Place-based continuing medical education in the rural North

The role of Internet and telemedicine infrastructure in Alaskan heath professional training

Lucas Trout, Tanya Kirk, Mark Erickson, MD & Arthur Kleinman, MD

Alaska Native leaders, community organizations, and health care partners have worked diligently to shape a future of equal health in rural Alaska Native communities (Sherry, 2004). These efforts include training innovations for rural health professionals to improve care quality, and cultural safety (Cueva et al., 2018; Trout et al., 2018). A promising model for accomplishing the triple aim of increasing the advancement of Alaska Native people in the health professions, accelerating the adoption of both best practices and cultural knowledge in clinical care, and reducing costs associated with high turnover and attrition is to capitalize on established Internet and telemedicine infrastructure to deliver place-based health professions education in rural and remote communities.

This article details an initiative designed to mobilize improved Internet connectivity and telemedicine systems to deliver quality Continuing Medical Education (CME) for rural Alaska’s primary care workforce. Partners at Maniilaq Social Medicine, Harvard Medical School, and Massachusetts General Hospital have completed a first year of programming under the education collaborative Northern Primary, connecting approximately 110 rural Alaska health workers, clinical partners, and affiliated trainees with faculty including national rural health experts, community stakeholders, and tribal leadership. By providing high-quality, practice-relevant, and community-based Continuing Medical Education for rural Alaska’s primary care workforce, Northern Primary aims to improve care quality, cultural safety, and health worker retention in rural and remote communities. Program design, technology, and future directions are discussed.

History of health telecommunications in rural Alaska
The history of telecommunications infrastructure in Alaska is densely interwoven with the advancement of medicine and public health practice, although the technology has been cast in varied, sometimes contradictory roles. In the context of decades of expressly assimilationist tactics employed by federal stakeholders, questions of adopting new technologies have fueled debate over the sovereignty, cultural life, and self-reliance of Alaska Native communities (Lanzarotta & Greene, 2017). At the same time, the languages of economic development, education, and improved health have been employed to narrate shifts in technology, from energy and transportation to health care and social services (Lanzarotta & Greene, 2017).

Rural Alaska’s primary care system sits close to the heart of this tension. Taking stock of community resistance to the displacement and hospitalization of Alaska Natives in the 1950s during Alaska’s tuberculosis epidemic, U.S. public health officials recalibrated with an ambulatory tuberculosis chemotherapy program in which Alaska Native community health workers provided care with the support of traveling Western nurses (Fortuine, 2005). The success of this program led many to champion the use of local health workers to deliver community-based care (Lee, 1971). However, limited communications infrastructure presented a barrier to the clinical oversight of community health workers, a concern fostered by an increased focus on standardization and quality controls in the rapidly advancing world of clinical medicine (Goodwin & Tobler, 2008).

The backbone of Alaska’s tribal health system is effective primary care delivery – and the backbone of primary care is the Community Health Aide-provider partnership.

Within this context, NASA pioneered the use of satellite technology connecting rural villages to physicians in hub communities, beginning in 1966 (Patricoski, 2004). Physician-to-community health worker communication became the basis for the federal authorization and expansion of the Community Health Aide Program in 1968, with efforts significantly bolstered over time by evolving satellite technology, increased government investment in rural U.S. communications infrastructure, and the embrace of health-promoting communications tools in village communities (Lanzarotta & Greene, 2017). As these programs scaled and evolved between 1950 and 1980, life expectancy for Alaska Natives grew by 20 years (Alaska Health Facts, 1991). Today, Community Health Aides/Practitioners serve as the frontlines of rural Alaska primary care, with an estimated quarter million annual patient encounters across 180 rural Alaska communities (Golnick et al., 2012).

