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Health Information Technology and

Telehealth Challenges in the U.S. Affiliated

Pacific Islands Region

Christina HIGA 1

Jessica OKAMURA, Sean OKAMOTO, Norman OKAMURA

University of Hawai‘i at Mānoa, Honolulu, HI, United States of America

Abstract. Small island developing states (SIDS) have much to gain from the use of

Health Information Technology (HIT) and telehealth to improve care, improve

population health, increase access to care, and lessen costs. At the same time,

planning, implementing, and operationalizing HIT is costly and requires significant

technical, human, financial and planning resource infrastructure to support

implementation and operations. This paper provides a broad overview of how HIT

and telehealth has evolved in the U.S. Affiliated Pacific Islands (USAPI) SIDS, the

progress that has been achieved, the role of political affiliations and international

assistance, and the many challenges that remain. The paper highlights the

differences in treatment between the territories and the nations affiliated with the

United States through the Compacts of Free Association (COFA), and the important

roles of other donor countries, regional, and international organizations. The paper

also raises questions of how advances in HIT and telehealth can be further achieved

and sustained in the USAPIs. Finally, the paper identifies the need for the building

of knowledge and skills to develop careful plans so pitfalls of silos, proprietary

systems, and inadequate technical support can be lessened or avoided in the grand

challenge of adoption and maturing of HIT and telehealth.

Keywords. Health information technology, telehealth, information and

communications technology, small islands development

Introduction

Health Information Technology (HIT) and telehealth are inescapably linked to the state

of telecommunications and information and communications technology (ICT). HIT

includes an extensive complex of technologies, systems and infrastructure. HIT

components touch a broad array of separated but increasingly interconnected networks

and information systems technology, and healthcare delivery support and management

mechanisms. Systems may include electronic health records, personal health records,

and public health registries. Applications involve health information exchange for health

care administrative operations, clinical services (laboratory, radiology, medication, etc.),

and telehealth. There is also a multitude of human resources and organizational capacity

requirements to technically support, manage and secure HIT.

1 Corresponding Author: Christina Higa, Assistant Specialist, Social Science Research Institute, College of

Social Sciences, University of Hawai‘i at Mānoa, 2424 Maile Way, Saunders Hall 713, Honolulu, Hawai‘i

96822, United States of America; Email: [email protected].

A common definition of telehealth is “the�collection of means or methods for enhancing

health care, public health, and health education delivery and support using

telecommunications technologies” [1]. Telehealth technologies and protocols enable

clinical care and public health services to be provided at a distance. Telehealth may be

used to directly support patient care, continuity of care, coordination of services, patient

and provider education, and evaluation of the quality of services. Information from these

systems may enable healthcare analytics to inform health care providers, patients, policy

makers and stakeholders. The possible intersects between telehealth service delivery and

health information are endless.

At the same time, there are a multitude of development considerations that affect the

trajectory, use, and ultimately the benefits afforded by HIT and telehealth. Vital factors

include systemic concerns about honoring core values and organization of health system,

services and finances; technical infrastructure, individual, and institutional capacity

development. The U.S. Affiliated Pacific Islands (USAPI) Small Island Developing

States (SIDS) have complex regional and international relationships that impact the

dynamics of development and sustainability in terms of aid and social and economic

growth and affects the access to and/or infusion of resources to support HIT and

telehealth in this region.

The challenges that the USAPI SIDS face include geography, size, availability

and accessibility of resources, infrastructure, languages, and ability to receive U.S. or

foreign assistance [2, 3]. This paper broadly examines how HIT and telehealth have

evolved over the past decades in the USAPI SIDS with particular attention to challenges

of development, capacity and resources in furthering HIT and telehealth advancement

for patient health care and public health. This paper provides a broad regional view but

is not able to elaborate here on the detailed intricacies of HIT and Telehealth

developments. Attention is focused, in part, on the grand challenge of the

telecommunications and ICT infrastructure in these USAPI SIDS, as an important and

core challenge for HIT and telehealth, and predecessor to the current grand challenge of

HIT and telehealth adoption [4].

