Selected Podcast
The Birth of TeleNICU and How it is Improving Virtual Care
Dr. Rashmin Savani and Dr. Jawahar Jagarapu discuss the birth of TeleNICU at Children’s Health and how it is improving virtual care for our smallest patients.
Featured Speaker:
Dr. Jagarapu has extensive experience in diverse health systems in three countries. He is board-certified in pediatrics and neonatal-perinatal medicine. He is a digital health enthusiast. Dr. Jagarapu has a significant interest in improving the quality of newborn care and he believes telemedicine plays a major role in enhancing newborn and pediatric care in the future. He is actively involved in the TeleNICU initiative at Children’s Health that is designed to promote newborn care in rural Texas.
Dr. Jagarapu’s research interests include studying applications of telehealth in neonatal care and measuring the quality of care and economic impacts of the programs in telehealth.
Rashmin Savani, M.B., Ch.B., specializes in caring for babies, from fetus to five, who will require intensive care. He is the Division Chief of Neonatal-Perinatal Medicine at Children’s HealthSM and serves as a Professor of Pediatrics at UT Southwestern Medical Center.
Dr. Savani received his medical degree from the University of Sheffield (England), then came to the U.S. for a residency at Duke University Medical Center. He completed fellowships in both neonatology and pulmonary biology at Cincinnati Children’s Hospital Medical Center.
Dr. Savani spearheaded our fetal neonatal program, which includes a 47-bed Level IV Neonatal Intensive Care Unit (NICU). He also helped create our FETAL Center, which provides specialized care for babies with conditions diagnosed before birth, and the Thrive program, which provides follow-up care for more than 250 new NICU graduates every year.
“The highlight of my life is getting to know these families and seeing my patients get better, go home and thrive,” Dr. Savani says.
Dr. Savani also helped create our TeleNICU program, which enables the expert neonatologists at Children’s Health to virtually examine infants in hospitals across North Texas. This helps many babies with health problems stay in hospitals close to home instead of being transferred to our facility in Dallas.
“With TeleNICU, we can put the needs of the infant first,” Dr. Savani says. “Our principal goal is doing what’s in the best interest of the baby, and we make every decision based on that.”
While Dr. Savani’s clinical work focuses on treating infant health issues, his research strives to prevent them. He and his colleagues have made discoveries that are helping doctors understand bronchopulmonary dysplasia, a severe lung disease that affects premature infants. Now Dr. Savani’s team is pursuing therapies that could make the disease less severe or prevent it altogether.
Dr. Savani grew up in Uganda, trained in England and worked in Canada before moving to the United States -- and he feels more at home here than anywhere else. In his free time, Dr. Savani enjoys swimming, playing with his three goldendoodles, traveling, and spending time with his wife and three children.
Jawahar Jagarapu, MD | Rashmin Savani, MD
Jawahar Jagarapu, M.D., FAAP, is a neonatologist at Children’s HealthSM and an assistant professor of pediatrics in the Neonatology division at UT Southwestern. He graduated from Andhra Medical College in South India followed by pediatric training in the United Kingdom with extensive work experience in National Health Service in the UK. He further pursued his interest in neonatology by completing a residency in pediatrics at Driscoll Children’s Hospital and fellowship training at the University of Miami.Dr. Jagarapu has extensive experience in diverse health systems in three countries. He is board-certified in pediatrics and neonatal-perinatal medicine. He is a digital health enthusiast. Dr. Jagarapu has a significant interest in improving the quality of newborn care and he believes telemedicine plays a major role in enhancing newborn and pediatric care in the future. He is actively involved in the TeleNICU initiative at Children’s Health that is designed to promote newborn care in rural Texas.
Dr. Jagarapu’s research interests include studying applications of telehealth in neonatal care and measuring the quality of care and economic impacts of the programs in telehealth.
Rashmin Savani, M.B., Ch.B., specializes in caring for babies, from fetus to five, who will require intensive care. He is the Division Chief of Neonatal-Perinatal Medicine at Children’s HealthSM and serves as a Professor of Pediatrics at UT Southwestern Medical Center.
