Alison Ross’ first nursing job was in a 20-bed hospital in Fort Smith, Canada, a sub-Arctic town of fewer than 3,000 residents that straddles Alberta and the Northwest Territories. “I had physicians and other nurses I could call for help if I was stuck, but on any given shift I was often the only RN in the building.”

Ross, an alumna who earned her Doctor of Nursing Practice degree from the Duke University School of Nursing in May 2016, said that experience more than a decade earlier was memorable and is a foundation for her current pioneering work in digital health care. “In that setting, I was able to have more autonomy, more independence as a nurse. I felt like I was doing much more, doing a job people didn’t want to do,” she said. “I liked it. I liked the remote community, and I liked that the patients really trusted the nurses in their community. They had to.”

She liked it so much, she moved deeper into the Northwest Territories to the First Nations community of Fort Liard, population 536. “I rode three hours by road and two by plane to get there,” she said. There Ross saw firsthand how remote health care is delivered. “Patients have to drive hours to the nearest health care center,” she said. “Snow and weather conditions render that impossible at times. Continuity of care is difficult. And the scarcity of local providers means a lot of communication with professional peers takes place via technology — phone, email, videoconferencing.

After three years in Fort Liard, personal reasons drew Ross to the East Coast, where she worked on her master’s degree remotely and took her first job doing what would become her passion — digital health care. Ross answered phone calls from people seeking medical care via a Nova Scotia telehealth program.

At that time, telehealth technology consisted of exactly what she was doing — fielding questions by phone and directing patients on what to do and where to go next — as well as videoconferencing consults between providers. Having used videoconferencing to talk with other providers when she was working in Northern Canada, Ross thought to herself, “Why aren’t we using this for some of these patients who need minimal physical assessments so they don’t have to travel so far?”

After earning her NP certification in 2012, Ross knew she wanted to go back to the indigenous communities that needed care. She took a job with McKesson Canada in Slave Lake, Alberta, a town of fewer than 7,000 people. For those living in the even more remote areas of northern Canada, Slave Lake is a central hub offering necessary amenities, such as grocery stores, retail shopping and, of course, health care. Patients in the outer regions would travel hours to get to the nearest health care facility, Ross said. “They’re coming for a 10-minute prescription renewal, and they are traveling a six-hour round-trip to get that prescription.”

When she began her doctorate at Duke University School of Nursing (DUSON), her capstone project was obvious. She would take the existing digital health technology, tweak it and bring it into the primary care setting. Instead of only providers teleconferencing with each other, Ross’ system allowed her patients to teleconference directly and privately with her. She found that the game changer was adding the plug-in components that allow her to do an actual exam: taking blood pressure, listening to lungs, checking the ears and, of course, seeing the patient.

To get the system off the ground, Ross proposed a three-month pilot project to her manager at McKesson Canada. He told her to run with it. Ross approached two First Nations bands about setting up the distal end of the system in their communities, and they agreed. Ross traveled to the First Nations communities and trained six people, all of whom have stayed with her throughout the project, which began in September of 2015.

Ross set up the sites in the Peerless Trout First Nation community. Patients can now go to a designated station where a community health representative — often a band member who is trained — helps them use the equipment. If Ross, on the other end in Slave Lake, wants blood pressure taken, the representative helps put the cuff on, and Ross has earphones to hear the heart - beat. A plug-in stethoscope allows Ross to listen to the patient’s lungs. And a camera, which Ross controls, can zoom in on different areas of a patient’s body, offering clear, sophisticated imaging.

There are obvious limitations, Ross said, but she hopes this approach might become a compulsory part of primary care, acting as a screening tool.

“I am really proud of the universal health care system we have that everyone has access to,” Ross said. “But it is not cost-free. It’s expensive. There is a lot of waste.” For instance, as part of heath care coverage, the government pays to transport the remote patient to hubs like Slave Lake. “That is a lot more expensive than seeing someone by video.” Ross knows it’s a balancing act, and her system is another tool in trying to provide the best health care as efficiently as possible.

“I’ve seen both sides of that,” she said. “We saw patients who waited too long — one was a teenage boy with lice. By the time he came in, he had to be hospitalized for infection.” But on the flip side is the patient who has a “runny nose for that one day,” she said, feigning sickness to get a free transport to town to take care of other business. If her system were first-access care, Ross said, she could recommend whether or not a trip to Slave Lake was warranted.

Ross believes she is the only provider in Canada offering this innovative service. The original three-month pilot approved by her employer has been extended as she continues to collect and analyze data. Ross has expanded her service to include residential treatment for drug and alcohol addiction. Patients can book appointments with her directly or attend a telehealth walk-in clinic that she offers three afternoons a week for an hour. An additional site is soon to be opened. “The hope is that as we gather more data that demonstrate its feasibility and sustainability, we will be able to expand further and encourage other providers to join as well.”