1. U.S. Affiliated Pacific Islands Small Island Developing States

Within the Pacific region, there are three USAPI SIDS countries that are members of the

United Nations (UN). These include the Republic of the Marshall Islands (RMI), the

Federated States of Micronesia (FSM) and the Republic of Palau (Palau). These countries

have Compacts of Free Association (COFA) with the United States. These COFA

countries conduct their own foreign policy and regional relations.

There are also three U.S. territories in the Pacific region that are non-UN members,

including American Samoa, the Commonwealth of the Northern Mariana Islands

(CNMI), and Guam. The participation in many regional meetings are not as member

states but rather as regional affiliates. Simple participation in such fora are often through

donor country, regional, and/or international organizations, as the USAPI SIDS do not

have the financial resources to participate in the many the regional and international

meetings.

The differences in the political status between the U.S. territories and COFA

countries are significant. This is principally because their affiliation with the U.S., along

with country characteristics (e.g. population size, density, etc.), determines eligibility for

grants and other available financial assistance [5]. So, while the U.S. territories are

C. Higa et al. / Health Information Technology and Telehealth Challenges34

eligible for Medicaid funding that provides direct financial assistance on a matching

basis for healthcare services for low income populations, and for the administration of

the federal-state/territory Medicaid program, EHR adoption and use, and others; the

COFA countries are not eligible for the Medicaid program but remain eligible for many

other U.S. federal programs as defined in the Compact treaties.

Table 1. General characteristics of the USAPI SIDS.

USAPI U.S. Affiliation Population Size (2017) Main Islands

American Samoa Territory 55,641 3

CNMI Territory 55,144 3

Guam Territory 164,229 1

RMI COFA Country 53,127 2

FSM COFA Country 105,544 4

Palau COFA Country 21,729 1

Note: There are many remote islands in the USAPI with small populations.

Source: HRSA Fact Sheets data.hrsa.gov/data/fact-sheets

2. U.S. Regional Activities in Telecommunications

Telecommunications, or the basic imperative to communicate over distances, predates

the advancements in information technology. From telegraphy to telephony, to radio to

satellite to fiber optics, the advances in telecommunications with affordable access are a

precondition to effective and efficient HIT and telehealth. For the USAPI SIDS, the

imperative to communicate is critical to this region given the vast distances and disparate

time zones.

2.1. Pan-Pacific Education and Communication Experiments by Satellite (PEACESAT)

The U.S. supported the first satellite telecommunications to the region through the Pan-

Pacific Education and Communication Experiments by Satellite (PEACESAT) program

that involved the National Aeronautics and Space Administration (NASA), the National

Oceanic and Atmospheric Administration (NOAA), and the National

Telecommunications and Information Administration (NTIA) of the U.S. Department of

Commerce. Through a series of cooperative agreements between these U.S. federal

agencies and the University of Hawai‘i, the satellite was initially used to test satellite

communications, including packet networks and grew to be used for “public service

communications” throughout the Pacific Islands region. The satellite was used for

government, education, and other public service and non-commercial purposes [6].

Use of the satellites was provided as a no-cost service for education and satellite

communications networks, and grew eventually to 144 earth stations throughout the

region. Initially, on the ATS-1 and ATS-3 satellites, there was only a Single Channel per

Carrier (SCPC) channel. However, following this was the use of the GOES satellite

series, which introduced multiple analog SCPC channels and ultimately digital carriers

over 3m antennas designed by a company in New Zealand. In the late 1990s, a “Digital

PEACESAT” program developed that enabled direct multi-channel voice and low-speed

data and 128 Kbps video teleconferencing. The PEACESAT program went through a

transition in 2012 with the de-orbit of the GOES-7 satellite. Then PEACESAT evolved

to assist in the implementation of dedicated fiber optics networks within the U.S.

C. Higa et al. / Health Information Technology and Telehealth Challenges 35

territories with dedicated commercial satellite links that redirected traffic for voice and

Internet access.

2.2. Other U.S. Telecommunications Programs and Support

The U.S. also supported the COFA countries by providing access to the Rural Utilities

Service loan program of the U.S. Department of Agriculture (USDA) for rural

telecommunications. This enabled the Republic of the Marshall Islands (RMI), the

Federated States of Micronesia (FSM), and the Republic of Palau (Palau) to acquire

digital telephone switches and network infrastructure through long-term, low interest

loans. These were significant multimillion dollar loans that were to be repaid on a long-

term basis. However, as can be imagined, all of the COFA countries have faced

difficulties in repaying the loans, due to the limited financial resources available.