Dr. Savani received his medical degree from the University of Sheffield (England), then came to the U.S. for a residency at Duke University Medical Center. He completed fellowships in both neonatology and pulmonary biology at Cincinnati Children’s Hospital Medical Center.
Dr. Savani spearheaded our fetal neonatal program, which includes a 47-bed Level IV Neonatal Intensive Care Unit (NICU). He also helped create our FETAL Center, which provides specialized care for babies with conditions diagnosed before birth, and the Thrive program, which provides follow-up care for more than 250 new NICU graduates every year.
“The highlight of my life is getting to know these families and seeing my patients get better, go home and thrive,” Dr. Savani says.
Dr. Savani also helped create our TeleNICU program, which enables the expert neonatologists at Children’s Health to virtually examine infants in hospitals across North Texas. This helps many babies with health problems stay in hospitals close to home instead of being transferred to our facility in Dallas.
“With TeleNICU, we can put the needs of the infant first,” Dr. Savani says. “Our principal goal is doing what’s in the best interest of the baby, and we make every decision based on that.”
While Dr. Savani’s clinical work focuses on treating infant health issues, his research strives to prevent them. He and his colleagues have made discoveries that are helping doctors understand bronchopulmonary dysplasia, a severe lung disease that affects premature infants. Now Dr. Savani’s team is pursuing therapies that could make the disease less severe or prevent it altogether.
Dr. Savani grew up in Uganda, trained in England and worked in Canada before moving to the United States -- and he feels more at home here than anywhere else. In his free time, Dr. Savani enjoys swimming, playing with his three goldendoodles, traveling, and spending time with his wife and three children.
Transcription:
Bill Klaproth: In 2013, Children's Health launched Texas's first and only dedicated neonatal telemedicine service. The program connects neonatologists at your hospital’s Level 2 or Level 3 NICU with UT Southwestern neonatologists and 150 clinical and surgical subspecialists. Today, we're going to talk about what it took to bring this innovative program to life and how it is continually improving the world of virtual care. This is Pediatric Insights: Advances and Innovations with Children's Health where we explore the latest in pediatric care and research. I'm Bill Klaproth, with us to discuss the TeleNICU and how it is improving virtual care is Dr. Rashmin Savani, a neonatologist and division chief of neonatal perinatal medicine at Children's Health and professor at UT Southwestern and Dr. Jawahar Jagarapu, a neonatologist at Children's Health and assistant professor at UT Southwestern. Dr. Savani and Dr. Jagarapu, thank you for your time. First off, Dr. Savani, can you explain what the TeleNICU is for those who may not know?
Dr. Rashmin Savani: Well, thank you, Bill. It's great to talk with you about this. So, TeleNICU is really a mechanism by which we can extend the level of our sophisticated care to communities that are far away from us. I first moved to Texas about 14 years ago, and I quickly realized that if you fly from Dallas to Los Angeles, two thirds of the way, you're actually over Texas. It's a huge state, and, the idea of allowing us to touch the lives of babies in more than our closest vicinity, we were going to need to use some technology to do that. And, so, we came up with the concept of telemedicine. Telemedicine of course has been around for a very long time, and, some applications in neonatology have been done, but the idea was to connect with outside neonatal intensive care units so that they could connect with us remotely using an audio visual line to allow us to then look at the baby, examine the baby, talk to the parents, talk to the doctors, look at x-rays, et cetera, so that we could provide some consultation and advice to the physicians or providers that are in the outside hospital. So, TeleNICU is really a way to electronically extend the reach of our ability to take care of babies. And, we are a Level 4 neonatal intensive care unit, so we represent the highest level of care that you can get anywhere in the world. And, so, we want to be able to help babies in more remote, more rural areas that may not have those kinds of facilities.