Moving from open radio traffic to closed communications featuring audio, and later Internet-facilitated video in the mid-1990s, rural Alaska health care became a function of increasingly networked village clinics and hospitals (Patricoski, 2004). This presented an opportunity to improve the accessibility and quality of care for remote patients, as well as an apparently viable funding strategy for the Indian Health Service. However, some feared that increasingly robust telemedicine systems would create negative dependency on untrusted, distant partners, while others posited that it would disincentivize the recruitment of highly skilled health professionals to rural and remote communities (Lanzarotta & Greene, 2017). Nevertheless, the clear benefits of immediate health care access from some of the remotest locations in the United States, facing some of its most severe health disparities, resulted in the continued growth of Alaska’s telemedicine programs (Sequist, Cullen, & Acton, 2011). Through multiple state- and federally-subsidized expansion projects, Internet-facilitated telemedicine – partnering CHA/Ps, regional providers, and specialists at tertiary care centres – became an important feature of Alaska’s tribal health system (Sequist, Cullen, & Acton, 2011).

Importantly, these technologies may reduce pressure to invest in local health and social services infrastructure, diminishing the apparent need to recruit and train local people with the desire to practice in their own communities and creating continued reliance on remote care (Lanzarotta & Greene, 2017). In this postcolonial context, the cultural safety of care systems may suffer as a result (Trout et al., 2018). Finally, telemedicine may create practice frameworks that rely on rapid escalation of care – resulting in primary care health workers assuming less responsibility for care, and fragmenting the local patient-provider relationship. Within this framework, it becomes challenging, as a rural primary care provider, to maintain a broad and well-practiced skillset to address a wide range of issues for which best practices are rapidly evolving. In the end, of course, the local care team is responsible for managing complexity in times of crisis – highlighting the importance of a strong workforce on the physical frontlines of primary care.

Building Northwest Alaska’s continuing medical education infrastructure
Even as connectivity grows, rural Alaska will require a versatile and well-trained primary care workforce. We contend that precisely those technologies developed to shift care to telemedicine systems can be used to increase the quality, cultural safety, and continuity of care delivered by, in, and for rural Alaska Native communities. The remainder of this article details the pilot year of Northern Primary, an education collaborative established by faculty partners at Maniilaq Social Medicine, Harvard Medical School, and Massachusetts General Hospital.

Rural Alaska care context, today
Today, Alaska’s unique tribal health system continues to draw upon primary care professionals to deliver an exceptional breadth of care in rural and remote communities with limited access to specialty care and an enduring legacy of health and health care disparities. Across 180 rural Alaska Native communities, networks of village clinics and regional hub hospitals serve approximately 90,000 patients, with a large tertiary care centre, Alaska Native Medical Center, in Anchorage (Sherry, 2004). Defined service areas fall under tribally-governed regional nonprofit health corporations that administer health and social services under contracts with the Indian Health Service, the federal agency responsible for providing health services to all American Indians and Alaska Natives (Sherry, 2004).

Village clinics are staffed primarily by Community Health Aides/Practitioners (CHA/Ps) and their counterparts in dental therapy and behavioral health – community health professionals with varying degrees of training that define a broad and graded scope of practice. CHA/Ps collaborate with mid-level providers and physicians at regional hospitals to perform assessments and provide basic primary, preventive, and emergency care. Typically, hub hospitals are the sole regional providers of physician-delivered primary, emergency, and dental care. With most communities not connected by roads to each other or to the rest of the state, referrals to regional health centres or tertiary care require expensive and complex air transport. Within this context, the backbone of Alaska’s tribal health system is effective primary care delivery – and the backbone of primary care is the Community Health Aide-provider partnership.

Program rationale
To improve access to culturally-safe, best-practice care, rural health organizations can leverage existing telemedicine infrastructure to link local health workers to subject matter experts via multi-point videoconference (Komaromy et al., 2016). The use of distance learning via Internet and telemedicine infrastructure has several clear benefits, including accommodation of remote location, financial hardship, and chronic understaffing at rural health centres and in village clinics; the ability to train-in-place local health workers whose life circumstances limit availability to travel; and the capacity to integrate continuing education into the daily rhythms of clinical care.

Partners
Northern Primary is an education collaborative connecting partners in Alaska’s tribal health system with faculty at Harvard Medical School, Massachusetts General Hospital, and Maniilaq Social Medicine. This collaborative produced two courses running from October 2017 until September 2018, with additional programming beginning in October 2018. Continuing medical education credits were awarded through a partner academic health system. The aim of each program is to improve care quality and cultural safety by addressing areas of concern identified by caregivers, tribal leadership, and community members. Each program is outlined below.