While the Compacts of Free Association provided broad latitude to be able to assist

the COFA countries with fiber and other telecommunications and connectivity matters,

it was never deemed a collective priority. Nonetheless, the U.S. did assist the RMI and

the FSM through sharing the use of a fiber cable that was being installed by the U.S.

Department of Defense (DoD) for the “Star Wars” Missile Defense System. As such, the

RMI and FSM were connected to fiber from the Kwajalein Atoll of the RMI, to Guam

and to Hawai‘i. These were essentially done through a fiber spur to the Pohnpei State of

the FSM and a link to Majuro of the RMI from Kwajalein in RMI. Only Pohnpei State

in FSM was connected to the fiber, the other FSM states of Kosrae, Chuuk, and Yap were

not.

In furthering the use of telehealth in the region, in March 2001, the U.S. Health

Resources and Services Administration (HRSA) held a workshop in Honolulu to educate

the region on the potential use of telehealth to improve healthcare services and access

educational programs and how the PEACESAT network could potentially be used by

healthcare organizations.

The U.S. Department of Defense (DoD) and the U.S. Department of Veterans

Affairs (VA) also aided the Pacific in several ways. The DoD used their dedicated T-1

satellite communications capacity to provide direct video consultations from their clinic

in Kwajalein Atoll of the RMI to the Tripler Army Medical Center in Hawai‘i. There

were occasional consultations for individuals on the island of Ebeye of the RMI with

clinicians at Tripler Army Medical Center.

The DoD further created the Pacific Islands Health Care Project that has provided

“humanitarian medical referral/consultation/care to >500,000 indigenous people of these

remote islands training for clinicians on specialty cases” [4]. This project was an early

use of the Internet and web access to provide a platform for clinical case consultations.

2.3. U.S. Universal Service Fund and the USAPI

The USAPI territories are under the regulation of the U.S. Federal Communications

Commission (FCC). The FCC has regulatory authority for international and domestic

telecommunications. Within states and territories, the FCC and states share regulation

based on legal authorities. The COFA countries, in contrast, are not subject to the U.S.

regulatory regime governing competition, interconnection, and/or the Internet. As such,

there are significant differences in the regulation and access to certain universal service

funds of which the COFA countries are eligible.

C. Higa et al. / Health Information Technology and Telehealth Challenges36

One important fund is the Universal Service Fund (USF) established by the FCC in

accordance with the Telecommunications Act of 1996. The fund levies universal service

fees on telecommunication service carriers and deposits the fees into the USF to assist

rural carriers and low-income residents, the Schools and Libraries Program, and the

Rural Health Care Program (RHCP). The RHCP supports both telecommunications

discounts and broadband connectivity through the Healthcare Connect Fund.

The Education Rate (E-Rate) program of the Schools and Libraries Program,

provides funding for U.S. K-12 schools and libraries and is funded at $4 billion U.S.

Dollars (USD) per year. The Rural Health Care Program provides funding assistance for

telecommunications and Internet services for eligible rural healthcare providers, and

expends over $400 million USD annually.

The use of the Universal Service Fund (USF) is limited to the U.S. territories in the

USAPI. An attempt by Palau, a COFA country, initiated by the Department of Education,

to participate in the program did not succeed. Palau was willing to open their

telecommunication market and become subject to U.S.-styled competition and

regulation. However, the other COFA countries did not support the idea in large part

because the communications monopolies did not want to introduce competition. Palau

again unsuccessfully sought to participate in the U.S. National Exchange Carriers

Association (NECA) to liberalize telecommunications, enable competition, and pay into

the USF but that proposal was rejected by the U.S. Joint Economic Management

(JEMCO). Table 2 shows the amount of funding that the territories received through

both the E-Rate and Rural Healthcare/Healthcare Connect programs.

Table 2. Estimated U.S. government funding to the USAPI from select Federal Communications Commission

(FCC) programs. All dollar amounts in USD.