Host: So being Texas’s first dedicated neonatal telemedicine service, this had to be quite an undertaking. Can you walk us through the history of the TeleNICU program and how it began and what did it take to establish this program and what were the obstacles you faced?
Dr. Savani: So, obviously it's not for the faint of heart. That you set up a program like this. There’s a lot of different things that need to be done. We actually launched the program in 2013. So we've been live with TeleNICU for quite a while now, coming up to seven years. But it took about two to three years of planning before we launched the TeleNICU program. And that involves a lot of different kinds of people. So, we need the technology, of course. We have to have the hardware and the software that can allow you to do this so that you need a secure connection so that patient information is protected. We needed to be able to reassure everyone that this was not able to be hacked, if you will. Obviously, it's an internet-based program, so we looked at quite a number of different technologies out there, and we settled on what we have now as being the most robust and flexible. We also needed the capability of using electronic stethoscopes, for example, or electronic odor scopes so we could listen to the baby's heartbeat, lung sounds and belly sounds remotely. We also needed to be able to have a high definition camera so that if there were some skin lesions, we could look at them in very close proximity and very crystal clear. So, the quality of the images and sound needed to be extremely good, as well. So those are the technology part of it. The regulatory part of this, of course, important also, the Texas Medical Board, Centers for Medicaid and Medicare services, the legislation in Texas. All of these have weighed into how people should do telemedicine, and we were very mindful following the rules, so we created the program in full compliance with all the regulatory requirements for such a program. Then we needed to make sure that we have obtained consent from the parents of the babies that we were going to consult on. So there was a legal, sort of, accounting of what we needed to do, so that we wouldn't be infringing on people's privacy or anything of the sorts. So there's a legal component to it as well. And then, what about documentation? Whenever a physician provides service, we need to document what we did. And, so, we had a full accounting of compliance people that allowed us to identify where the note would be written, how we would communicate to the outside facility. And, so, we document the encounter actually in the children's health medical records so there is a permanent record of what was done, what was said, what the advice was, so that we could go back and audit it later on. So there's quite a few steps to all of this and we spent at least two to three years making sure that all of these different things were accounted for.
Host: So when you said this isn't for the faint of heart, you weren't kidding.
Dr. Savani: No, you have to be tenacious.
Host: That's right. And, Dr. Jagarapu, let's talk about the day to day operation of this. How does the TeleNICU work? Can you walk us through the steps that the team goes through?
Dr. Jawahar Jagarapu: Sure, that's a good question, Bill. Suggest to give a perspective, the model, it's what we call it is a hub and spoke model where, the hobbyist, the Level 4 N-I-C-U, which is our Children's Medical Center, which is a quaternary, peer institution. And, then, it's connected to the different N-I-C-Us use in the rural areas, which are ranging from Level 1 to Level 3s, which are the lower-level N-I-C-Us, and, typically, whenever we have a baby who, the referral hospitals, they would like to, consult on for specialist care and everything, they initiate a consult by calling the access center, which is present at the Children's Medical Center, and, then, they would like to request for a TeleNICU physician who is on-call, and, by the way, the service is a 24/7 service, so at any time in the middle of the night, if they have an emergency or something, they would like to consult, there is always a TeleNICU physician on call who can take the call. So, once they contact the access center, depending on the urgency, sometimes if it is a less urgent one, they would like to, schedule a time and a date, which is, convenient for both the families who are in the rural areas in the lower level NICUs and also for the physician here. And, then, would like to initiate a consult at that time. And if it is an emergent consult, I think we have the ability to connect within 15 minutes. And we have the ability to use our laptops as a medium, to connect to the lower level N-I-C-Us. And, once the consult is scheduled, at that time, and then, usually the referral hospitals are equipped with something called telemedicine cart. So these are, the sophisticated equipment, which Dr. Savani was mentioning earlier. It has a screen and it has mounted cameras, which are the Cisco high-tech cameras, along with the peripherals attached to it, like stethoscope, otoscope and the matter scope. So that cart is vital, in terms of our consultation process. And, that cart gives us the eyes on the baby. We are able to manipulate those remote cameras from our laptops, from our end, so that we can zoom in and look at the baby. And it also allows us to do all the examinations as Dr. Savani mentioned. You know, when the stethoscope is connected to the baby, we can hear the heart sounds, you know, on a live basis, not even recorded, it's like a direct transmission. And once we examine the baby, we discuss the plan with the families, and, with the referral physician as well. And, the consultation is kind of completed at that time and we make a decision whether we need to see the baby here or whether we can keep the baby over there and continue to follow up. And, once the consultation is finished, we document the whole encounter in our charts at Children's Medical Center.
