• Healing from a Distance

    An interview with Curtis L. Lowery Jr., MD Mar 24, 2014

    A maternal-fetal telemedicine program has been saving babies, one by one, for nearly a decade. The program's founder believes these types of distance health technologies have the potential to heal the entire U.S. healthcare system.


    Medical experts-developed during years of training, followed by years of practice-are the most expensive elements in the healthcare system, says Curtis L. Lowery Jr., MD. Historically, that expertise has been used inefficiently because of geographical limits. But this is changing.

    "Technology is revolutionizing healthcare delivery," says Lowery, who is director of the Center for Distance Health at the University of Arkansas for Medical Sciences (UAMS). "Through telemedicine, I can now be available as a consultant anywhere in the world. I can also write smartphone apps that help other physicians manage their patients, or I can develop care delivery protocols that can be disseminated through a telemedicine network."

    Lowery, who chairs UAMS's department of obstetrics and gynecology, helped the academic medical center win a federal grant worth more than $102 million to spread communications technology across the state. Through this funding, fiber and broadband connections were built and upgraded at more than 400 medical sites, including Arkansas hospitals, the state's trauma network, community health centers, mental health clinics, and home health agencies.

    As a result, Arkansas now has one of the most connected state healthcare systems in the nation. That is saying something for a state that has a high poverty rate and low access to technology. At the time the grant was awarded, Arkansas ranked 50th in the percentage of households with a computer and Internet access.

    ANGELS to the Rescue

    A largely rural state, Arkansas also has a history of poor access and poor health status. The state ranks among the nation's worst for infant mortality, women's health services, and low birth-weight deliveries.

    Lowery started tackling those problems in 2003 when he helped create the Antenatal & Neonatal Guidelines, Education & Learning System (ANGELS) to address the needs of high-risk pregnant women across the state. The program includes three technology-driven components:

    • Telemedicine consultations that allow high-risk obstetrical patients and local physicians to be supported by UAMS specialists via interactive video
    • An around-the-clock call center staffed by obstetrical nurses who answer calls from mothers experiencing complications and from physicians who need expert help with high-risk patients
    • Weekly telemedicine conferences in which UAMS specialists confer with community physicians about individual cases and provide education on more than 100 evidence-based obstetrical guidelines developed through the ANGELS program

    Since its implementation in 2003, ANGELS has delivered more than 21,000 telemedicine consults and facilitated nearly 6,000 high-risk maternal transports to the most appropriate hospital. Moreover, ANGELS has helped reduce the statewide 60-day infant mortality rate by 0.5 percent.

    Systemic Improvements

    After ANGELS's initial success, the UAMS telemedicine program has expanded to psychiatry, stroke care, geriatrics, and other specialty services. The program allows the quality of health care delivered in Arkansas to be improved in a systematic fashion.

    In obstetrics, for example, ANGELS has disseminated a standardized order set to all Arkansas obstetricians for the use of oxytocin to induce labor, along with a checklist that physicians use to decide whether labor should be induced. "If the patient doesn't meet the criteria on the checklist, then the physician has to justify why he or she is inducing that patient," says Lowery.

    As new evidence-based protocols are developed, medical experts can disseminate the new information through the ANGELS system quickly so that mothers in isolated corners of a highly rural state get the same care provided at an academic medical center. "That's the way I see health care going," says Lowery. "An individual physician can now combine his or her individual expertise with that of a network of physicians and national standards."

    Coming up next: ANGELS is about to start a program to increase the use of progesterone, which has been shown to reduce the incidence of pre-term birth. "We're going to deploy a statewide program to make progesterone available to practitioners and patients as needed around the state," says Lowery. "And we're working closely with Medicaid and Arkansas BlueCross BlueShield to make this a systems approach for statewide care delivery."

    The Future

    ANGELS will begin offering obstetrical simulation drills using a life-size robotic mannequin to rural and outlying providers in Arkansas. The program will focus on four to six hospitals over the next year by demonstrating simulated scenarios on breech delivery, shoulder dystocia, eclampsia seizure, and postpartum hemorrhage. These hands-on demonstrations will provide rural physicians, nurses, and other members of the healthcare team with opportunities to participate in drills at their local hospitals without traveling to the distant UAMS medical center or attending an out-of-state conference.

    Curtis L. Lowery Jr., MD, is director, Center for Distance Health, and chair, department of obstetrics and gynecology, University of Arkansas for Medical Sciences, Little Rock, Ark. (Momanley@uams.edu).