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Multimedia System Delivers obstetrics into the digital age

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Multimedia system delivers obstetrics into the digital age

Obstetrical telemetry and telemedicine is being successfully incorporated into the daily evaluation and management of pregnant patients.

Telemedicine technologies are shaping the way prenatal care, labor, delivery, and postpartum care will be documented in the digital information age. Numerous examples of electronic data transmission between distant clinics and tertiary prenatal care centers already exist. Few of these incorporate live interactive sessions with laboring patients, but applications under development will permit obstetricians not only to diagnose patients via telemedicine but also to provide continuous management.

Obstetrics is the ideal specialty in which to merge telemedicine system components with a multimedia computer-based patient record. This collaborative system will assist ongoing management and documentation of the pregnancy. The cyclical nature of pregnancy allows a finite set of data to be incorporated into a relational database, studied, and assessed for outcomes.

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The telemedicine industry is evolving as issues of privacy, government regulation, licensing, cost, and performance emerge. The passage of the Telecommunications Act is expected to stimulate telemedicine development. The design of telemedicine systems, their cost, and connectivity issues are being shaped by available transmission modes. It is unclear how and when reimbursement questions will be resolved. Also unclear is where obstetrics fits into this big picture.

Monitor of telemedicine system displays
summary of multimedia patient record components,
including images, text reports, and audio and video clips.

What is known is that mal-distribution of healthcare, particularly prenatal care, is a critical issue. The number of uninsured people in the state of Louisiana is estimated at 500,000. The state has one of the highest percentages of pregnant patients who receive no prenatal care. Not all of these patients qualify for Medicaid. Obstetrical telemedicine has the potential to address these issues.

At the Pregnancy Institute, we are testing ways to merge telemedicine technologies with obstetrical practice to increase access and foster integration of care.

The Obstetrical Telemetry and Telemedicine Project (OTTP) began in 1988 with the use of facsimile transmissions of fetal heart rate graphs. Next we incorporated fetal heart rate telemetry software (Corometrics) to allow real-time study of fetal monitoring from any location at any time. Using a Mitsubishi 286 laptop, transportability and phone line compatibility were tested locally and across the country. The next step was identifying a telecommunications tool that would allow integration of various applications.

We investigated a system from vendor md/tv of Orlando, FL, and found that its combination of functions, adaptability, connectivity, and cost satisfied our requirements. We then embarked on a number of assessments, including acceptability and equipment reliability.

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Regarding acceptability, we wondered if laboring patients would allow this form of electronics into the intimate realm of the delivery room. Would privacy be an issue? Would nursing staff adjust to its presence? After 30 labors, the answer is "no problem."

Some patients specifically requested use of the system. The most verbal advocates were husbands. There is a great desire for the obstetrician to be in touch with ongoing events. But staying with patients through the entire labor is something obstetricians can rarely afford to do in this managed-care era. Telemedical systems that permit ongoing interaction between patients and physicians may provide the solution.

Next we tackled equipment reliability and continuity of care. Obstetrical patients need more time than the average internal medicine or pediatric patient. For example, a live ultrasound study can take 30 minutes. Labor lasts 12 hours on average. How long can a telemedicine station remain on? The system we have been using has been tested continuously for as long as four days while managing the same patient.

Labor and delivery rooms vary in size and shape. Multiple components compete for electrical outlets. What with the warmer for the newborn with its vital signs display, alarm systems, cable television monitor, and the mother's vital signs monitor, adding a telemedicine station may seem excessive. But ultimately, the telemedicine station will integrate all the other components.

In the interim, placement of a telemedicine station that is out of the way yet still a functioning part of the delivery room has been accomplished. Setting a similar station at the obstetrician's office in a way that ensures both privacy and accessibility has also been achieved.

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Flexibility is a requirement for system hardware and software. Downtime is unacceptable in obstetrics, A labor and delivery-based telemedicine station must have alternative ways to maintain data flow. Our station uses a Tl line between the office and hospital. Backup is provided by an analog phone line that allows real-time, laptop display of the fetal heart rate. A separate phone line can be linked to a facsimile machine if that mode fails. If all lines fail, beepers are used. Expansion of these concepts is planned.

With the assistance of Bell South, a T1 cable was made available to establish an infrastructure for wide-band telecommunications to carry audio, video, and data. This T1 line connects the labor and delivery room at the local hospital -- North Shore Regional Medical Center -- and our offices several miles distant.

The telemedicine platform consists of two Pentium 66-MHz-based computers, two 17-inch monitors, a Touchmate Touch-Screen, codec, 384-Kbps video channel, and a CCD video camera. Software is based on Windows.

