Due to many factors, including the downsizing of IHS and the elimination of regional programs, the Northwest Tribes have been without epidemiology services since 1995. The Northwest Tribes are concerned about the lack of access to regional and tribal specific health status information, the lack of chronic and infectious disease surveillance, and the inability to respond adequately in case of disease outbreaks. The project will incorporate health data collected from the tribal health programs into health policy decision-making and create a more effective evaluation of public health interventions. Communications made available through this connectivity will dramatically decrease the time it takes for outbreaks of infectious disease to be recognized and provide tribal health programs with rapid, coordinated notification of infectious disease cases and outbreaks. The Circle of Health will also increase the capacity of tribes to address health research, disease surveillance, and information technology issues.

Q. What are the goals of the Circle of Health Project?

A. The goal of the “Circle of Health” is to use the national information infrastructure to address the lack of disease surveillance and epidemiology information in geographically remote tribal communities in the Pacific Northwest. The NPAIHB will work in partnership with 40 tribes in Idaho, Oregon, and Washington, state health departments, the Indian Health Service (IHS), the Washington Information Network for Public Health Officials (INPHO), and the National Library of Medicine/Regional Medical Library. IHS and Washington State Intranets will be extended to local area networks at eight tribal health facilities to connect clinical and administrative staff to Intranet and Internet resources. The eight tribes will be selected based on: (1) leadership commitment and administrative support for building information infrastruc-ture; (2) representation of tribes from all three states; (3) and the ability of tribes to commit resources to sustain the information infrastructure after the grant period. Course material will be developed to train tribal health program staff to utilize the epidemiology and other information resources and communication tools inside these Intranets and across the Internet. The specific focus of the training will be on utilization of this information for public health planning. With assistance from the NPAIHB epidemiology center, Washington tribes will participate in the State of Washington’s electronic communicable disease reporting system. The NPAIHB and Washington DOH will develop site specific Internet access planning documents for the remaining 32 tribes. The NPAIHB will create listserv’s and websites for tribal collaboration on administrative issues and program delivery.

Expanded access to health data for analysis of key health events like disease outbreaks and identification of important health issues will assist tribes in the preparation of local health status reports, allow for the incorporation of health data into health policy decision-making, and create more effective evaluation of public health interventions. Communications made available through this connectivity will dramatically decrease the time it takes for outbreaks of infectious disease to be recognized and provide tribal health programs with rapid, coordinated notification of infectious disease cases and outbreaks. Communication will also facilitate tribal collaboration and NPAIHB information dissemination. This project will increase the capacity of tribes to address health research, disease surveillance, and information technology issues. The beneficiaries of this project will be tribal health program managers and providers, and ultimately consumers of services provided by Indian health care programs.

Q. What are the objectives of the Circle of Health Project?

A. The objectives of the project are as follows:

* Objective 1. Connect eight Northwest Tribes to the Washington Department of Health, the IHS Intranets, and the Northwest Tribal Research Center.
* Objective 2. Train technical staff at these eight sites to maintain their local area networks.
* Objective 3. Train these eight tribal sites to utilize public health and epidemiology information created by each of these organizations, and other health information accessible on the Internet. Training at more tribal sites will be provided as time permits.
* Objective 4. Train participating Washington tribes (at least 4 of the eight) to utilize Washington State Department of Health electronic disease reporting mechanisms.
* Objective 5. Conduct pre and post assessment at the eight sites to evaluate whether access to these information resources impacted tribal health policy making or health care delivery planning.
* Objective 6. Create planning documents for the 32 remaining Northwest Tribes describing costs and alternatives for Intranet/Internet access. Provide connectivity technical assistance to any site that has resources to invest in information infrastructure.
* Objective 7. Publish information about tribal health programs on NPAIHB web page, and create electronic mailing lists for peer groups at Indian health care delivery sites.
* Objective 8. Disseminate the results of implementation and evaluation.

Q. What organizations are involved in the Circle of Health Project?

A. The Circle of Health project is a collaborative effort between the Northwest Tribes, the Board and several federal, state and local agencies as outlined below.