Project ECHO
Project ECHO Alaska is a case-based clinical education program directed at building capacity among rural primary care providers to deliver best practice care for common, complex conditions in community health care settings. The model, developed by Dr. Sanjeev Arora, links clinicians with expert teams through videoconference-based clinics, in which both traditional lectures and case presentations are used to support clinical mentorship, guided and reflective practice, and practical gains in knowledge (Arora et al., 2007). The 2017-2018 ECHO program, with clinics taking place monthly over the course of the year, focused on psychiatry and addiction medicine with a particular emphasis on culture, resilience, and social determinants of mental health. Participants included nurses, case managers, physicians, mid-level providers, CHA/Ps, Behavioral Health Aids (BHAs), mental health counselors, trainees at affiliated programs at Harvard Medical School and Massachusetts General Hospital, and other rural Alaska health workers throughout the state. The core faculty included an Alaskan clinical psychiatrist (Mark Erickson), a medical anthropologist and psychiatrist (Arthur Kleinman), and a local community health worker (Tanya Kirk).

Social medicine grand rounds
Social medicine grand rounds bring together hospital and village clinic-based care teams, social and tribal service workers, and community members to study and apply social medicine perspectives to health care delivery (Trout et al., 2018). The model uses a case-based curriculum to drive clinical-community collaboration and critical analysis of health care delivery challenges focused on four broad priority areas established by tribal leadership: maternal and child health, chronic disease, mental health, and infectious disease. Using telemedicine systems, videoconference software, and clinic spaces, grand rounds serve to build interprofessional communities of practice for learning, deliberation, and action on social determinants of health in Northwest Alaska and at academic partner sites. Faculty during the year-long pilot included content area experts in local tribal governments and at the WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho) School of Medical Education, Harvard Medical School, Massachusetts General Hospital, and Maniilaq Association.

Northern Primary is one example of many that highlights the application of Internet and telemedicine infrastructure to build local health care delivery capacity.

Next steps
These two programs reached approximately 110 rural Alaska health workers, clinical partners, and affiliated trainees in 2017-2018. To scale the effort, Northern Primary will begin offering courses through a web-based learning platform, in Fall 2018. This will allow time-flexible engagement with learning materials including formal courses, brief practice updates, and research and policy reviews designed for Northern caregivers. Northern Primary courses can be found at www.northernprimary.org.

Conclusion
Northern Primary is one example of many that highlights the application of Internet and telemedicine infrastructure to build local health care delivery capacity. This technology has historically been underutilized to deliver education to existing and aspirational health professionals. We believe that the future of rural Alaska primary care is best served through a combination of increased recruitment of local health professionals, robust training infrastructure for rural providers, and the use of telemedicine systems to deliver distance care, case consultation, and clinical education. Within this framework, health workers can be supported in working at the top of their licence with both increased knowledge of the communities and patients they serve, and increased capacity to manage medical complexity. The benefits of telemedicine – centralized, standardized, and relatively low-cost care systems – can be counterbalanced by the local context, relationships, and continuity of well-trained primary care teams on the frontlines of care. ◉

Lucas Trout is Social Medicine Program Manager at Maniilaq Association and Lecturer on Global Health and Social Medicine at Harvard Medical School. He directs the Northern Primary collaborative, which can be found at www.northernprimary.org.

Tanya Kirk is Native Connections coordinator at Maniilaq Association and chair of the board’s social services committee. She has dedicated the past two decades to improving health care and social services for rural Alaskans. Tanya holds her Inupiaq culture and subsistence lifestyle central to her identity and work in mental health and prevention. She lives in Noatak, AK.

Mark Erickson is a practicing psychiatrist at Maniilaq Association. His work has spanned from San Francisco General Hospital to the Alaska Psychiatric Institute, Southcentral Foundation in Anchorage, and for the State of Alaska in rural mental health/tele-psychiatry.
Arthur Kleinman is Esther and Sidney Rabb professor of anthropology at Harvard University, professor of medical anthropology in the Department of Global Health and Social Medicine at Harvard Medical School and the Victor and William Fung Director of Harvard University’s Asia Center.

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