Host: So let's talk more about the technological advances. We heard about the electronic stethoscope, you talked about mounted cameras. Can you tell us more about the state-of-the-art equipment that's used for the remote exams and why is this equipment so important for the program's success?
Dr. Jagarapu: You know, when I joined here five years ago, that was the most fascinating part. When Dr. Savani made the TeleNICU suite. And, so, the telemedicine carts, which I was mentioning, it has something called the high-def cameras, which are mounted on the screen, and the cool thing about them is you can manipulate it from your end, the referring physician doesn't need to touch it. We can manipulate them from our end so that you can have a closer look at the baby. You know, it's like being at the bedside. So, the technology's advanced so much that we can perform those maneuvers. And the other things are the stethoscopes. Again, you can hear the heart sounds and the murmurs very clearly given there's a very good broadband connection, and also the things are, that there matter scope where if we want to look at a skin lesion or, you know, something, a rash, which I think the referral patient is worried about, and they're not. Sure of what it is. I think that also gives us a live, kind of, feed to see them and to see the pictures and otoscopes scopes are where you can, use for, looking at ears and you can even look into the oral cavity to perform a detailed examination. I would say with the current technology available; you can virtually do everything except the only thing we could not do is the hands-on palpation. So, the inspection can be done which is a very vital thing for a newborn examination. It's almost like 70 to 80% of the cases. And, an auscultation can be done with the stethoscope. So, the only thing I could not do is a palpation, which we kind of sometimes rely on the local, referral physicians exam.
Host: So with this equipment, you can virtually replicate an in-office visit. I know nothing will replace an in-office visit, but this is certainly the next best thing. And then can you explain why the TeleNICU is a win for patient families and for the health care system?
Dr. Jagarapu: Yeah, great question, and it speaks to the soul of the program. You know, when Dr. Savani established it in 2013, I think there were like very core objectives, which, you know, one is to extend our specialist care or quaternary care to the rural areas. You know, that was one of the main objectives. And the second thing is keeping the newborn babies closer to their homes, right? Like, you know, we connect to the N-I-C-U, which are 500 miles away from here, or this is one of our centers. I think one of the biggest wins for the families is basically to stay locally at their own hospitals and receive the highest level of care, which they need, without doing a trial of 500 miles one-way trip. And, so, that's one of the things. And, from the study we conducted a review of our program, and we are in process of publication. But, basically, the study showed that no more than half of these babies whom we are doing consultations were kept at the local hospitals. So, in the absence of a TeleNICU program, I think all these babies would have been triaged to phone calls in the past, and they all would have been transferred, because with the phone call system, you can't even see the baby. You can't assess, their status. But, I think the telemedicine gives the leverage of, truly examining them and make the decision confidently, so that we can manage babies locally and, you know, keep them and transfer them whenever it is needed. And for the health care systems, I think it's a huge win, win situation. For Children's Medical Center, which is a Level 4 center, which is a, very busy center. And we are kind of, you know, always, scarce of our beds because of all these referrals for the specialist care, we always, keep it very, tight, but control kind of process. And, so we can decide which babies need to be transferred and you can avoid, some of those, if there is a way to, or some of those transfers can be managed locally. So that would be a perfect idea, and for the local hospitals, the rural hospitals, I think it's a huge win for them because they have 24/7 access to our specialist care. And they can keep the babies locally there. And, you know, that kind of reinforces the family centered care of NICU where we we're trying to benefit the families as much as they can by keeping the babies closer to their homes. So it's a three-way benefit to the local hospitals for the quaternary center like us and for the families, as well.