* Forty Tribal Communities - 8 initial connections and plans for connectivity of the remaining 32 tribes
* NPAIHB
* Indian Health Service (IHS)
* Washington Information Network for Public Health Officials (INPHO)
* National Libary of Medicine/Regional Medical Library
* State Health Departments

Telecommunications Discount Programs
USD (Universal Services Discount Program):

The Telecommunications Act of 1996 created the Federal Communications Commission Universal Services Discount Program. The “universal service” system was originally designed to make local telephone service available to all Americans at reasonable rates. In many cases, universal service policies have required that rates for certain telecommunications services be set above the cost of providing those services to generate a subsidy that could be used to reduce the rates for local service provided to residential customers. Many other federal and state programs are presently used to ensure universal service. This program is in its 1st year of grant delivery for applicants. Although it is still evolving and some major changes will take place as it progresses, tribes should be aware of the availability of grant and loan funds. Schools, libraries, and health care providers as well as residential and rural customers will be the primary universal service beneficiaries. The new law requires that the FCC and the states base the revision of the universal service system on seven principles, including the principle that elementary and secondary schools, libraries, and health care providers should have access to advanced telecommunications services.

* RHCC (Rural Health Care Corporation)-- The Rural Health Care Universal Service Support Program has funds up to $400 million per year based on comparison to the nearest urban area telecom costs.

* SLC (Schools and Library Corporation )-- more commonly known as the E-Rate Program, the SLC is an independent not-for-profit corporation established to administer universal services for Schools & Libraries. Funded at up to $2.25 billion annually, the Program will provide discounts of 20% to 90% on telecommunications services, Internet access and internal connections. E-Rate Forms Online

Here are some other discount programs and their related websites where you can find more information.

* RICHS (Rural Information Center Health Service)-- The Rural Information Center Health Service, known as RICHS, is a joint project of the Office of Rural Health Policy, DHHS, and the National Agricultural Library (NAL), USDA. Operating as part of the Rural Information Center, RICHS collects and disseminates information on rural health issues. By calling RICHS, users gain access to a national collection of rural health resources. RICHS addresses issues common to rural areas such as recruitment and retention of health care personnel, programs for special populations, facilities administration, network development and innovative service delivery.

* DLT (Distance Learning and Telemedicine)--Since 1993 this program has provided 90 grants totalling $27.5 million to rural schools, hospitals and medical clinics in 39 states. RUS’ Distance Learning grant program provides grants directly to rural schools, libraries, and other educational institutions for the development of advanced telecommunications systems. For more information contact Rural Economic and Community Development, 14th and Independence Ave. SW, Washington, DC 20250. (202) 720-1007.

* MSA ... Am I Rural or What? (The Metropolitan Statistical Area)-- How the Government and states determine who is living in a rural setting and who is not. This determination is necessary for eligibility in some of the Universal Services Discount Program.

* LifeLine Assistance Program--Low-income families and senior citizens are eligible for $8.25 in monthly credits for discounted phone service, thanks to recent changes made to the Ameritech Lifeline Telephone Assistance Program. The larger discounts went into effect Jan. 1 as a result of the federal telecommunications Act of 1996 and changes to the Michigan Telecommunications Act. Customers with incomes equal to 150 percent of the poverty level qualify for the Lifeline program. That means a family of four could have a monthly income of $1,950 ($23,400 annually) to qualify for the program in 1997.

* Link Up America--Off-sets up to $30.00 of initial hook-up charge for low-income subscribers. The FCC asks local companies to offer a deferred payment plan for remaining costs.

Can you talk the talk?

Glossary of often used telecommunications terms.
FAQ’s about USD
More FAQ’s about USD
Telecommunications Funding Resources
Federal Telecommunications Funding Sources
FCC Forms available on the Internet

Project Objectives

1. Phase II Implementation

The Circle of Health staff has recently completed network implementation and training at all four of our Phase II sites (December 1999)! During this phase all four sites received a mail server with appropriate mail software. Three sites were connected to Washington State’s IGN while the fourth site is dialing out to a local ISP to send and receive e-mail. These services are being installed to connect tribal health staff to colleagues and professionals at federal, state and private health agencies. (Please see the chart below for a quick update on the participating site activity.)

Phase I Implementation
2. The Circle of Health project has completed Phase I (February 1999). Four sites, Port Gamble, Lummi, Grand Ronde and Coeur d’Alene are currently utilizing Internet services (to include e-mail) and the designated health and social service staff have been trained on how to use these newly implemented services.