USAPI

Total E-Rate Funds

(FFY 2016-2018)

Total Rural Health Care

Funds (1998-2017)

American Samoa $2,260,264 $1,512,327

CNMI $5,663,630 $ 42,675

Guam $2,730,536 $ 981,877

RMI Not Eligible Not Eligible

FSM Not Eligible Not Eligible

Palau Not Eligible Not Eligible

Source: USAC Website www.usac.org

3. U.S. Regional Activities in Health Information Technology

There are significant differences between U.S. support for the USAPI territories and

COFA entities. Depending on the eligibility as a U.S. territory or COFA country,

different U.S. federal agencies interact directly with the USAPI.

3.1. Lead U.S. Federal Agency for Support for COFA Countries

The general administration of financial assistance programs involving the COFA

countries is the responsibility of the U.S. Department of the Interior (DOI) Office of

Insular Affairs (OIA). For the COFA countries, the OIA serves as the primary interface

for grant expenditures and appropriates funding by the U.S. Congress for technical

assistance and other programs. The annual allotment of grant funding under the COFA

C. Higa et al. / Health Information Technology and Telehealth Challenges 37

agreements for these countries are managed through a Joint Economic Management

Committee (JEMCO) for the FSM, RMI, and Palau. The general allotments for sector

funding (e.g., education, health) are subject to review through the JEMCO.

3.2. U.S. Regional Healthcare Assistance

In the health sector, the U.S. Department of Health and Human Services (HHS) has

several important agencies that work with the region. These include the Centers for

Disease Control and Prevention (CDC), the Centers for Medicare and Medicaid Services

(CMS) in the U.S. territories, and the Health Resources and Services Administration

(HRSA). In addition, the Department of Veterans Affairs (VA) and the Department of

Defense (DoD) also provide healthcare support to their respective beneficiaries in the

region. The U.S. territories are eligible for the CMS programs although with Medicaid,

the territories are not provided the same levels of funding or Federal Matching Assistance

Percentages (FMAP) as the states. As such, all funding assistance for medical assistance

in the Medicaid program for the territories are capped by the U.S. Congress; and all

healthcare providers must qualify with the same Medicare Conditions of Participation as

the state hospitals to ensure quality for service reimbursement.

Table 3. Estimated U.S. government funding to the USAPI from select Centers for Disease Control and

Prevention and the Health Resources and Services Administration (HRSA) of the CMS. All dollar amounts in

USD.

USAPI

CDC Program Funds

(FFY17)

HRSA Health Center Funds

(FFY17)

American Samoa $4,002,162 $5,541,393

CNMI $3,632,137 $1,086,654

Guam $6,654,325 $2,053,190

RMI $2,679,364 $1,129,248

FSM $4,419,153 $2,564,289

Palau $2,660,195 $1,065,115

Source: CDC Grants Detail Profile (2017), HRSA Fact Sheets (2017)

3.3. Centers for Disease Control and Prevention (CDC)

The Centers for Disease Control and Prevention (CDC) has many programs operating in

the USAPI territories and COFA countries and has regional offices and health officers

supporting different programs. The CDC also has deployed many public health

information systems and also supports “cloud services” applications provided through

contractors for other CDC program functions.

3.4. Centers for Medicare and Medicaid Services (CMS)

In 2009, the U.S. adopted into law the Health Information Technology for Economic and

Clinical Health (HITECH) Act. Implementation of the HITECH was mainly the

responsibility of a newly established Office of the National Coordinator for HIT (ONC)

and the Centers for Medicare and Medicaid Services (CMS) that manages the health

insurance programs for the elderly and disabled, and the low-income populations. The

HITECH Act established the CMS EHR Incentive Programs to encourage the

meaningful adoption of EHRs by eligible hospitals and providers, promote health

C. Higa et al. / Health Information Technology and Telehealth Challenges38

information exchange, and to support the interfacing of EHRs with public health systems,

among others through financial incentives. Incentives are paid to eligible hospitals and

providers meet the program’s objectives and quality measures reporting requirements.

The cost of the national program was initially budgeted for in the amount of $25 billion

USD. However, the hospitals in the territories are not eligible for the Medicare EHR

Incentive Program incentive funds.

