Reaching Out Across the Miles: The Role of Telehealth in Maternal and Child Health

1. Reaching Out Across the Miles: The Role of Telehealth in Maternal and Child Health Lorie Wayne Chesnut, DrPH, MPH University of Kentucky College of Public Health With special thanks to Rob Sprang, MBA, Director, Kentucky TeleCare Photo by Pat Richter, Colorado

2. It all started with a question from a State Title V leader ... “I wonder how other states are using telehealth systems to improve maternal and child health? “

3. Telehealth and MCH Examples from the field Photo by Don Chesnut: Upper Peninsula, MI

4. Methods • Search Terms Used • Telehealth • Telemedicine • Tele- • Teledentistry • Telerehabilitation • Telepsychiatry • Teleaudiology • Telegenetics Data Source: Title V MCH Block Grant TVIS System (2012/2014) Annual Reports and Applications Step 1: Narrative Text Search Step 2: What telehealth project is associated with each National or State Performance Measures ? Step 3: Compile results for each performance measure. Step 4: Calculate frequencies and conduct in-depth interviews for particularly interesting or creative telehealth applications https://perfdata.hrsa.gov/mchb/TVISReports/Default.aspx

5. Limitations • States strive to include information in their annual report about programs that improve access and care for disparate populations. But space for narrative within the TVIS system is limited. • This fact may result in a lack of information about telehealth activities currently underway in communities around the state. • More may be going on then is reported in the Title V narrative. Photo: Don Chesnut. Seney Wildlife Refuge, Upper Peninsula, MI, 2013

6. Most Common Telehealth Applications by Title V NPM

7. Additional Telehealth Applications by Title V NPM

8. The MCH Pyramid Examples of Telehealth Applications Medical consultations, outreach clinics, follow-up services for patients with established diagnoses. CYSHCN. School-based dental exams, cleanings, fluoride varnish application, dental sealants. Mental health counseling, telepsychiatry consults, family and individual therapy. Direct Health Services Health education, individual and family support, case management, translation support, rural outreach. Genetic counseling. High-risk maternal and infant transport coordination. Telehealth services bring access to rural populations by reducing travel time to clinic sites. Enabling Services Health Screenings including school-based dental and mental health screenings, hospital-based audiology screenings. High-risk pregnancy monitoring Population-Based Services Provider training and continuing education, evidence-based guideline development, evaluation, health care quality and standards, service monitoring, billing systems, stress management and mental health support for health professionals in rural areas. Infrastructure Services

9. Overview: Telehealth Activities to Address Select MCH Outcomes Newborn Metabolic Screening Children/Youth with Special Health Care Needs Newborn Hearing Screening High Risk Delivery Dental Services

10. Newborn Metabolic Screening/Genetic Services Telegenetics is defined as “the use of telemedicine for the provision of clinical genetics services.” Clinical genetics includes types of sub- specialty areas including prenatal, pediatric, biochemical and cancer. • Providers are often based in urban areas at tertiary centers, thus out of the reach of infants, children and their families who live in rural areas. • States set up genetic clinics on a rotating schedule based on population need. While this improves access to care, needs of children and families are often not met or only partially met. • In 2004, the Maternal and Child Health Bureau funded 7 regional genetic collaboratives and a national coordinating center to support genetic services for pregnant women, infants and children in the U.S. (National Coordinating Center for the Regional Genetic and Newborn Screening Service Collaboratives @ http://www.nccrcg.org)

11. HRSA Regional Genetics and Newborn Screening Collaboratives* Initial visits are usually done in person. Telegenetics is typically used for genetic counseling and follow-up care. • Barriers specific to telegenetics practice: • Fewer clinical geneticists and genetic counselors are being trained. While telehealth improves their ability to consult with individuals in remote sites, their time may be even further stretched with the acquisition of additional patients. • Interstate practice issues (such as licensing) are also a problem. This is a particular issue for “supersubspecialists” who might specialize in rare genetic disorders and who might be needed to consult for only a few cases each year. *Source: NNSGRC. Accessed 01-14-14 at http://genes-r-us.uthscsa.edu/resources/genetics/StatePages/genetic_region_map.htm

12. Children & Youth with Special Health Care Needs (CYSHCN) • Broad categories of services include clinical management (endocrinology and diabetes care, neurology, dermatology, cardiology, etc.), nutritional counseling, rehabilitation and neurodevelopmental services, family case-management, etc. • Many states note telehealth services for the CYSHCN population. • Children in rural communities often have difficulty accessing medical specialists, rehabilitation services, neurodevelopmental services. Example: Telerehabilitation, defined as “the delivery of rehabilitation services via information and communication technologies”. The delivery of these services may include a broad array of providers including physical therapists, speech-language pathologists, occupational therapists, audiologists, dieticians, psychologists, assistive technologists. Source: ATA, A Blueprint for Telerehabilitation Guidelines (2010)