Host: And Dr. Savani, are there any other benefits of the TeleNICU program that we haven't talked about?
Dr. Savani: The cost of care is lower in a lower acuity center. So, levels one, two, three are cheaper than the care that's provided in the Level 4. And, so, if you retain patients in the outside hospital, you actually save health care dollars. And I think that Dr. Jagarapu’s study actually shows that just the cost of the transport alone saves a huge amount of money. Dr. Jagarapu, can you tell us what your findings were?
Dr. Jagarapu: Yeah, I think the transport costs savings itself, you know, just because we are ordered a transfer, more than 50% of the babies, the transport cost savings itself is up to like point $9 million. It's not even taking into the equation families who are able to continue with their jobs because the baby is able to stay closer to their NICU. And there are some other studies which looked at loss of pay and everything because the families had to take time off from work and also the travel savings, you know, they have to travel all the way, 500 miles away from their center to the quaternary care. So there are some of the other significant cost savings as well. But, from our study, it's just from the transport cost savings for the health care system up to like zero point $9 million.
Dr. Savani: Over two years.
Dr. Jagarapu: Yeah.
Host: And this is such a remarkable program. Dr. Savani, what advice would you give to other systems who may be looking into the possibility of offering a similar program?
Dr. Savani: So, absolutely. I think that this kind of approach will save money and keep families closer to their geographic locations, and should be shared with multiple other centers that are interested. In fact, we've had four or five centers call us to say, well, how did you do this? And they're very methodical steps and we've actually helped University of Minnesota, Johns Hopkins and others that have asked us. And you have to be very, very methodical in the way you approach it. You have to have the right people at the table. So, in the same way as I told you about the hurdles, we have to have legal at the table. We have to have compliance at the table. We have to have the IT technology gurus at the table. And it's important to have the physicians at the table, too, that can speak to how would we deal with an emergency situation versus the scheduled situations and so on. You also have to have program managers, so that what is the workflow here? The phone call comes into the access center. What are the questions that the technician on the access center is going to ask? How do we get the neonatologist to tell the NICU doctor on the line as quickly as possible to the outside center. And while we give 15 minutes, we actually, most of the time can connect with the TeleNICU doctor within two minutes. So we try and get that outside facility connected to the TeleNICU doctor as quickly as possible. So, all of those hurdles, you have to have the right people there. And each person has their own job to do, which is, then coordinated in a sort of committee that met, when we set it up, we met every two weeks and everyone had homework to do. And, you better have your homework done by the time you get to the next meeting, otherwise you would be blamed for delaying the onset of the progress. So everyone held everyone else to account, and I think that, looking at all the applicable regulations is important. So I think having a very, very organized, thoughtful, check-the-box kind of approach is very important so that you don't drop the ball, and you know, you've set it up so that when you actually go live, it just goes so smoothly and so seamlessly. And for the users now, who do telemedicine consults, you just press a button and it works. But behind that one press of a button is a whole series of things that were put in place to make sure that that was seamless and without hassle. And, of course, the last thing I will say is you've got to have a technical crew available 24/7 in case things go wrong. Sometimes the outside hospitals have had difficulty remembering which club to put the stethoscope in, and, so there's a technical crew available to them to say, no, no, no, no, no. The black wire goes in the black socket, you know, that kind of thing. So that the telemedicine concepts can happen flawlessly, seamlessly and quickly.
Host: And is there anything else we should know about the TeleNICU program?
Dr. Savani: The one thing I will say is that it demonstrates the partnership extremely well. So, Children's Health and UT Southwestern partner to put this program together and we're fully committed to advancing that partnership. I think that being the only academic center for children in North Texas is a really important attribute, and I think it allows us to do things together that the individual parts couldn't do on their own. And I think that that partnership is something that we are to use to further advance care for children, and you know, really reach all the rural and remote parts of Texas so that we can help every baby get the care that they need without having to travel a whole huge distances to get that care. So we're very proud of it, and we're very proud of that connection that we have between Children's Health and UT Southwestern.
