Not every director of a regional health information organization hosts a personal Web site devoted to the restoration of her 1946 Aeronca Chief seaplane. But this is Alaska--and a seaplane comes in handy in a state that is the nation’s largest, boasts the lowest population density among all the states and touts dog mushing as its official sport.
“There are 257 villages in Alaska that have clinics and none of them is accessible except by air,” says Rebecca Madison, director of Alaska ChartLink, the Anchorage-based non-profit initiative to build a statewide health information exchange. After receiving an initial $100,000 in seed money from the Health Resources and Services Administration, ChartLink is being incubated by the Alaska Native Tribal Health Consortium, a not-for-profit organization that provides health services to all the state’s tribes, until it achieves 501(c)3 status.
Madison, who lives in Fairbanks and restored the classic seaplane as a gift to her husband, was hired to lead ChartLink at its launch last January, in no small part because she’s seasoned to the health care challenges of Alaska’s vast spaces. Previously she was CIO for a health care provider corporation that serves a mostly Native American population from a hospital in Bethel and 53 far-flung village clinics scattered over 80,000 square miles.
And that’s just a chunk of the larger Alaskan land mass, which if placed over the Lower 48 would stretch from Florida to California. About 650,000 people live here in an area of 572,000 square miles, and just under half that population in the cities of Anchorage, Fairbanks and Juneau. Not surprisingly, telehealth has been a mainstay of care in this state for several decades and provides the foundation and impetus for ChartLink’s digital initiative.
“We’ve had a very active telemed program up here, but we needed more than just images,” says Tom Nighswander, M.D., a family practitioner at the Alaska Native Medical Center in Anchorage and facilitator of the Alaska Telemedicine Advisory Council (ATAC), whose members represent hospitals, Blue Cross Blue Shield and AARP and which spawned the RHIO idea in the first place.
“ChartLink is a natural extension of telemedicine, which can only go so far. Sharing images and getting consultations is useful for ear, nose and throat, dermatology and radiology, but you can’t share lab test results, problem lists or medication lists, which are so critical to primary care,” he says. Also, the Alaska telemedicine system relies on store-and-forward, or asynchronous technology, which does not allow real-time communication.
Nighswander, who also facilitates ChartLink’s steering board for the state, has practiced in Alaska since 1972 and is well aware of how its vast landscape creates longitudinal-sized degrees of separation. In addition to treating Native Americans at the medical center, he trains the community health aides who are the only providers in 35 “really remote” villages, some of them 1,200 miles distant in the Aleutian Islands and most of them 200 to 300 miles apart.
A major challenge for Alaska ChartLink, says Nighswander, is getting physician offices to expand their thinking as part of a larger, interoperable network. “The tendency for individual physicians is to talk directly to [an electronic health record] vendor, but that’s probably the last thing to do. Much of [the available products are] vaporware. They’re all eating each other’s children,” he says, referring to the multitude of EHR vendors warring with one another over small physician offices. Most physicians in Alaska work in offices of two to three doctors, which if left to their own devices, could result in a nightmare patchwork of disparate systems. “The interconnectivity piece in ChartLink means not having to build interface engines for 60 different EHRs,” says Nighswander.
An EHR in Every Office
Getting it right is critical to ChartLink’s success.
“The biggest issue to us is having an EHR in every physician’s office,” says Madison. To address this issue, the Alaska EHR Alliance was formed in 2005 to help small doctors’ offices across the state overcome the hurdles to acquiring an EHR. She estimates that the combined statewide initiatives will require about $34 million: $20 million for Alaska ChartLink and $12 million to $14 million for the EHR alliance.
With backing by the Alaska State Medical Association and consumer groups, the EHR Alliance brought in Linda Boochever early last year as executive director to incorporate it as a 501(c)3 organization and implement a strategic business plan. Its application to become a non-profit is pending with an IRS agent on the West Coast.
“He’s sitting with 20 RHIO applications, waiting for an IRS ruling as to whether there are conflicts of interest” involved in such initiatives, Boochever says. Complicating the issue is the fact that the alliance’s mission is to promote and support development of a statewide, interoperable EHR network by assisting Alaska’s non-public sector health care providers in EHR adoption.
“Initially we had put it out to all physicians, including those with the Alaska Native Tribal Health Consortium, but they declined to be included in our mission because they are government-assisted and either already have or are in the process of adopting EHRs,” says Boochever. That leaves about 800 of the 1,300 physicians in the state eligible for the program. “Our target is 1,000 providers,” she says.
Seed money from the HRSA grant and local hospitals has enabled completion of the business plan. The next step is selection of three EHR vendors for the state that will allow some variation at the same time it ensures interoperability. “In Alaska, one size does not fit all--ever,” Boochever says. That step will be closely followed by a pilot involving 50 physicians. The alliance has estimated it will cost about $20,000 per provider, including hardware, software and training, and it favors an application service provider model because it allows the remote hosting of the application software.
Boochever says the EHR Alliance’s success depends on getting significant help from the state, but she feels sanguine about those prospects. “Alaska is a very rich state,” she says, noting that it has no state taxes and every man, woman and child receives a check yearly from the oil-revenue-fed state permanent fund.
Even if EHRs were funded for every physician’s office in Alaska, the financial sustainability of ChartLink itself remains a question. Madison says the RHIO’s stakeholders have agreed that it will be some kind of subscription plan likely to be paid by employers or payers estimated at $20 per person per year. Fortunately, that question is still a ways off. After standardizing security, privacy and consent statements and completing the business plan, Madison is now seeking interim funding from both private and public sources.
Still, it won’t be cheap. “Telecommunications is a very big challenge here. Everything [outside the major three cities] is by satellite because there are no land lines. T1 communication over a satellite costs from $8,000 to $10,000 a month, so we have huge challenges. Some of the new satellite technology is exciting because it gives us more [bandwidth],” she says.
It all goes back to Alaska’s unique vastness.
“We think it’s different in Alaska because we’re really spread out,” Boochever says. “The rural population comes in for medical care a lot. A RHIO has more relevance in Alaska because we have more of a need to be connected. Alaska has a much higher Internet use than other states, and we’ve always been early adopters up here. Any way to bridge those distances.”
Chuck Appleby is a freelance writer specializing in health care and technology.
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This article first appeared on July 25, 2007 in HHN's Magazine online site.
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