3. Site Visits
Project staff have been active at the tribal health clinics of the eight project participants. However, the project staff are now travelling to the remaining 32 NPAIHB tribal sites to perform information technology infrastructure assessments and assist in devising a plan for connecting the health centers to the Wide-Area Network (WAN). This will occur over the next 4-5 months.

4. Hardware/Software
One of the primary tasks accomplished for the Phase I tribes in this project is the determination of which types and quantities of hardware and software to purchase and deliver to the sites for integration into a network system. After reviewing each site and consulting with their Information Systems staff, a number of Compaq Proliant Model 2500 servers have been purchased, tested and made ready for delivery. These machines, equipped with network operating system software (2 sites with Novell Netware and 6 sites with Microsoft NT) and e-mail software (2 sites with Groupwise, 4 sites with Exchange and 2 sites with POP3/IMAP compliant software), are shipped to the tribal health centers.

5. Network Design and Implementation
The Northwest Portland Area Indian Health Board is currently working with the Indian Health Service, Washington State Department of Health / Department of Information Services and the Northwest Tribes to design a telecommunications network that will bridge federal, state and private networks. It will be cost-effective, user friendly, available, accessible, and useful for local level providers, while continuing to create standardized aggregate data that supports advocacy for Indian health programs at the national level. While the scope of our work is aimed towards the tribal health facility/facilities, we are also able to incorporate tribal-wide infrastructure into the design and implementation of the WAN. This produces a win-win situation everyone!

6. Continued Support from the Board’s Research and Information Technology (RIT) Workgroup
The Research and Information Technology (RIT) workgroup of the Board has the charge of being the Advisory Panel for the Circle of Health project. They provide guidance, recommend solutions, do research and advocate for new and improved information technology resources (among other things). This project has great impact as it seeks to design a telecommunications network encompassing 40 northwest tribes, the IHS, the Washington State DOH and other federal, state and private agencies. In fact a special meeting was held in Albuquerque during the week of July 27th (IHS Technology Conference) involving all these parties to start working on the design and plan for this network. You can find this meeting’s minutes under the RIT section of this site.

7. Telecommunications Discount Programs
This is a confusing area for most people. The FCC and the various organizations that are tasked with administering these discount programs are at best, very time consuming and paperwork laden. The Circle of Health staff will be working, on behalf of the 40 tribes we serve, to sift through these programs and find appropriate discounts for the telecommunication services contracted for by the health facility. We have listed the major discount programs on a separate page for your research.

Circle of Health Site Update

PHASE I TRIBES
Coeur d’Alene Tribe (2/99)
The Wellness Center has opened at this site, which also boasts a well-established clinic. Services implemented include a dedicated 384KB line, e-mail software applications and training for the health and social service staff . The tribe will continue to grow its network and integrate more workstations and services into the infrastructure.
For more information on the Coeur d’Alene tribe, please see our tribal profile web page.

Grande Ronde Tribe (1/99)
An extended intertribal network has been implemented to link multiple offices to the new clinic and administration buildings. Circle of Health resources include a new mail server, router, dedicated T-1 line and training for the health and social service staff.
For more information on the Grand Ronde tribe, please see our tribal profile web page.

Lummi Nation (12/98)
An extensive tribal network already exists here and the addition of the Circle of Health services will work to enhance the Internet connectivity. Circle of Health resources include a new mail server, new mail server software and training of the health and social service staff. They also look forward to the completion and opening of their new Fitness Center.
For more information on the Lummi tribe, please see our tribal profile web page.

Port Gamble Tribe (10/98)
Port Gamble is now connected to the Washington State IGN network. Circle of Health resources include a new mail server, mail software, router, a dedicated 384KB connection and training of the health and social service staff. The network is expanding to include other tribal offices. They are tackling the continued integration of Macintoshs and Windows based PCs into their network.
For more information on the Port Gamble tribe, please see our tribal profile web page.

PHASE II TRIBES
Shoshone-Bannock Tribe (4/99)
This site has an extended health network spanning about 7 facilities. Several of the facilities are connected via fiber optic connections and are part of the newly established LAN. Services implemented include a dedicated T-1 line, e-mail server and training for health and social service staff. This site has also successfully bridged the IHS health network to the tribal network, a first for our region.
For more information on the Shoshone-Bannock tribe, please see our tribal profile web page.