HIT was further advanced through the Patient Protection and Affordable Care Act

(ACA) passed in 2010. While the main purpose of the Act was to lessen the uninsured

population, the ACA also included many programs to improve the quality of care,

especially in the territories.

Table 4. Estimated U.S. government funding to the USAPI from select Centers for Medicare and Medicaid

Services (CMS) and CMS programs. All dollar amounts in USD.

USAPI

Total Medicare

EHR Incentive

Funds (FFY13-

16)

Total Medicaid

EHR Incentives

Funds (FFY12-

17)

Federal Medicaid

Medical Assistance

Funds (FFY16)

Federal Medicaid

Administrative

Funds (FFY16)

American

Samoa

-0- Not Available $18,573,242 $3,206,809

CNMI -0- $1,906,047 $20,268,290 $334,769

Guam $938,457 $3,839,991 $44,136,388 $1,625,143

RMI Not Eligible Not Eligible Not Eligible Not Eligible

FSM Not Eligible Not Eligible Not Eligible Not Eligible

Palau Not Eligible Not Eligible Not Eligible Not Eligible

Sources: CMS www.cms.gov; State Medicaid EHR Incentive Programs; MACPAC www.macpac.gov

3.5. Health Resources and Services Administration (HRSA)

The Health Resources and Services Administration (HRSA) of the CMS has many

programs that benefit both the USAPI territories and COFA countries. HRSA provides

funding to both the USAPI territories and COFA countries to operate Health Centers that

provide direct clinical care, supports clinicians to provide care in these areas, supports

the direct development of telehealth, and supports the development of networks in rural

communities.

The Office for the Advancement of Telehealth (OAT) within HRSA was an early

pioneering office in furthering telehealth throughout the United States. In 2000, the OAT

reached out to the PEACESAT program to introduce telehealth to the region together

with the University of California at Davis. The UC-Davis Center for Health and

Technology was an early pioneer in providing direct clinical consultation and boasts

providing service in 50 specialties and to 200 clinics and hospitals in rural areas and the

sessions sensitized participants to the possibilities. Unfortunate, the high cost of both

telecommunications and telehealth technologies did not permit broader use of the

telehealth peripheral equipment to be implemented in the region.

3.6. Department of Defense (DoD) and Department of Veterans Affairs (VA)

Citizens of the USAPI are eligible for enlistment in the U.S. military. The U.S. Naval

Hospital Guam serves the U.S. military population of Andersen Air Force Base, U.S.

Naval Base Guam, and other eligible service personnel in the military. The U.S.

C. Higa et al. / Health Information Technology and Telehealth Challenges 39

Department of Veterans Affairs (VA) also has a direct presence in the region. The VA

operates a recently built Community-Based Outpatient Clinics (CBOCs) in American

Samoa and Guam, and the VA hires private clinicians in the CNMI to provide primary

care for the veteran population. Inpatient and other services (e.g., radiology, laboratory)

are obtained through the other healthcare providers. The HIT network connectivity is

provided directly by the DoD and VA and through dedicated private connections.

The VA is currently exploring the use of community centers to host telehealth kiosks

to extend services to the remote veteran populations in the COFA countries. However,

providing services to veterans in the COFA countries have been more challenging

because of the “international” classification of the COFA veterans that are under the

International Program for U.S. Veterans. The VA Pacific Islands Health Care System in

Honolulu, Hawai‘i coordinates services to the veterans in this area and is collocated with

the Tripler Army Medical Center in Honolulu.

4. International Regional Assistance by Select Donor Countries and International

Organizations

The USAPI SIDS have received assistance from other donor countries and regional and

international organizations.

4.1. Regional Assistance by Select Donor Countries

Australia, Japan, Taiwan, China, Norway, and others have also provided aid to the

USAPI SIDS countries and assistance has been provided through the donor countries to

regional organizations that aid the USAPI, principally the COFA countries. The World

Bank, Western Pacific Regional Office (WPRO) of the World Health Organization

(WHO), and Asian Development Bank also provides aid to the USAPI SIDS, especially

the COFA countries. The International Telecommunications Union (ITU) has also

provided regional ICT training, workshops and technical assistance to develop ICT plans

in the COFA countries.

