Telemedicine comes to the American frontier

From the mHealthNews archive
By Eric Wicklund

For the residents of an isolated Native American community perched on 112,870 acres of grassland and desert along the border of Nevada and Utah, healthcare will soon be available at the click of an icon.

The Confederated Tribes of the Goshute Reservation – a couple hundred descendants of the Shoshone-Goship people, who settled the area long before Columbus set foot on American soil – are the latest recipients of telehealth services being arranged by TruClinic, a Salt Lake City-based company that's piloting the service in several locations across the West.

For the Goshutes, whose name is derived from the native word Kutsipiuti, which means "desert people," the reservation is a home and a way of life, a collection of farms a full 70 miles from the nearest town of any size and 200 miles from a good-sized city.

"When I first visited, they had no Internet access of any kind, and (few) had ever seen an iPad," said Justin Kahn, TruClinic's founder and CEO. "Nonetheless, Goshute tribal elders quickly saw the potential for video conferencing to serve the needs of the tribe, and were just as quick on the technology uptake. Now each Goshute household will receive free Internet access for the first year as we roll out the platform."

TruClinic, which launched in Salt Lake City in 2010 as a developer of cloud-based telehealth solutions, is using technology grants from the Utah Governor's Office of Economic Development to bring healthcare to this remote region. A first grant awarded in 2012 linked the tribe to Arnold Thomas, a chaplain and member of the Shoshone-Paiute Tribes who provides mental health counseling to Native Americans across North America. A second grant, awarded in June, is being used to provide free, satellite-based Internet service to all homes on the reservation, thus linking them to the TruClinic telehealth portal.

"TruClinic is the next evolution in effective healthcare delivery," said former U.S. Senator Bob Bennett (R-Utah), who now chairs Bennett Group International and is helping TruClinic expand in both the public and private sectors. "TruClinic's revolutionary technology has made mHealth available to everyone, regardless of location. It extends the reach of healthcare providers, opening up new possibilities for patient engagement and interaction. It is an extension of the brick-and-mortar clinic without the limitations."

Kahn, who grew up in and around VA clinics around the nation, sees the Goshutes as an ideal test-bed for remote telehealth. They're one of 525 confederated Native American tribes in North America, many of which face barriers to healthcare access that range from geographical to cultural to financial.

"Tribal and remote populations get it right away," said Kahn, "but so do urban populations who would rather not spend hours for seven minutes of face-time with their physician. My passion is to provide a service that eliminates as many barriers of entry as possible into telehealth, with the goal (being) to increase all kinds of patient access to care."

"Rather than duplicating the functionality of providers' established practice management systems, we created complementary features that help extend those systems into the mHealth space," he added. "For example, we help patients access their records online and, just as importantly, create personal health records by capturing notes during online consultation and journaling outside of consultation that can later be shared with providers."

For Thomas, a substance abuse and suicide prevention counselor for a number of Native American populations around the country, including the Volunteers of America's Circle of Hope program and inmates in Utah's correctional system, TruClinic offers him a vital link to the Goshute tribe.

"TruClinic has really opened up another door," said Thomas, who has traveled by train, plane and taxi in the past to visit remote tribes throughout North America – a difficult task, because he's blind. "I have always been of the mindset that I needed to be in the same space as the individual. (But) as technology has advanced and as I have also become more comfortable with technology, I have been able to adapt and become more comfortable with offering mHealth to tribal communities."

"With a lot of tribal communities I have consulted with over the years in the U.S. and Canada, I notice that there is a disparity with what type of healthcare is offered," he added. "In very remote regions in both countries, oftentimes with our tribes in the United States, the healthcare the tribes receive is from providers (who) for whatever reason are not the best quality of providers. I know there have been efforts over the years to improve the quality of care in clinics on tribal lands, and that’s where mHealth enables a more robust quality and accessibility of care being delivered to the Goshutes."

Chrissandra Murphy-Bullcreek is an alcohol and drug prevention coordinator for the Confederated Goshute Tribe. She's just starting to use the TruClinic platform. "It's an exciting service for our tribe," she said.

"We live in a remote area – 200 miles from the nearest big city, where most of our counselor/therapists live," she said. "They must travel or we must travel this distance to have the clients meet with the providers. It is really a hardship. An all-day travel and you never know what kind of weather you will run into."

