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
January 2014
Photo by Pat Richter, Colorado
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? “
January 2014
Examples
from the field
Photo by Don Chesnut: Upper Peninsula, MI
January 2014
Methods
Data Source: Title V MCH Block Grant TVIS
System (2012/2014) Annual Reports and
Applications
Search Terms
Used
Telehealth
Telemedicine
Step 1: Narrative Text Search
Tele-
Step 2: What telehealth project is associated with each
National or State Performance Measures ?
Teledentistry
Step 3: Compile results for each performance measure.
Step 4: Calculate frequencies and conduct in-depth
interviews for particularly interesting or creative
telehealth applications
Telerehabilitation
Telepsychiatry
Teleaudiology
Telegenetics
https://perfdata.hrsa.gov/mchb/TVISReports/Default.aspx
January 2014
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.
January 2014
Photo: Don Chesnut. Seney Wildlife Refuge,
Upper Peninsula, MI, 2013
Most Common Telehealth Applications by Title V NPM
NPM # and Description
# of States Reporting
Use of Telehealth
(12/14 Application/Annual
Report)
NPM #01: The percent of screen positive newborns who received timely
follow up to definitive diagnosis and clinical management for condition(s)
mandated by their State sponsored newborn screening programs.
9 states
NPM #05: The percent of children with special health care needs age 0 to
18 whose families report the community-based service systems are
organized so they can use them easily.
9 states
NPM #12: The percent of newborns who have been screened
for hearing before hospital discharge.
NPM #17: The percent of very low birth weight infants delivered at
facilities for high-risk deliveries and neonates.
January 2014
7 states, 1 territory
6 states
Additional Telehealth Applications by Title V NPM
NPM # and Description
# of States Reporting
Use of Telehealth
(12/14 Application/Annual
Report)
NPM #03: The percent of children with special health care needs age 0 to
18 who receive coordinated, ongoing, comprehensive care within a medical
home.
5 states, 1 territory
NPM #09: Percent of third grade children who have received protective
sealants on at least one permanent molar tooth.
3 states
NPM #15: The rate (per 100,000) of suicide deaths among youths aged 15
through 19.
2 states
January 2014
The MCH Pyramid
Examples of Telehealth Applications
Direct
Health
Services
Enabling Services
Population-Based Services
Infrastructure Services
January 2014
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.
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.
Health Screenings including school-based
dental and mental health screenings,
hospital-based audiology screenings. Highrisk pregnancy monitoring
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.
Newborn Metabolic Screening
Children/Youth with Special Health Care Needs
Newborn Hearing Screening
High Risk Delivery
Dental Services
January 2014
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 subspecialty 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)
January 2014
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
January 2014
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)
January 2014
Newborn Hearing Screening: Applications and Public
Health Implications
For teleaudiology in general, two
 Not yet widely used, first use about 15
years ago.
synchronous models:
•
 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**.
•
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.
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
January 2014
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:
1. Management Protocol
2. Technical Protocol
3. Tool Kit
January 2014
For more information about North Dakota’s TeleAudiology
Protocol and Tool Kit, contact:
Neil Scharpe, Director
Great Plains Center for Community Research and Service
Minot State University
500 University Ave. West
Minot, ND 58707
neil.scharpe@minotstateu.edu
Phone 701-858-3596
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
January 2014
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
1. To enhance primary obstetrical care in rural areas and small communities
across Arkansas
2. To increase appropriate referrals of high-risk obstetric cases to boardcertified 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
January 2014
ANGELS: Distant Obstetric Care Delivery in Arkansas
Empowering the local provider
through:
 Telemedicine support
ANGELS Components
1.
 Consultation
 Best Practices development and
adoption
Fetal-Medicine Specialists (all
located in Little Rock)
 Promote interaction between
providers statewide
 Enable earlier recognition of highrisk pregnancies/births
 Facilitate transfer to Level III
hospitals when indicated
 Increase accessibility to FM
specialists.
January 2014
2.
3.
4.
5.
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.
ANGELS: Distant Obstetric Care Delivery in Arkansas
Connecting ...
 Area Health Education Centers (AHEC)
 ~ 40 hospitals and rural health centers
via telemedicine network
Enabling ...
Evaluating ANGELS
1.
2.
 Consultations with rural practitioners
and patients
3.
 Live examinations and ultrasounds over
interactive video
4.
 Meetings with hospital administrators
and their staff
 Dissemination of protocols, bestpractice information, etc.
5.
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
January 2014
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
January 2014
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:
1.
2.
3.
4.
5.
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
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.
January 2014
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:
January 2014
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.
January 2014
Resources for Further Information
A Few Websites for Future Interest
American Telehealth Association
The Center for Telehealth and e-Health Law
American Academy of Pediatrics
Health Resources and Services Administration: Telehealth.
The Telemedicine & Advanced Technology Research Center (TATRC) (Department of
Defense).
January 2014
Resources for Further Information
A Sampling of MCH Programs Utilizing Telehealth Technology
AFHCAN Telehealth Solutions
TeleAudiology: Taking Diagnostics to the Infant
The Antenatal and Neonatal Guidelines, Education and Learning System (ANGELS)
(Arkansas)
January 2014
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
January 2014
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.
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