Bringing Technologies to Rural and Remote Communities DR. VERONICA MCKINNEY DIRECTOR, NORTHERN MEDICAL SERVICES U OF S HIGHLIGHTS IN MEDICINE 2018 6/28/2018 Speaker Disclosure I do not have an affiliation (financial or otherwise) with a pharmaceutical, medical device or communications organization I do not intend to make therapeutic recommendations for medications that have not received regulatory approval (i.e. “off-label” use of medication). 6/28/2018 Presentation Disclosure No financial or in-kind support was received from a commercial organization to develop this presentation. The speaker has not received any payment, funding or in- kind support from a commercial organization to present at this event. 6/28/2018 Learning Objectives Will be able to name 2 challenges to providing care in remote communities. Will be able to name 2 innovative technologies that can enable patient care from a distance. Will be able to name 2 advantages to using technology 6/28/2018 Introduction Saskatchewan – many rural and remote communities Some of the largest challenges exist in the Northern parts of our province/country Often are the homes of our First Nations, Inuit and Métis Reduced access to care E.g. Morbidity and mortality rates in women and children that rival those in third world countries 6/28/2018 Northern Medical Services Division within Dept. Academic Family Medicine, U of S Mandates: Primary Medical Care and Health Promotion Consultant Medical Care Public Health/Medical Health Officer Research Education Provide physician services to Northern half of the province (Northern SHA, Athabasca Health Authority) 6/28/2018 40,000 people -50% live on reserve 307,000 km2 >85 % Indigenous (FN, Metis) -65% First Nations >65% speak a language other than English as first language -Cree -Dene -Le Michief 6/28/2018 50% our population < 25 yoa Fewer Elderly Higher dependency ratio 8 Double the birth rate compared to general population 6/28/2018 Labour and Delivery More women are voting with their feet and staying in the community to deliver. Challenge is that they often have poor prenatal care (if any) and then are delivering as ‘urgent’ or ‘emergent’ deliveries – not ideal, potential for poor outcome. Some physicians have not provided obstetrical care in recent times. 6/28/2018 Northern SK - Challenges High mortality rates Health disparities Added burden of colonization, legacy of residential schools, 60s scoop, children in government care Cult ural issues Racism – internalized, personally mediated, institutional Northern SK - Challenges Food Housing Safet y Few employment opportunities Povert y Reduced access to health care professionals Huge land mass, communities ‘spread out’ Reduced Access to Care Travel Road/Air Limited access Medical vans to urban centers Childcare Financial 6/28/2018 Reduced Access to Care Prenatal care Often miss appointments May not obtain an ultrasound Increased morbidity and mortality Labor and Delivery Outside of their community, away from family Gynecological issues Pap tests STIs 6/28/2018 Health Care Services Family Physicians are stationed out of 5 sites: Ile a la Crosse La Loche Stony Rapids La Ronge Pelican Narrows 6/28/2018 Health Care Services Local Hospitals at sites where physicians reside (except Pelican Narrows – is a nursing station) Only La Ronge has planned deliveries No OR capacity Physicians provide in person services to outlying communities (in/out same day), phone support to nursing staff Jurisdictional issues (Federal/provincial/interprovincial) 6/28/2018 Health Care Services 3 of our sites have itinerant physicians Staff turnover less than other Northern sites (Canada) for physicians Nursing – high turnover rates Often feel unsupported Wide variation in level of experience/knowledge Specialists attend clinics at hospital sites or see patients in regional or tertiary care centres 6/28/2018 Community visits U/S Technicians Pediatrics Obstetrician/Gynecologist Orthopedics ENT Psychiatry General Surgery Internal Medicine Dermatology Missed appointments Limited volume Limited times (3 – 4x per year) Cost Travel 6/28/2018 6/28/2018 Technology – Smart Phones Texting: appointment reminders Messaging re: self-care Facebook Messages/reminders More often used in context of clinic Smart Phone Apps Have one for mental health Potential to develop for prenatal care Technology - Video-conferencing Computer/ipad based program Requires camera, microphone and speaker Allows for team meetings when members are distributed ‘face to face’ contact Improves communication Ability to record Can plan ahead or do immediately Requires adequate band width Not HIPPA safe Facetime and Skype fall into this category 6/28/2018 Technology – Traditional Telemedicine Are available at most of our nursing stations and hospitals Poor uptake by our physicians – especially specialists Often have to go to hospital or special area to use Requires ‘set up’ – often a tech for each site Have to book ahead – can