemic that escalated the move from offering telehealth services in regional and local facilities into patient homes.

ANTHC went from having zero in-home consultations in February and March to about 6,000 a month starting in April, Ferguson says.

“That’s just ANTHC. Statewide, the Alaska Tribal Health System is doing many thousands of telehealth visits directly into patient homes every month,” Ferguson says.

“We’re able to manage the care of the patients in many ways without them having to come back into our facilities. There are many organizations, ours included, that have invested significantly in the technology. This was not something that we just flipped the switch and did easily. We had to find and purchase the right technology—the platforms that we use for this—through rigorous testing and evaluation with our partners, and we listened to our patients.”

TTAC’s rapid review of teleconference solutions on the marketplace in the wake of the pandemic resulted in the company’s preference for a now household name: Zoom.

Zoom was “definitely better” when it came to managing the connectivity challenges associated with satellite-based communication, as well as providing the best possible image and audio file transfers for the fewest number of bytes, Ferguson says.

“You have the situation where people that have cell plans in the villages are sometimes limited by the number of bytes per month they can use before they get into overcharges or slowdowns,” Ferguson notes.

ANTHC is also using telehealth to better support care for mental health services.

“With the increased stress and challenges COVID has brought us, ANTHC has re-tooled their Crisis Incident Stress Management (CISM) team to deliver services via telehealth. With support from the Substance Abuse Mental Health Services Administration, ANTHC has launched treatment recovery interventions [called TRIAGE COVID-19] to address gaps escalated by COVID-19,” ANTHC Director of Behavioral Health Dr. Cody Chipp says.

“TRIAGE offers a call line to provide on-demand brief support and links individuals to care with an ANTHC CISM team member, a behavioral health provider in their own community, or with other behavioral health providers, all via telehealth,” Chipp says.

“To date, we’ve received approximately 200 calls, with about 50 calls needing additional support beyond the initial connection. We are excited to continue this work to support our communities statewide during these challenging times.”

Providence is supporting another effective form of telemedicine—in the ICU.

ICU telemedicine allows small hospitals with limited capacity in their critical care unit to work with an organization with high-end ICU specialists who can monitor patient health remotely. Such systems allow staff to potentially intervene earlier if needed and to make decisions if the patient has to be transferred to the next level of care.

The Providence Alaska Medical Center adopted ICU telemedicine about a decade ago.

“Healthcare organizations are large sophisticated organizations, so they’ll evaluate technology, processes, equipment, programs, services, just like any other, where you go through a clinical and business evaluation,” says Preston Simmons, chief executive for Providence Health & Services Alaska.

Clinical evaluation reviews establish equipment performance, determining if the technology makes a difference, is a more effective substitute for something that already exists, or creates better value.

“When you look at those aspects from a patient lens: Is it going to provide value to the patient? Is it going to improve outcomes for quality of life… their daily living requirements?” Simmons asks. “Then you also have to look at it from a business standpoint as an organization: Is it cost-effective?”

Residents living beyond well-equipped, urban hubs rely more heavily on community-based hospitals or critical access hospitals, which are often connected to one of the larger healthcare providers in the state.

“In Anchorage, in terms of technology, we have [almost] anything the Lower 48 has,” Simmons says, pointing toward Providence’s advanced CyberKnife system, infusion therapy, and linear accelerators used at the Providence Cancer Center.

“CyberKnife is a pretty rare type of technology. You might have one of those in Seattle or [other places in] Washington State, for example. We really try to make sure that the care and technology that’s needed for… neurosciences, cancer, heart disease, orthopedics… are provided in the Anchorage community and elsewhere.”

Providing technology that is economically viable in Anchorage or in more remote parts of the state boils down to affordability, which often has to do with population health size, Simmons says.

“As you can imagine, in a market in the Lower 48, you might have millions of people that support a certain type of technology. Here, you have a much smaller population, so it is more expensive to have those technologies up here,” Simmons says. “There is a balance of having a certain type of technology… and having to spread that cost over a smaller population. But you really need it, because it’s a 1,500-mile flight from Anchorage down into another population center that might have those types of technologies. We have to have them just to be able to support the trauma and those needs.”