Host: And then lastly, Dr. Savani, I do want to talk about COVID-19. How has COVID-19 impacted the TeleNICU and how has it benefited you through the COVID-19 pandemic?
Dr. Savani: Right. This is such an important question. As you know, the world is grappling with an incredibly, serious and devastating disease, and I think that telemedicine has really taken off and really been given a sort of shot in the arm, if you will. So the idea that you can provide care from a distance decreases the chances of health care workers and consultants and others from actually contracting the disease. And, so, we have now set up a consultation service even within the Children's Medical Center where a subspecialist can provide consultation remotely using the system TeleNICU so that they don't have to go in and examine the patient physically. They can actually be at a safe distance and provide the same level of consultation that they could otherwise. And I think that's going to significantly help folks from actually catching disease while they're providing care. As you know, health care workers have been affected dramatically by COVID and taking care of patients with COVID. The other thing that's happened, of course, is that ambulatory appointments have almost completely gone virtual.
And I think that that sort of portends to how it's going to be in the future. We won't ever not have in-person, outpatient visits, but I think the advent of COVID has really, galvanized us to say that we can provide care virtually and if the outcomes are exactly the same as if we did it in person that allows us to triage patients properly, not have backlogs of outpatient visits and continue to provide the high level of care that we want to.
Host: Well, this was such an important tool before COVID-19 and who would have thought how instrumental it's use is right now. Dr. Savani and Dr. Jagarapu, this has been fascinating. Thank you so much for your time today. That's Dr. Rashmin Savani and Dr. Jawahar Jagarapu. Thank you for listening to Pediatric Insights. For more information, please visit childrens.com/teleNicu and if you found this podcast helpful, please rate and review or share the episode. And please follow Children’s Health on your social channels.
This is Pediatric Insights: Advances and Innovations with Children's Health. Thanks for listening.
Bill Klaproth: In 2013, Children's Health launched Texas's first and only dedicated neonatal telemedicine service. The program connects neonatologists at your hospital’s Level 2 or Level 3 NICU with UT Southwestern neonatologists and 150 clinical and surgical subspecialists. Today, we're going to talk about what it took to bring this innovative program to life and how it is continually improving the world of virtual care. This is Pediatric Insights: Advances and Innovations with Children's Health where we explore the latest in pediatric care and research. I'm Bill Klaproth, with us to discuss the TeleNICU and how it is improving virtual care is Dr. Rashmin Savani, a neonatologist and division chief of neonatal perinatal medicine at Children's Health and professor at UT Southwestern and Dr. Jawahar Jagarapu, a neonatologist at Children's Health and assistant professor at UT Southwestern. Dr. Savani and Dr. Jagarapu, thank you for your time. First off, Dr. Savani, can you explain what the TeleNICU is for those who may not know?
Dr. Rashmin Savani: Well, thank you, Bill. It's great to talk with you about this. So, TeleNICU is really a mechanism by which we can extend the level of our sophisticated care to communities that are far away from us. I first moved to Texas about 14 years ago, and I quickly realized that if you fly from Dallas to Los Angeles, two thirds of the way, you're actually over Texas. It's a huge state, and, the idea of allowing us to touch the lives of babies in more than our closest vicinity, we were going to need to use some technology to do that. And, so, we came up with the concept of telemedicine. Telemedicine of course has been around for a very long time, and, some applications in neonatology have been done, but the idea was to connect with outside neonatal intensive care units so that they could connect with us remotely using an audio visual line to allow us to then look at the baby, examine the baby, talk to the parents, talk to the doctors, look at x-rays, et cetera, so that we could provide some consultation and advice to the physicians or providers that are in the outside hospital. So, TeleNICU is really a way to electronically extend the reach of our ability to take care of babies. And, we are a Level 4 neonatal intensive care unit, so we represent the highest level of care that you can get anywhere in the world. And, so, we want to be able to help babies in more remote, more rural areas that may not have those kinds of facilities.