13. Newborn Hearing Screening: Applications and Public Health Implications • For teleaudiology in general, two • synchronous models: • High-quality interactive video, remote (local) technician tests under the supervision of the clinician located at the hub site. Patient data obtained, clinician diagnoses, recommends management. • Remote-control computer enables clinician at hub site to test patient directly at remote site. No technician necessary at remote site, however facilitator needed for some tasks. • Not yet widely used, first use about 15 years ago. • Few published articles regarding efficacy – need for more research. • Needed to provider/family access in rural areas • Loss-to-follow-up following after failure of hearing screening* (HRSA estimates 40% of infants recommended to return never do ) • HRSA funding a teleaudiology pilot project in North Dakota**. Resource: Krumm M & Syms MJ. (2011). Telehealth in otolaryngology Teleaudiology. Otolaryngologic Clinics of North America. Volume 44 (6):1297-1304 ** Rural Assistance Center. Teleaudiology: Taking Diagnostics to the Infant http://www.raconline.org/success/project-examples/641

14. TeleAudiology: Taking Diagnostics to the Infant (North Dakota, Minot State University) • Developed by Neil Scharpe, Steve Peterson and Tom Froelich at Minot University and completed in August 2010. • Funded through a 2-year HRSA contract awarded to the North Dakota Center for Persons with Disabilities at Minot State University (one of about 60 Centers of Excellence for persons with disabilities in the nation) • Charged with creating protocols to complete audiology diagnostics with infants 0-6 months of age using the internet • Three deliverables: • Management Protocol • Technical Protocol • Tool Kit For more information about North Dakota’s TeleAudiology Protocol and Tool Kit, contact: Neil Scharpe, DirectorGreat Plains Center for Community Research and ServiceMinot State University500 University Ave. WestMinot, ND 58707neil.scharpe@minotstateu.eduPhone 701-858-3596

15. Regionalization of Perinatal Care – Level of Care and Volume of Deliveries Matter! Why is the system “breaking down”? • Shortages of providers in rural areas (preference to practice in urban locations) • High cost of malpractice insurance driving OB/GYNS and Pediatricians out of rural communities • High-risk patients in rural areas • Medicaid reimbursement issues • Financial competition among hospitals for patients • Patient choice – they want to remain near home ACOG Committee Recommendation: Encourage and participate in efforts to utilize effective telemedicine technologies to expand and improve services for rural women. - ACOG Committee Opinion Number 429, March 2009, Obstetrics & Gynecology, 113(3):762-765. Hall et al., 2010

16. ANGELS: Distant Obstetric Care Delivery in Arkansas • ANGELS = Antenatal & Neonatal Guidelines, Education and Learning System • Collaboration between Arkansas Medicaid Program and the University of Arkansas for Medical Sciences. Link: http://angels.uams.edu/ Purpose • To enhance primary obstetrical care in rural areas and small communities across Arkansas • To increase appropriate referrals of high-risk obstetric cases to board-certified maternal –fetal medicine specialists To assure that all Medicaid obstetric recipients have access to the highest quality perinatal care including genetic counseling Lowery et al., 2007

17. ANGELS: Distant Obstetric Care Delivery in Arkansas Empoweringthe local provider through: • Telemedicine support • Consultation • Best Practices development and adoption Fetal-Medicine Specialists (all located in Little Rock) • Promote interaction between providers statewide • Enable earlier recognition of high-risk pregnancies/births • Facilitate transfer to Level III hospitals when indicated • Increase accessibility to FM specialists. ANGELS Components • Statewide telemedicine and clinic network • Education and support program for obstetrical providers • Case management services • A 24-hour call center • An evidence-based guidelines development and distribution network. Lowery et al., 2007.

18. ANGELS: Distant Obstetric Care Delivery in Arkansas Connecting ... • Area Health Education Centers (AHEC) • ~ 40 hospitals and rural health centers via telemedicine network Enabling ... • Consultations with rural practitioners and patients • Live examinations and ultrasounds over interactive video • Meetings with hospital administrators and their staff • Dissemination of protocols, best-practice information, etc. Evaluating ANGELS • Volume of MFM consults to OB patients • Volume of case management calls moving through the call center from OB patients and providers • Volume of high-risk maternal transports at UAMS • Volume of evidence-based guidelines distributed to OB providers • Volume and proportion of LBW and VLBW births delivered at Level III facilities Lowery et al., 2007

