Ultrasound and Telemedicine in Arkansas - SD

Introduction

My name is Dr. Te anco.

I'm a professor of radiology, obstetrics, and gynecology at the University of Arkansas for Medical Sciences in Little Rock, Arkansas.

This is a presentation of our experience in the state of Arkansas about ultrasound and telemedicine and its impact on statewide high risk obstetric health care delivery.

I have no disclosures.

Program Overview

Our program is entitled Antenatal Neonatal Guidelines Education and Learning System, also known as Angels.

And this is a federally funded project that started in 2003, basically funded by Medicaid of Arkansas in collaboration with the Obstetrics and Gynecology Department, the chairman of which is Dr. Curtis Lowry, my co-author in this presentation.

My involvement in this project is really on a consultation basis because I also have a joint appointment with the Obstetrics and Gynecology department, and I pretty much run their health clinic, the high risk refer or ultrasound clinic one day a week.

Background

As a background, the Arkansas healthcare population has really been one of the most challenged in the state.

We are 45th in stroke mortality, 40th and preterm births, 46th in occupational fatalities.

And more importantly, we are 48th overall in health.

And this is according to the United Health Foundation for the year 2010.

So the program was started basically to provide healthcare in the medically underserved areas, which in our state means 73 out of 75 counties.

As you can see, little Rock is in the middle of the state and therefore it's in an ideal situation to where we can network throughout different areas in the state.

By currently T one lines, which are slower means of communication as we speak, we have been granted more than a hundred million dollars in federal grants to lay broadband throughout our state.

So hopefully in the future, we can transmit faster data and maybe go into CA evaluations and ultrasound because of the distance of most of these counties from the Central Referral Center, which is in Little Rock, Arkansas, access is the most overwhelming reason for poor health.

Standing of Arkansas from Little Rock to any place in the border is at least a two and a half to three hour ride, and most of our patients cannot afford to come to the Referral Center at the University of Arkansas at Wales.

Purpose and Goals

So the purpose of the project is to ensure that every woman in Arkansas at risk of having a complicated pregnancy, receives the best possible perinatal care under the circumstances.

And we accomplish this by offering community needs based services, not just diagnosis, but also education and training for our providers Locally, centralized technology and scheduling call center support, which is available 24 hours a day, seven days a week.

We also offer telemedicine network and infrastructure where patients and local providers really have access for consultation with the experts in Little Rock.

We also provide evaluation of the project and research related to healthcare access.

And we coordinate cases and provide evidence-based guidelines and protocols for multiple needs of high risk pregnancy women.

The goal of our project is fourfold.

We hope to reduce Medicaid expenditures, improve birth outcomes, decrease healthcare disparity, and hopefully, eventually improve the quality of healthcare in our state.

The first three have been addressed and believed to be successful, but the fourth reason cannot be attained, as I will discuss later, because as we discover more and more high risk situations, the expenditure for in-hospital care and physician services have also increased proportionately.

So therefore, the reduction in Medicaid expenditures could not be accomplished.

Telemedicine Tools

Telemedicine tools that we provide to rural areas consist of realtime video conferencing units designed to use in examination rooms where local physicians can consult with experts by video in surgical settings and in their emergency departments.

We also provide each site a high performance portable ultrasound device that is hooked directly to the video conferencing unit.

And therefore we not only communicate with the sonographer performing the examination, but we can also directly link to the ultrasound screen so we can see exactly what the sonographer is seeing.

The ultrasound images are stored in a storage system that is retrieved at will and is in an archive at the University of Arkansas.

So therefore it can be accessed at many points, not only around the medical center, but also at home.

Network and Operations

Our telemedicine network expansion currently consists of 30 sites and growing.

It is outfitted to deliver a comprehensive range of services in the most rural population.

As you can see on this image, the ultrasound machine that's provided to each site is portable and it is hooked up to a video screen where the patient and her husband and any relative who might wanna participate in the consultation can directly see the healthcare provider and an interpreter if needed to go over the different consultation needs of the patient.

Currently in the year 2010, we have several Kelly Health sites, and as you can tell, here's Little Rock in the center of the state, and each one of these sites are connected by our tele video conferencing.

And if they need a consultation at any time at all, all they need to do is call A hotline number and consultation is available.

We have an advanced practice nurse Rosalyn Perkins, who coordinates and schedules all the consultation and if needed, she can call upon any expert or specialist to cater to the needs of the patient.

So we could have geneticists, we could have dieticians, we could have any other kind of physician that would be needed for counseling.