Direct bilateral country assistance has been provided. For example, Japan provided

technical assistance and support through its Japan Ministry of Foreign Affairs (MoFA),

Japan International Cooperation Agency (JICA), and others focused on ICT.

Additionally, Japan has supported the COFA countries with organizing workshops and

education through the Sasakawa Pacific Islands Nations Fund (SPINF) of the Sasakawa

Peace Foundation (SPF). The Hokkaido Cancer Institute in Japan supports a

telepathology applications in the FSM. Digitized specimen images are sent to Japan and

or evaluated simultaneous in real-time with the FSM lab technician.

On a regional level, Japan funded the Japan-Pacific ICT Training Centre, in 2010,

at the University of the South Pacific in Suva, Fiji. The purpose of the center is to build

ICT capacity and may have significant regional impacts over time with the further

development of ICT, unfortunately however, there is no like center in the USAPI. For

historic reasons, the academic organizations of higher education has been separate

USAPI institutions; and, although there is collaboration among the institutions, there has

not been any coordinated effort to support regional ICT training. As a result, in the

USAPI SIDS there is insufficient ICT-trained personnel to support advanced HIT or a

shared network of telehealth services. Taiwan is also providing HIT support through

access to electronic medical record systems through academic institutions in both Palau

C. Higa et al. / Health Information Technology and Telehealth Challenges40

and the RMI. These have been arranged mostly through bilateral technical assistance.

The US Centers for Disease Control (CDC) and Australia Respiratory Council supports

a Pacific Island Tuberculosis Nurses’ network that conducts Tuberculosis case

consultation for USAPI nurses.

4.2. Regional Assistance by Select International Organizations

A most important international development project for the COFA has been the Pacific

Regional Connectivity Program of the World Bank. This project extended submarine

fiber optics capacity to the COFA countries. The World Bank project funded

connectivity together with the Asian Development Bank (ADB) for Palau.

Of importance to HIT and healthcare is the World Bank’s clear recognition of healthcare

as one of the supporting reasons to improve connectivity in the region. This is evident

in the World Bank statement that “[t]hese connections will play a crucial role in linking

families, creating economic and employment opportunities, reducing transaction costs,

providing remote education and healthcare, and boosting national and international

coordination” [7]. Included in the World Bank program is the requirement to open

telecommunications markets to competition. A regulatory resource center was created to

help the transition from monopoly to competitive environments. The theory is that

increasing competition will improve the services and lessen the costs with competitive

carriers having access to high-speed transport on an equal access basis. The World Bank

program took away the expense of this enhanced capacity by providing grants and

partnered with the ADB to enable submarine fiber optic capacity for Palau through low-

interest loans.

5. Future Outlook – the Next Grand Challenge

The telecommunications infrastructure challenge has been diminished substantially for

most of the USAPI SIDS. While the telecommunications infrastructure has greatly

improved, there still remains challenges in the affordability in the use of HIT in support

of telehealth. Nonetheless, the grand challenge of a core telecommunications

infrastructure for the USAPI has been greatly reduced.

While there will be many important intermediate steps to establish HIT and

telehealth application experiments in various parts of the USAPI healthcare systems,

there is also a fundamental need to build human resource capacity to understand the HIT

challenges in the significantly resource constrained USAPI SIDS, understand and

develop strategies that will optimize on the sharing and reuse of HIT, and avoid costly

silo and proprietary technologies. There is also the need for technical support to assist

the USAPI to take advantage of some of the existing programs that are available to

USAPI entities [8].

The next grand challenge will be for the USAPI to continue to comprehensively plan

and implement the full complement of HIT in support of improved healthcare, including,

EHR or EMRs, HIE, telehealth technologies, and the like. In confronting these

challenges, there will continue to be the omnipresent and omnipotent need for USAPI

SIDS to continuously address issues of HIT integration; costly, proprietary and silo

systems; capacity building for HIT professionals; health information exchange; and the

use of data warehousing to enable analytics. While these are challenges for all countries,

C. Higa et al. / Health Information Technology and Telehealth Challenges 41

states, and other political subdivisions, given the challenges and resource constraints of

the USAPI SIDS, attention to the planning and capacity building is an imperative.

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