19. Why Do We Need Teledentistry? • Shortage of dental providers in rural areas • Shortage of dentists, dental hygienists and other dental professionals nation-wide. • “Graying” of the nation’s dental workforce – retirement, fewer days worked for current practitioners and too few providers trained at U.S. Schools of Dentistry • The cost of setting up a new dental practice is high – providers prefer to practice in urban or metropolitan areas • Dental Hygienists scope of practice – independent or under the supervision of a dentist (varies state-to-state and by service) “Advanced communication technologies may create new bridges among dentists. Advances such as videoconferencing and real-time on-line collaboration will make various forms of "teledentistry" possible and practical. Legal, licensure, and political considerations may prove more difficult to address than technical ones.” - The Future of Dentistry: Today’s Vision: Tomorrow’s Reality, ADA, 2001

20. Arizona’s Oral Health Workforce Grant (Teledentistry) 2009 Purpose: “To promote and develop enhanced dental teams utilizing teledentistry practice and/or affiliated practice to improve workforce capacity, diversity and flexibility for providing oral health services to underserved populations and underserved areas”. Objectives: • Build and expand regional/local program development infrastructure • Train providers for enhanced dental teams and increase provider understanding and competencies for teledentistry practice and affiliated practice • Educate and increase awareness of program administrators, policymakers and funders about enhanced dental teams and how teledentistry practice and affiliated practice can increase workforce capacity and flexibility in community settings • Increase the number of enhanced dental teams at the state, regional and local levels • Develop and gather resource materials, tools and lessons to support development of practice models, making this information accessible to providers, programs and communities. Accessed 01/16/14 at http://azdhs.gov/phs/owch/oral-health/azsmiles/documents/about/EDT_Grant-Program-Key-Points.pdf

21. Arizona’s Oral Health Workforce Grant (Teledentistry) 2009 Benefits Realized Include ... • School-based preventive care for pre-school and school-aged children. Kids don’t have to miss school –the services come to them. Oral health evaluation collects data and triages children based upon needs. Time-saving, child not lost-to-follow-up. • Allows for partnership with Head Start – this group may be difficult to reach. Families may live a long way from a dentist • Involves school nurses – a great resource for children and families • Provides preventive care to inner-city children. • Develops curricula for dental hygienists – what is really needed in the “real world” – in partnership with North Arizona University. • Provides training for dentists on how to treat children/youth with special health care needs. • Building partnerships throughout Arizona, between dental providers, policy specialists and other stakeholders. Source: Personal Communication Julia Wacloff, RDH, MSPH 01/11/11. Note: In Arizona, registered dental hygienist s are allowed to provide dental hygiene services under an affiliated practice relationship with a licensed dentist.

22. Arizona TeleDentistry: Lessons Learned • Strong infrastructure critical (advanced IT support, business model, administrative support, encryption) • Equipment and technology continue to evolve. Equipment you purchase today (whether technology or peripherals) is outdated in just a few years. • As equipment and techniques change, so must people evolve. Training needs are continuous and challenging. • Reimbursement continues to be a challenge. Not all children involved are Medicaid enrollees. Few private insurance policies support teledentistry. In Arizona, IHS insurance adds to the mix. • For both patients and providers, teledentistry can be a GREAT educational tool. Families and the child can see the decayed tooth. • Oral cameras can also be used to teach youth about oral cancers – visual images make a difference. Source: Personal Communication Julia Wacloff, RDH, MSPH 01/11/11 More about teledentistry in Arizona: http://www.azdhs.gov/phs/owch/oral-health/documents/reports/teledentistry-arizona.pdf

23. What’s next? Watch our site for a special series of webinars entitled “Telehealth & You: All you need to know but just what you need to know!” • This series will have short presentations directed to Title V MCH Leadership, Providers, and Technologists, as well as others. We won’t overwhelm you with all of the “nuts and bolts” of complete telehealth systems – you can pick and choose depending upon your interests and needs. Presentations and papers about the uses of telehealth technology to improve MCH outcomes – learn about teleaudiology, teledentistry and how the field of mental health use telehealth systems to improve access to care! Consulting by Rob Sprang, MBA, Director, Kentucky TeleCare for specific state needs regarding telehealth. Rob has a long history of working in telehealth and has also served as President of the Board of Directors for the Center for Telehealth and e-Health Law (Washington DC) and is currently President of the Board of Directors for CTeL Innovations. Rob is always pleased to share his expertise about telehealth systems and how these can be used to improve MCH outcomes.