Because of the need to balance cost of care and care provided within the state, there are some devices and systems that don’t make sense to maintain in Alaska, such as a cyclotron—a high-tech device used for imaging procedures, Simmons explains.

“We try to keep as much care locally as possible—that’s important. We have the only children’s hospital in the state and that is heavily, heavily subsidized, because we have all these sub-specialists, which typically take millions of population to support,” Simmons says. “We don’t have that, but it’s the right thing to do for the children of Alaska. So, we have very sophisticated newborn intensive care units, transport systems, subspecialties, and those types of things. The care provided is commensurate with things you would get down in major children’s hospitals.”

In addition to many of the advanced—and heavily subsidized—technologies Providence offers in Anchorage, Simmons recognizes the vital importance of telehealth in Alaska.

He says there’s been a long-term investment in telehealth, and funding is really “ramping up.” Part of this digital revolution within healthcare services are technological systems that perhaps are not as flashy as a CyberKnife but more ubiquitously vital—record keeping.

“Traditionally, healthcare has been very acute centric, meaning that a lot of healthcare in many communities is wrapped around the hospital, and everything becomes kind of siloed… what we’re moving to at Providence, overall, is something we’re calling Healthcare 2.0,” Simmons says.

Healthcare 2.0 is a system of care perspective that digitally enables patients and providers to connect throughout the entire lifecycle of the patient. The multi-million dollar medical record system at the Providence enterprise level connects about 20 million patients and providers across seven states.

“We’re actually creating innovations and developing digital applications in partnership with large tech companies, as well as smaller tech companies, and bringing those to market relatively quickly,” Simmons says.

A major benefit of digital systems is the ability to create integrated care pathways.

“What Twistle does, for example, as an automated, high-engagement platform, is it guides the patient through episodes of care,” Simmons says. “It really helps the recovery protocol for patients through education reminders messaging; all of it is HIPAA compliant.”

Pilot projects testing Twistle, run by Providence, saw a 16.5 percent reduction in overall complications from spinal surgery, a 5 percent reduction in length of stay, more than a 22 percent reduction in appointment cancellations, and a 7 percent increase in satisfaction rates compared to patients who don’t use the application.

“There was a 26 percent reduction in patient calls to the clinic, meaning that they were less confused because they had the information they need,” Simmons says.

Providence has also been investing heavily in building virtual care platforms, such as Providence Express Care, which was rolled out in Alaska last year.

The platform works as a substitution for situations where patients were going to the emergency room for issues that are not considered medical emergencies.

“They’re a higher-touch, lower-cost way for patients to get access to primary care,” Simmons says.

Without insurance, the cost of an Express Care visit is $149, while an Express Care Virtual visit is $49 dollars, Simmons says.

“The Express Care Virtual visit you can do on your cell phone. The physician can prescribe medicine… they can look at your throat and those types of things—it’s pretty impressive,” Simmons says, noting that there was a surge in Express Care Virtual appointments during the COVID-19 pandemic.

In Anchorage three Express Care facilities were transformed into Express Care Virtual.

“It decompressed our emergency department, helped prevent the spread of COVID, and it literally transformed care very rapidly because of the technology innovations that we have made,” Simmons says.

Within a two-week period, the Providence system converted to virtual care platforms for about 8,000 physicians in seven states so they could provide Zoom consultations for their patients, many of whom are expected to permanently adopt the high-touch, virtual experience.

“Those are technology investments in terms of virtual care that we, because of the historical investments we made, were able to turn over and respond to COVID, which now will make a permanent change in terms of how healthcare is provided for years into the future,” Simmons says.

“Those types of advancements in Alaska will be very important to continue to keep care local and do telehealth advancements into the small communities through telecenters, tele-behavioural health, and tele-ICUs… It creates better patient satisfaction and value by creating access to care and capacity at a much lower cost.”