Before the Arkansas START (System To Access Rural Telecolposcopy) program began offering telecolposcopy through rural clinics, thousands of women were either delaying important gynecological treatment or simply going without. Telemedicine projects like these are contributing to a growing telehospital/clinic market, which was worth $8.1 billion in 2011 and is expected to grow to $17.6 billion in 2016, according to BCC Research (Wellesley, Mass.). In Arkansas, some in the medical community began to recognize the gaps in follow-up gynecological care for Medicaid patients. Medicaid covers the reimbursements for routine pap smears and services for those patients suffering high-grade cervical dysplasia (abnormal changes in the cells), but it did not cover the colposcopy (a procedure to closely examine the cervix, vagina, and vulva for signs of disease) if results came back normal. “A lot of patients knowing that up front, wouldn’t do it, so they would delay care for a long time,” says Wilbur C. Hitt, Jr., M.D., assistant professor, Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Division Director, General OB/GYN Division, and principal investigator for Arkansas START. “So there was this gap in coverage, which we found difficult to accept. That’s what begat the need to do this program.”
Wilbur C. Hitt, Jr., M.D.The Arkansas START program is a collaborative project that has been operational since 2004 that covers public health units in three underserved rural communities: Cross County, Hempstead County, and Johnson County. The program incorporates both the University of Arkansas for Medical Sciences (UMAS) network and the Arkansas Department of Health and is the recipient of a three-year Health Resources and Services Administration (HRSA) grant for close to $750,000 that began in September 2009.As a part of the program, there are four telehealth sites that operate weekly, half-day clinics and can each provide up to 10 women, who have had abnormal pap smears, with real-time telecolposcopic evaluations. Since 2006, the START program has treated 3,023 patients.When the patient is referred by the health department to the local health unit, they are seen by a technician. A gynecologist and expert colposcopist in the OBGYN faculty, Dr. Hitt being among them, watches all the sites at the same time from UAMS in Little Rock, Ark. via a clinical teleconferencing system (Tandberg, New York, N.Y.) and a video colposcope (Welch-Allyn, Skaneateles Falls, N.Y.). There is one main image that the expert colposcopist does his colposcopic exam from and three smaller images to monitor the other clinics that are all sent from the rural sites via high-speed T1 data lines. The expert colposcopist speaks with the onsite colposcopist to decide where to biopsy if needed and provides a colposcopic impression, which is recorded at the hub site via a schematic of what the cervix looked like, what was seen, and what was biopsied.After the exam is done, biopsies are sent to the UAMS pathology department and the report is generated and sent to telecolposcopy coordinator and advanced practice nurse Gordon Lowe. A week after the colposcopic exam, the pathology report and patient chart are reconciled, and Hitt makes recommendations, which he returns to the coordinator, who mails out instructions to the patient on next steps.The IT process isn’t yet fully electronic. Even though UAMS has an electronic health record (EHR), the information cannot be input into the system without that patient getting a bill, which would be against the grant requirements; so all patient records from the rural site and UAMS are faxed, then scanned on to secure hard drives, and paper copies are placed in the patient’s folder. There is currently a proposal to replace the UAMS inpatient and outpatient EHRs with an enterprise system, and potentially from there, the START program will cut out the paper processes.One part of the project that Hitt and his team are working on now is telestration, which allows the expert colposcopist to draw on the colposcopic image and send it to rural site to help the less experienced colposcopist. “We think that is going to take the skill level at the distant site way down,” he says. “The person at the distant site will only really need to put a colposcope in, then need a little practice on doing the biopsy. But they don’t need to worry about where to take the biopsy and be very comfortable that they know exactly from the expert colposcopist the spot that looks abnormal.”A study on the START program will be released this week showing high patient satisfaction scores and consistent treatment statistics with live colposcopy. “The rate at which we find dysplasia and our correlation with pap smear results looks about like previously published data on live colposcopy,” says Hitt.Hitt hopes to secure another grant to expand the program statewide by adding four more telehealth sites. This would reduce the driving distance for some patients, some who now drive close to 100 miles to reach the clinics. Another option remains to negotiate with the state health department to cover these clinics on statewide basis.Hitt adds this type of telemedicine program is replicable anywhere, and there have even been discussions of starting similar projects India and Tanzania.“With the increasing pressure on healthcare, [health] systems are going to have to think about leveraging technology to make themselves more efficient, and I think this is prime example of it,” says Hitt. “If I’m a private practitioner, which I have been in the past, there is no way I could do 20 colposcopies in a day. But you can take healthcare workers that are trained just enough to do the physical things, and you can leave the higher decision-making at a central spot and make the [best] use out of everyone’s talents and skills.”