24. Resources for Further Information A Few Websites for Future Interest American Telehealth Association http://www.americantelemed.org/i4a/pages/index.cfm?pageid=1 The Center for Telehealth and e-Health Law http://www.telehealthlawcenter.org/ American Academy of Pediatrics http://www2.aap.org/sections/telecare/ Health Resources and Services Administration: Telehealth. http://www.hrsa.gov/telehealth/default.htm The Telemedicine & Advanced Technology Research Center (TATRC) (Department of Defense). http://www.tatrc.org/

25. Resources for Further Information A Sampling of MCH Programs Utilizing Telehealth Technology AFHCAN Telehealth Solutions http://www.afhcan.org/ TeleAudiology: Taking Diagnostics to the Infant http://www.infanthearing.org/meeting/ehdi2010/ehdi_2010_presentations/TeleAudiology.pdf The Antenatal and Neonatal Guidelines, Education and Learning System (ANGELS) http://angels.uams.edu/(Arkansas)

26. Resources for Further Information Selected Reports Hein, MA. (2009) Telemedicine: An Important force in the Transformation of Healthcare. U.S. Department of Commerce, International Trade Administration. Hersh, WR., Hickam, DH., Severance, SM., Dana, TL., Krages, KP, Helfand, M. (2006) Telemedicine for the Medicare Population: Update. Oregon Evidence-based Practice Center, Portland, OR. (Prepared for the Agency for Healthcare Research and Quality, HHS). Clinical Diagnosis & Management Cluster (2006). Telegenetics Summary Document. Region 4 Genetics Collaborative. Center for Telemedicine Law (2003). Telemedicine Reimbursement Report. Washington, DC. Puskin, DS., Kumekawa, JK. (2001). 2001 Telemedicine Report to Congress. Office for the Advancement of Telehealth, HRSA/HHS

27. Citations (page 1 of 2) Books: Darkins, AW and Cary, MA. Telemedicine and Telehealth: Principals, Policies, Performance, and Pitfalls. New York, NY; Springer Publishing; 2000. Institute of Medicine. Telemedicine: A Guide to Assessing Telecommunications in Health Care. Washington, DC; National Academy Press; 1997. Additional Reports and Publications American Telemedicine Association (2010) A Blueprint for Telerehabilitation Guidelines. Accessed 01/23/11 at http://www.americantelemed.org/files/public/standards/ATA%20Telerehab%20Guidelines%20v1%20(2).pdf Au, S., Hasegawa, L, Silvey, K., Stock, J. (2010) Regional Genetic Services Practice Model Evaluation: Report on Delivering Genetic Service via Outreach and Telehealth in Guam and the Western States. Western States Genetic Services Collaborative. Bronstein JM, Ounpraseuth S., Jonkman J, Fletcher D, Nugent RR, McGhee J, Lowery CL. (2012). Use of speciality OB consults during high-risk pregnancies in a Medicaid-covered population: initial impact of the Arkansas ANGELS intervention. Med Care Res Rev. 69(6):699-720. Hall RW, Hall-Barrow J, Garcia-Rill E. (2010) Neonatal regionalization through telemedicine using a community-based research and education core facility. Ethnicity and Disease. 20(1 Suppl 1): S1-136-40 Kim EW, Teatue-Ross TJ, Greenfield WW, Keith Williams D, Kuo D, Hall RW. (2013) Telemedicine collaboration improves perinatal regionalization and lowers statewide infant mortality. Journal of Perinatology. 33(9):725-30.

28. Citations (page 2 of 2) Krumm, M., Ribera, J., Schmeidge, J. (2005) Using a Telehealth Medium for Objective Hearing Testing: Implications for Supporting Rural Universal Newborn Hearing Screening Programs. Seminars in Hearing. 26(1):3-12. Krupinski, E., Dimmick S., Grigsby, J., Mogel G., Puskin D., Speedie, S., Stamm, B., Wakerfield, B., Whited, J., Whitten P., Yellowlees, P. (2006). Telemedicine and e-Health. 12(5):579-589. Lamar, R. (Ed.). (2004) Evolution Summative Evaluation of the Alaska Federal Health Care Access Network Telemedicine Project. Alaska Native Tribal Health Consortium, University of Alaska, Alaska Telehealth Advisory Council. Lowery C, Bronstein J, McGhee J, Ott R, Reece EA, Mays GP. (2007). ANGELS and University of Arkansas for Medical Sciences paradigm for distant obstetrical care delivery. Am J Obstet Gynecol. 196(6):534.e1-9. Nemes, J. (2010). Tele-audiology, a once-futuristic concept, Is growing into a worldwide reality. The Hearing Journal. 63(2):19-24 Novotney, A. (2011). A new emphasis on telehealth – How can psychologists stay ahead of the curve – and keep patients safe? Monitor on Pcyshology(APA). Accessed 01/16/14 at https://www.apa.org/monitor/2011/06/telehealth.aspx Patricoski, C. (2004) Alaska Telemedicine: Growth Through Collaboration. International Journal of Circumpolar Health 63(4) 365-386 Scharpe, N., Peterson, S., Froelich, T. TeleAudiology: Taking Diagnostic to the Infant. North Dakota Center for Persons with Disabilities and Minot State University Center of Excellence. Accessed 01/24/11 at http://www.infanthearing.org/meeting/ehdi2010/ehdi_2010_presentations/TeleAudiology.pdf