be bumped System is geared to doing one consult vs a clinic Good for meetings, education Requires another health care provider to make use of accessories (e.g. stethoscope, dermatoscope) 6/28/2018 Technology – Remote Presence Pelican Narrows First Nation community Population 3500 Closest hospital is Flin Flon, MB (1.25 hr drive) Airstrip is 45 min away over rough/rolling gravol roads Funded for 4 ‘Dr Days’ a week Nursing station 50% population < 20 yoa 6/28/2018 Remote Presence – Pelican Narrows Large gaps in service Recruitment and retention of staff difficult Lack of resources TB outbreak – housing issues Trauma Death of children Poor morbidity/mortality rates pregnant women, newborns 6/28/2018 Remote Presence – Pelican Narrows Started with communit y engagement Community had heard about Nain experience Supporting community as they seek better access to health care – walking with Need to build relationships, trust 6/28/2018 Remote Presence – Pelican Narrows Engagement of Decision makers Federal Government Provincial Government Tribal Councils/ Band NITHA Regional Health Authority 6/28/2018 Remote Presence – RP7 6/28/2018 “Rosie” Provider can move on their own – doesn’t need a nurse or other provider to do Amazing resolution Bi-aural hearing – can run a code, direct a delivery Can overlay icons/’hands’ on screen to show/demonstrate to person on receiving end Several attachments, including an ultrasound 6/28/2018 Remote Presence in Pelican Narrows – Pediatric Care 40 kids in respiratory distress Pediatrician ‘saw’ these children in the nursing station Treatment was initiated immediately 60% were able to remain in the community Of the 40% that were sent out, 40% were able to go to a regional hospital (closer to home) Savings in transportation along was $240,000! Have now seen over 150 kids! 6/28/2018 Remote Presence – Benefits Noted Ability to provide direct patient care where the patient is Much improved engagement and empowerment of our patients/families Family can attend Patients are able to see and hear what the physician is seeing and hearing – improved understanding Have picked up other pathologies (e.g. heart murmurs) Able to do follow up clinics using this technology as well 6/28/2018 Remote Presence – Benefits Noted for providers “On the ground Providers” feel much more supported both by specialist and with patient improved relationships with tertiary care improved communication Learning opportunities Specialists Improved communication/relationship with on the ground staff Better understanding of community/resources Direct communication with patient/family 6/28/2018 Remote Presence – “Doc in the Box” Portable Can take it to the patient’s home Have used to provide prenatal care/ultrasound in real time from as far as 6000 km away! Very simple to use 6/28/2018 Remote Presence – “Doc in the Box” Have been using to allow patients care in their own homes/places of comfort E.g. Patient who requires PT/OT/follow up visits Used in cases where stigma may be associated with coming into health centre/issues of confidentiality HIV Mental Health Post-op 6/28/2018 Where do we have this technology? Stony Rapids Fond du Lac Wollaston Lake (Hatchet Lake) La Loche Clearwater Dene First Nation Southend Pelican Narrows English River First Nation (Patuanak) (Ile a la Crosse) 6/28/2018 Technology – Remote Ultrasound 6/28/2018 Technology – Remote Ultrasound Technician or radiologist is at a different location than the patient A “cage” is held in place by a lay person (minimal training) Ultrasound is performed in real time 6/28/2018 Technology – Remote Ultrasound Initial study completed comparing traditional u/s to remote – no significant difference. (In fact, remote picked up 2 minor cysts not seen on traditional). Have deployed to both Stony Rapids and La Loche Have been utilizing to provide abdominal u/s, prenatal u/s on a weekly basis with good uptake by the community. Will be looking at adding in acute (urgent/emergent) u/s in the future 6/28/2018 Technology – Point of Care Testing Chemistry analyzer Hematology analyzer HIV 6/28/2018 Final Thoughts Reduced access is a challenge on many levels Use of this technology has allowed for increased access and improved outcomes Cultural continuity Restructuring must include Indigenous ways of being, with meaningful engagement and decision making with/from our communities Technology will allow for increased access, decreased transportation costs, and increased relationship building, supporting true team approach with patient/family at the centre. Summary You don’t have to be a ‘techie’ to use technology More and more is becoming available Make our work/lives better, but more importantly, really improve the care of our patients/families/communities Can provide a real option in terms of empowerment, support, patient-centered care Can provide care in remote areas that is as expedient as urban centers! No more ‘curb side’ medicine 6/28/2018 Kitatamihin! Thank you! \ 41.