MObile Maternity (MOM) project

Supporting women’s maternal health through telemedicine

Dr. Shiraz Moola, OBGYN Nelson, BC | Jude Kornelsen, PhD CRHR | Mona Mattei, Project Coordinator

Project Summary

Dr. Moola (OBGYN – Nelson) provides real-time obstetric consultations for elective and emergent conditions through the use of Interior Health’s secure technology (RealPresence) using mobile devices and facility endpoints.

These consultations range from booked, elective tele-video appointments to urgent bed-side assessments in hospital, clinic or at home.

Practically, this may involve improved shared care of high-risk pregnancies to reduce patient travel to see a specialist, and, in less common situations, support for precipitous deliveries in communities without a local maternity care program.

Background The disparity in the distribution of prenatal care has maternal/newborn health care consequences

Geographic location, weather, and socio economics status play a role in disparities to access to care

The morbidity for pregnant mothers and their offspring who need to travel for maternity care is evident in BC ( Grzybowski et al 2013)

Numerous applications range from electronic data transmission between individual patients or providers, distant clinics in rural areas and tertiary prenatal care centers, to live interactive sessions between providers and patients

Many of the novel telemedicine programs are focused on providing better linkage

between rural providers and urban specialists

(ie: ANGELS program – Arkansas)

Telemedicine uses in obstetrics

Text messaging – to engage with patients, education, improving attendance at clinic visits

Telecounselling

Fetal Echocardiography

Management of diabetes in pregnancy

Fetal monitoring

Postpartum care

Tele US

A Cochrane review of video- consults and home health care or self-monitoring at home have shown no detrimental effects of this type of equipment, but neither have they shown unequivocal benefits. The authors of the Cochrane review caution about increased use and investment in this type of technology without further research validating benefits.

Project Description We have equipped primary maternity care providers clustered around six rural hospitals and medical clinics across Interior Health Authority with portable tablets;

The consulting OB/GYN at Kootenay Lake Hospital located in Nelson, BC is linked for virtual face-to-face communication between patients and providers using tablets or facility video systems;

This represents a change from traditional linear communication between patient and specialists, to an all-inclusive approach that involves all three stakeholders. This change enhances the conditions for optimal care to a triad model (patient, primary care provider, specialist);

Funding through Specialist Services Committee

Nov 2016 – Nov 2018

Key Activities/Outputs

Obstetrical consultations for high-risk pregnancies/antenatal consultation and post-partum complications via video conference infrastructure.

Didactic educational learning through joint clinical visits (between primary care provider and specialist)

Peer support opportunities in the event of unexpected perinatal complication.

Remote assessment of fetal surveillance (non-stress test) by specialist.

Review of radiologic assessments; “tele-preceptor/telementor” point-of-care Ultrasound assessment

Training and Orientation to MOM Preparation of consent forms, evaluation tools

Creation of: ◦ Telehealth guidelines based on physician

workflow preferences

◦ Best practices tool based on IHA guidelines and COACH guidelines

◦ Suggested emergent care algorithm

◦ Patient handout

◦ Additional promotional information for patients

◦ Feedback surveys to capture immediate impressions of experience for both patients and physicians / midwives

Training and Orientation (continued) Reference tool for use of video conferencing software

Troubleshooting guide with IH IT team for desktop software

Specialist visit log and comments

One hour orientation session with physicians and provision of toolkit

Optimization of iPads with IT support

Online evaluation surveys linked to iPad

Evaluation and Anticipated Outcomes

TARGET GROUP OUTCOME MEASURES

Rural Parturient Women

Increased capacity for women to remain in home community; improved access to specialist care; reduced patient travel for fetal surveillance

Patient survey/follow-up interviews; patient data through chart audits

Summative Overview 8 Virtual consultations to date ~ 6 GP/MW present for the appointments

Patients said:

They were happy with (technical) quality of the consult

None felt the need for a follow up face to face meeting

reported improved communication between primary care provider and Specialist

Primary care providers:

Reported high level of engagement (Specialist requested information)

Expressed ‘learning something of value’ during the consult

Reported the technology improved patient care “very much”

Patient Quotes DID YOU SAVE MONEY?

“Absolutely… $50.00 in gas, then I have to take a holiday for my time off and arrange for either before or after care for my son. This is an excellent idea.”

DID ‘MOM’ HELP MITIGATE THE CHALLENGES OF RURAL CARE?

“Travelling is a challenge, living in a rural area. Having access to the video conference was very convenient and reduced our need to travel more than necessary in the middle of winter.”

Care Provider Quotes HOW DID THE TECHNOLOGY IMPROVE PATIENT CARE?

“The reassurance of the specialist definitely prevented inappropriate intervention, and possibly transfer out.”

“The convenience of the videoconference cannot be stressed enough. My patient felt that she received an assessment, and had an opportunity to get all her questions answered.”

“We do not have specialists in house to assist with urgent/emergent situations. We also have to appreciate the inability to deliver care during transport, and therefore keep and manage situations that are usually managed by a specialist. With the iPad, we can patch a specialist into the delivery room in real time to assist virtually. Viewing a worrisome strip together is much more effective than trying to fax it piecemeal or describe it over the phone.”

DID YOU LEARN SOMETHING OF VALUE?

“Yes. Was great to know plan of care and be able to be involved in plan. Was great to ask questions in person instead of waiting to see if they were answered in a consult letter.”

“Absolutely. As a GP surgeon, I find it incredibly helpful to hear how (and which words) Dr Moola obtained surgical consent. I will definitely change my practice by focusing more on this and finding better ways to explain to the patient what we are doing, risks etc.”

“Definitely. I had a complex question about hormone profiles and treatment that I did not understand. I will be able to manage my patients much better in the future, now that I understand his way of thinking”

Opportunities for Expansion

‘Scale and spread’ to North Vancouver Island

Expansion in West Kootenays

Economies of scale: preparatory work to develop key infrastructure in place with ability to transfer and localize information easily with spread of program

Keys to success

◦ To have personal contact for training and testing with physicians and midwives in remote sites

◦ Build close relationship with IT team to provide support

◦ Patient recruitment – OB/GYN needs to triage cases and approve / encourage use of system along with champions on site in rural areas

◦ Ease of use: the more “unconnected” the system the more challenging it will be – wifi vs. wired; Cellular vs. wifi

◦ Willing to use a variety of telehealth modalities to achieve goal

◦ Championing the choice to use telehealth vs. in person

(Anticipated) Benefits/Sustainability

Low cost/high benefit ratio

Ease of uptake

Fee-for-service codes facilitate GP-specialist video conferencing (fee code 13020 GP telehealth assist and individual SP codes)

Costs to the patients lessen with respect to decreased travel, time away from work and family to seek specialist assessment.

“I think this is a fantastic program to provide for people in rural areas, especially for those who live on limited incomes and the cost of travelling can become a financial burden. All of my questions were answered, as well as information was given to me about the procedure that I seek to have done, and I feel that I walk away from this very well informed and comfortable.”

~ Patient