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Addressing Critical Concerns of Healthcare Systems Serving American Indians/Alaska Natives

Infrastructure & Technology


Russell Pittman (Yankton Sioux), Director, Information Technology Support Center, National Programs, Indian Health Service, U.S. Department of Health and Human Services, Albuquerque, NM.

Arnold D. Miller, D.O. (Retired), Former Director, Department of Medical Imaging, Northern Navajo Medical Center, Shiprock, NM.

Role of Technology

Technology can strengthen and enhance the service delivery system of healthcare facilities—particularly those in rural and isolated areas—in many ways, including:

  • Enhanced communication and ability to collaborate.
  • Increased opportunities for staff to keep knowledge/skills up to date by participating in long-distance learning programs.
  • Decreased isolation.
  • Increased access to specialists and specialty services.

Facilities considering creating technology infrastructure first need to assess requirements:

  • What are current and future needs?
  • Is there a long-term payoff to using a particular technology?
  • What is the cost? How will it be covered?
  • Who would use it? What kind of expertise and training would they need?
  • What would be considered an appropriate use?

To evaluate potential technology, Russell Pittman encouraged facilities to:

  • Determine available vendors: Mr. Pittman emphasized that facilities are best served by standardizing their pieces of technology and finding a vendor who can handle all. Mr. Pittman also encouraged finding a vendor who speaks in lay terms.
  • Establish levels of assurance/uptime: For example, if the vendor promises that the system will be up 99.99 percent of the time, the facility will be able to use it for all but 9 hours a year.
  • Make systems scalable: Have vendors demonstrate how the proposed technology will be able to move up at least two levels.
  • Develop protocols/guidelines that are easy for potential users to understand.
  • Develop a detailed timeline for installation and maintenance.
  • Determine support requirements in advance and hold the vendor to these requirements.

Issues to consider in setting up technological infrastructure include:

  • How to ensure confidentiality/privacy.
  • How to obtain reimbursement.
  • How to "sell" the idea to decisionmakers when cost-effectiveness data do not exist.
  • How to ensure compliance with regulations related to the U.S. Food and Drug Administration (which licenses medical technology) and the Health Care Financing Administration (which oversees Medicare and Medicaid).
  • How to handle storage requirements over time.

The Information Technology Support Center (ITSC) of the Indian Health Service (IHS) can provide technical assistance to Indian health facilities seeking to create or improve their technology infrastructure. ITSC also offers training through multiple methods such as Web-based training and video conferences.

Navajo Area Indian Health Service Teleradiology Network

The Navajo Area Indian Health Service Teleradiology Network is an example of how technology infrastructure can be developed. The network covers approximately 25,000 miles in the Four Corners region, with health resources spread thinly.

In 1991, the primary need of this IHS area was for better coverage of orthopedics in emergency rooms that lacked full-time radiologists or orthopedists. If X-rays "didn't look quite right," it would be difficult to tell if a fracture had occurred or if a specialist should treat it. These questionable X-rays often had to be driven to the nearest large facility; the average driving time between facilities is one and a half to two hours. In other cases, staff would attempt to describe the X-ray over the phone.

To purchase the equipment in 1991, the Navajo Area Radiology Committee obtained IHS year-end uncommitted funds. Purchased equipment included laser digitizers (which transform X-rays to be transmitted over phone lines) for the 11 sites that would send X-rays and equipment for viewing/receiving the X-rays at the four hospitals with radiologists and orthopedists. The system was expanded in 1993 to include the University of New Mexico Hospital, then again in 1998 to include a private radiology group in New Mexico, thus providing greater access to specialists.

Arnold Miller asserted that training is more important than the equipment. He urged facilities interested in developing teleradiology infrastructure to include a requirement for ongoing training from their vendors. He also suggested that a facility designate one or two people to become experts.

Challenges related to slowness of the digitizing processes and transmissions led to the purchase of a new system in 1999. Federal "Y2K" funds were obtained, as the 1991 equipment was not Y2K-compliant. The new system improved the power and the intrahospital network, as well as started a computerized radiology system (the first step toward filmless radiology).


Allen A. Decision making for teleradiology: an interview with Dr. Jim Logan. Ft. Lauderdale (FL): Telemedicine Today 1999.

Allen A, Stein S. Cost effectiveness of telemedicine. Ft. Lauderdale (FL): Telemedicine Today 1998.

Cullen T. A strategy for information technology implementation. The IHS Prim Care Provider 2000 Mar;25(3):33-5.

Mintzer CL, Wasem CJ, Puskin DS. Lessons learned from the rural telemedicine grant program. Ft. Lauderdale (FL): Telemedicine Today 1999.

Moskowitz DB, editor. Assessing medical innovations: how health plans pick what technology to cover. Washington (DC): Faulkner and Gray; 1997 May.

Successful strategies for increasing direct health care quality, accessibility, and economy for American Indians and Alaska Natives: teleradiology reduces the distance to heath care on the reservation. Rockville (MD): Indian Health Service, U.S. Department of Health and Human Services; 1995 Aug. p. 55-6. Contract No.95-85016.

Ruggiero C. A teleradiology primer. Ft. Lauderdale (FL): Telemedicine Today 1998.

Wachter G, Brown N, Allen A. Teleradiology service providers. Ft. Lauderdale (FL): Telemedicine Today 1999.

Whitten P, Allen A. Organizational structure in telemedicine programs. Ft. Lauderdale (FL): Telemedicine Today 1999.

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