Swinomish Tribe (12/99)
The new clinic is under construction and is slated to open in September 1999. The clinic is being wired for LAN connectivity and fiber optics are being installed for connectivity to other tribal health buildings. This site is currently considering a dedicated connection to the IGN. An e-mail server is ready to put in place for them when the clinic opens.
For more information on the Swinomish tribe, please see our tribal profile web page.

Samish Tribe (12/99)
This site has a new office which has been wired for a LAN. New PCs were ordered and installed with the latest O/S and office software. An e-mail/file server was brought on-line to complete their LAN. A dial-up solution to a local ISP provides the routing of the Internet e-mail. The staff have been trained how to utilize e-mail and web tools.
For more information on the Samish Tribe, please see our tribal profile web page.

Quinault Nation (5/99)
Quinault recently installed a dedicated line from the WA State IGN to service their entire Taholah campus. Services implemented include a dedicated line to the IGN, an e-mail server and training of the health staff. A new social service building is being built next to the clinic and services are expected to expand into this new facility. Quinault is also challenged with integrating their remote Queets campus into the main network. Work still continued with the WA State DIS to accomplish this task.
For more information on the Quinault tribe, please see our tribal profile web page.

Washington State Department of Health/Department of Information Services (DOH/DIS)
Washington State Department of Health has agreed to cooperate with Washington State tribes in allowing connections to the Washington State WAN (IGN). This network has many health resources available for those who desire to access them. Databases, libraries, medical alerts, and information about health-related topics are only a few of the advantages of being connected to DOH/DIS. Their Internet connection is one of the fastest in the state and they have worked hard to make this feature available to Northwest Tribes participating in the Circle of Health Project.

Current Northwest Tribal Information Technology Issues

* Year 2000 - We are pleased to report the Northwest fared well on the January 1, 2000 date rollover. There were virtually no outages and so far critical medical equipment is functioning according to specifications. Of course the staff at the NPAIHB will continue to monitor Year 2000 activities as future critical dates roll around. View the NPAIHB Y2K plan and special dates to watch for throughout the year.
* TCP/IP Addressing Schemes

* There is a current shortage of IP addresses both within IHS and on the Internet. Many tribes are using addresses allocated to them through the Indian Health Service or the Bureau of Indian Affairs. These ranges of addresses may not be addressable on the Internet and will only work on the internal LAN at the tribal site. This issue is currently being discussed with IHS and DOH design teams. Some tribal sites have opted to use an internal IP addressing scheme and then either have it translated by their ISP or their Proxy/Firewall setup to a handful of Internet known IP addresses. Fiber Optics/Building Infrastructure

* Increasing use of this technology by Northwest tribes is making faster and easier connectivity to various network resources possible. How to pay for these lines and who can make the best use of them is a recurring theme in our area. Health facilities need to recover costs from insurers and third parties. This can only be accomplised in an efficient and cost-effective manner when these systems are integrated with tribal accounting and administration networks. This could be one of the advantages of planning, designing and building telecommunications infrastructure at tribal sites. Consolidation of Telecommunications Resources

* Many tribal sites in the Northwest have multiple data lines entering their facilities, which represents a duplication of effort and resources that may be better spent elsewhere. Using one data or phone line for multiple purposes is of prime concern at this time. Bridging Private Networks

* One of the current issues we are working on with the Indian Health Service is the bridging of private health networks. The Washington State Department of Health is one of the first state health agencies with on-line electronic data sharing capabilities wanting to work with tribal health staff and the Northwest Portland Area Indian Health Board to ensure clinicians have access to critical state, as well as federal, epidemiology and health information. We will address such issues as creating gateways and multi-point Internet exit points on the network. Financial And Budget Considerations

There’s one thing you can count on - technology doesn’t stand still. As soon as you implement one technology another one is released to take its place. So it is very important for IT managers and the finance personnel to carefully analyze the needs and growth potential of their networks and related applications. Not only do you need to factor in the recurring monthly maintenance costs, the purchase and implementation of new technology, but the staff personnel and/or vendors needed to support your infrastructure.

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