The display allows a multimedia presentation of test results, still images, and sound recordings. An audio/video recording can be captured and stored. There are templates for patient exams, with vital signs and tools for detailing documents and images.

Live video sessions can be controlled remotely, using a Cannon camera to change views at either the office site or the labor and delivery site. It is also easy to switch to a fetal heart rate telemetry display to assess real-time physiology while maintaining patient contact.

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The system has proved useful in 30 patient sessions. For example, one pregnant patient developed pre-eclampsia at 36 weeks. She was admitted to labor and delivery for observation, fetal monitoring, and lab tests. A telemedicine-telemetry session was initiated and continued for 12 hours. During that time, the obstetrician saw a regular schedule of clinic patients interspersed with interactive consults with the hospitalized patient.

The session, captured on videotape, demonstrates the ability to continuously evaluate a patient's vital signs, symptoms, and telemetry information. The patient was stabilized with a combination of blood pressure management, fluids, medicines, and bed rest, and was released. When asked about the experience, she responded that she was reassured by it and by the ability to contact the physician at will.

Another patient was admitted in labor and dilated 5 cm. Continuous monitoring and an ongoing telemedicine session documented her discomfort. Although she was attempting delivery by the Lamaze method, it was clear she was not tolerating the contractions. Contact with the patient was maintained throughout the day. The patient eventually delivered and a two-minute video of the event was made for the patient record.

During the session, all family members agreed that being in real-time contact with the physician was preferred. They expressed anxiety about the physician's absence from the labor and delivery room. Their assumption was that the physician was not aware of what was transpiring and therefore not concerned or paying attention. This impression has been reiterated with numerous patients.

In a few instances the telemedicine system required rebooting, and one of our early lessons involved synchronizing the codec connection. During some sessions, husbands of patients assisted by turning on the telemedicine station, then navigating the menu to dial and connect. The few times this was necessary, it was discovered that these family members had never before used a computer.

Linked to a fetal heart rate monitor, telemedicine
system sited in labor and delivery room documents
ongoing status of obstetrics patients.

With this initial group of 30 pregnant patients, we have incorporated an obstetrical telemetry and telemedicine system into daily evaluation and management. This technology has been placed in the labor and delivery room and accepted by patients and families. Issues of ergonomics, reliability, flexibility, and ease of use seem to have been resolved. Issues of cost are still unclear, but we estimate that a fee of $100 per patient would support the use of the system we are using.

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Several changes in our obstetrical telemedicine practice are planned. An upgrade of the md/tv software will allow either site to dial the other without an operator presence at both sites. Smoother switching from remote to local view and vice versa has been attained. Audio and video recording and editing are available. Connection to electronic stethoscopes and similar peripheral devices is also possible.

Integration of a computerized patient prenatal chart is next and will be evaluated with a prenatal data system. This software is already configured with an existing relational database. The telemedicine station will serve as the terminal emulation, through which we will be able to enter the PC-based patient chart. Privacy will be maintained through identifier codes and a closed Tl loop.

System permits post-delivery acquisition of
placenta pathology that can be placed in digital
patient record for documentation and newborn
outcomes analysis.

We will also study a reconfiguration of how lab results are captured and transmitted. A summary page of ongoing labor events such as dilation, descent, and vital signs will be evaluated.

Backup alternatives under consideration include a switch to a fax/modem card in the computer if the T1 line fails. Automatic information display to a common beeper will serve as an alternate backup.

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Eventually, a T1-based home station will be incorporated to offer continuous patient care and to supervise physician extenders. This will be tested for accuracy and reliability. The desired result is a complete telemedicine-documentation system.

Futuristically, patients will connect to the system using regular phone lines or the Internet to make an appointment and register for billing purposes. The patient's initial visit, labs, photo, and ultrasound image will be placed in a permanent archiving system. Her exam results will be recorded and filed.

Subsequent visits will be entered, including 15-minute fetal heart rate strips, which will be upgraded and compared to previous strips. If necessary, home telemetry and monitoring results will be included.

Once the patient is in labor, the total multimedia obstetrical chart will be available to the managing obstetrician or nurse midwife. Delivery will be recorded and features of care, newborn response, and placenta pathology documented. Final laboratory data and microscopic images of the placenta and umbilical cord will be transferred from the lab to the archived chart file. A postpartum stay and discharge summary will be added to the file to complete the process. This detailed obstetrical patient file will be available for outcomes studies, research, and clinical reviews.

Published in TeleMedicine and TeleHealth Networks, May 1996

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