"I would like to see healthcare services such as doctors (who) can diagnose the injury or health problem immediately," she said. "People that work with dialysis patients that can do their own dialysis, helping to make sure that things are done right. Many of our people leave the reservation to be closer to the dialysis centers, or they are transported three times a week over 150 miles one way to a dialysis center – a long day for a sick person.  Also people that work with the health insurance issues. Many times the papers aren't completed or followed up because it wasn't explained right/not understood."

Murphy-Bullcreek pointed out that her father was a "traditional Indian man" who ignored "white man medicine" in favor of traditional healing methods (the only exception being immunizations, which were required for school enrollment). Times have changed, she said, in that most Native Americans now see a doctor or visit a clinic.

"I chuckle when I think about what he would have thought of all this technology," she said.

Kevin Parzych uses TruClinic as a communication tool, connecting with patients who might not be able to get to his Salt Lake City office.

"I find that TruClinic is a more than viable tool to expedite healthcare, especially for my patients that live remotely from me," said Parzych, who's also on TruClinic's advisory board. "I have numerous patients that live more than two hours away, and being able to dialogue fairly quickly with them about issues in facilitating their healthcare is incredibly valuable."

"The limitations of time and space are always difficult to surmount with patients between their busy schedule and mine. Phone calls as well were a surmounting problem as my staff would be the ones who would mostly triage those. Now utilizing TruClinic I can have a quick dialogue with my patient. There is much to be gained with a video call interaction that you would not get over a phone call. I find I provide a better quality of care even in the momentary dialogue than I would have had over the phone or even in a face-to-face."

"There might be some limitations in that we cannot put our hands on the patient, more devices are being created that will support the use of mHealth platforms. Whether Bluetooth-enabled stethoscopes, blood pressure monitors, blood glucose downloads, I believe that the technology is catching up to that. The one limitation is the fact that I cannot place hands on the patient, but we are still face-to-face. There are many cues and subtleties through the patient encounter that can still be transmitted through video as well as data that can be collected electronically. For example when my staff is triaging over the phone, they do not get any of the cues as to the amount of stress a patient is in. When you are having a face-to-face dialogue, again many times there are subtleties of that interview that can be assessed through a video dialogue, rather than just an auditory dialogue.  So, I believe that you can facilitate care much easier this way."

While his work with the Goshutes remains Kahn's pride and joy, it's just one of several partnerships that he's forged for TruClinic. He has separate projects in the works with other Native American tribes and ongoing relationships with a number of physicians and physician groups in and around Utah.

TruClinic got its start with a grant from Utah Valley University in Orem, Utah, where the platform was introduced to the student population through a needs assessment and feasibility study that asked if telehealth services for mental health issues would be willingly accepted and used at UVU's four campuses across the state. TruClinic's latest client is the University of Utah Health Care network, where the portal is being used in a number of clinics. And the company has branched out into hospital networks, physician's offices, clinics and the Native American tribal network.

TruClinic's partnership with University of Utah Health Care was extended this month through a new deal with UUHC's Department of Telemedicine, which will use the TruClinic platform to extend its videoconferencing resources throughout the health system, which encompasses four hospitals, 10 community clinics and several specialty centers.

"This technology … has proven to augment the proper delivery of healthcare," said Robert Preston, an assistant professor in the Department of Surgery at the University of Utah, a full-time intensivist in the surgical intensive care unit and associate director of the Huntsman Cancer Institute intensive care unit. "It is not a substitute for the way we have done medicine for decades – it is a complementary tool. It allows the healthcare we deliver to be more accessible, affordable and efficient."

"I think this technology will not only not get in the way, it will improve the quality of care positively," added John C. Nelson, MD, MPH, a senior advisor at Leavitt Partners and former president of the American Medical Association who serves as TruClinic's chief medical officer. "This technology has the potential to dramatically improve the ability of patients and caregivers to get on the same page for the betterment of the patient. What this is going to do is allow individuals to catalogue the things they do more carefully, to be more accurate about the things they do, to be more complete, have real-time access to their caregivers and have information flow freely between provider and patient."