Consultations and Growth

As you can see, since we started Angels in 2003, the number of consultations have ballooned significantly from 215 to 3,306, and this will be surpassed in the year 2011 according to our latest logs.

Key Personnel

This is Dr. Lowry, who is the chairman of our Department of Obstetrics and Gynecology, who idea this was to begin with and as we speak, he continues to try to gather federal support for this project.

And when it started in 2003, it was a $10 million project, and now the budget has ballooned to about $22 million for fiscal year 2010, 2011.

This is our chief sonographer, Mandy Dixon, who goes around the state training local talent on basic obstetric ultrasound.

And there are two other sonographers, one an expert in fetal echocardiography who does the same thing.

Training and Monitoring

And depending upon what's available, it's usually a radiologic technologist or a nurse that she trains to perform the very basic ultrasound examination.

And since we are monitoring this by real time, we can ask for more images or instruct the sonographer or the operator of the machine to get certain images that we may need from this consultation.

If we deem it necessary for the patient to come to Little Rock because of special tests that we have to perform, then they can make the long trip.

But this does not happen very often because most of the time we can solve the problem by telemedicine on Wednesday mornings.

When I run the high risk obstetric clinic, I also have a pediatric echocardiography expert.

This is Dr. Meyer who runs the clinic with me, and she alternates with another physician, Dr. Tom Best in consulting on fetal echo problems.

Fetal Echocardiography

So even if they can watch the scanning live on screen, more often than not, they would ask for the patient to be transported to Little Rock for better evaluation of difficult see areas.

In the year 2010, we provided 60 tele fetal echos and this is also going to be exceeded in 2011.

Currently, there are four clinics that hold fetal echocardiography consultations, but sometimes are pediatric echocardiographers travel to those sites when there are enough patients to do in one day.

Impact on Healthcare

So the question is, has our Project Angels made a difference in the overall healthcare in the state of Arkansas as shown by these graphs?

The quality of care that our population has received a time of diagnosis has definitely in increased or improved over the years.

And as you can see, this is first trimester, second trimester, and third trimester.

And first trimester screening has ballooned our state and has been availed of by multiple high risk patients.

The quality of care at the time of delivery has also changed significantly.

We do not see very many pregnancies, less than 25 weeks gestation, but above 25 and up to term, there has been a significant increase or change in the delivery of these patients at tertiary care centers.

And the bottom graph shows you the percentage of infants that were delivered in hospitals, which has also increased over the years.

Now, when patients need some specialists in other areas, their access has also been increased, especially from the northeastern part of the state where most of our referrals come from.

And so not only can we provide maternal fetal medicine experts and ultrasound expertise, we also provide other medical or surgical expertise is needed at delivery.

We have several ways to improve the outcomes of delivery if needed.

We can fly the patient over by helicopter in urgent cases, but most of the time we have delivery planning where the patient comes about four weeks before her due date and delivery is planned and everybody's present.

And if the fetus needs any special immediate care, it could be provided in a teamwork type setting.

Birth Outcomes

Our birth outcomes have significantly changed.

Our mortality rates have decreased over the years.

And in this graph down here and all ages of gestation, the neonatal deaths per thousand births have significantly decreased.

These are more graphs showing the weight, fetal weight at delivery.

And as you can tell, there has been quite a significant change in the way we deliver babies.

Medicaid Expenditures

This is the goal that failed.

Initially, we felt that we could save Medicaid dollars by providing this access to healthcare, but as you can see, the emergency room visits, the cost of drugs, the cost of the number of ultrasounds that we perform all contributed to an increase in the per capita expenditure for every mother that we deliver that has a high risk pregnancy.

But this really wasn't dissipated because it was difficult to have a baseline when a lot of the women that we should have seen did not have access to healthcare at that time.

Achievements

So what have we achieved by this project?

We have an increase in the number of telemedicine ultrasounds performed.

We enhance the quality of care not only at the time of diagnosis, but also at the time of delivery.

We likewise enhance quality of pediatric and neonatal care because once these patients are enrolled in the project, they're followed through even after delivery.

We enhanced access to consultations and tertiary care services for high risk pregnant women where most of these women who never had a chance to come to a referral center before can now be examined in their hometowns and connected to the right experts.

We therefore have improved breath outcomes because of not only increased access to care, but also better management of medical problems.

Conclusion

So if there are any more information about the programs that are needed, you can log into this website and learn more about the Angels Project.

And with that, I will end my presentation.