Host: So being Texas’s first dedicated neonatal telemedicine service, this had to be quite an undertaking. Can you walk us through the history of the TeleNICU program and how it began and what did it take to establish this program and what were the obstacles you faced?
Dr. Savani: So, obviously it's not for the faint of heart. That you set up a program like this. There’s a lot of different things that need to be done. We actually launched the program in 2013. So we've been live with TeleNICU for quite a while now, coming up to seven years. But it took about two to three years of planning before we launched the TeleNICU program. And that involves a lot of different kinds of people. So, we need the technology, of course. We have to have the hardware and the software that can allow you to do this so that you need a secure connection so that patient information is protected. We needed to be able to reassure everyone that this was not able to be hacked, if you will. Obviously, it's an internet-based program, so we looked at quite a number of different technologies out there, and we settled on what we have now as being the most robust and flexible. We also needed the capability of using electronic stethoscopes, for example, or electronic odor scopes so we could listen to the baby's heartbeat, lung sounds and belly sounds remotely. We also needed to be able to have a high definition camera so that if there were some skin lesions, we could look at them in very close proximity and very crystal clear. So, the quality of the images and sound needed to be extremely good, as well. So those are the technology part of it. The regulatory part of this, of course, important also, the Texas Medical Board, Centers for Medicaid and Medicare services, the legislation in Texas. All of these have weighed into how people should do telemedicine, and we were very mindful following the rules, so we created the program in full compliance with all the regulatory requirements for such a program. Then we needed to make sure that we have obtained consent from the parents of the babies that we were going to consult on. So there was a legal, sort of, accounting of what we needed to do, so that we wouldn't be infringing on people's privacy or anything of the sorts. So there's a legal component to it as well. And then, what about documentation? Whenever a physician provides service, we need to document what we did. And, so, we had a full accounting of compliance people that allowed us to identify where the note would be written, how we would communicate to the outside facility. And, so, we document the encounter actually in the children's health medical records so there is a permanent record of what was done, what was said, what the advice was, so that we could go back and audit it later on. So there's quite a few steps to all of this and we spent at least two to three years making sure that all of these different things were accounted for.
Host: So when you said this isn't for the faint of heart, you weren't kidding.
Dr. Savani: No, you have to be tenacious.
Host: That's right. And, Dr. Jagarapu, let's talk about the day to day operation of this. How does the TeleNICU work? Can you walk us through the steps that the team goes through?
Dr. Jawahar Jagarapu: Sure, that's a good question, Bill. Suggest to give a perspective, the model, it's what we call it is a hub and spoke model where, the hobbyist, the Level 4 N-I-C-U, which is our Children's Medical Center, which is a quaternary, peer institution. And, then, it's connected to the different N-I-C-Us use in the rural areas, which are ranging from Level 1 to Level 3s, which are the lower-level N-I-C-Us, and, typically, whenever we have a baby who, the referral hospitals, they would like to, consult on for specialist care and everything, they initiate a consult by calling the access center, which is present at the Children's Medical Center, and, then, they would like to request for a TeleNICU physician who is on-call, and, by the way, the service is a 24/7 service, so at any time in the middle of the night, if they have an emergency or something, they would like to consult, there is always a TeleNICU physician on call who can take the call. So, once they contact the access center, depending on the urgency, sometimes if it is a less urgent one, they would like to, schedule a time and a date, which is, convenient for both the families who are in the rural areas in the lower level NICUs and also for the physician here. And, then, would like to initiate a consult at that time. And if it is an emergent consult, I think we have the ability to connect within 15 minutes. And we have the ability to use our laptops as a medium, to connect to the lower level N-I-C-Us. And, once the consult is scheduled, at that time, and then, usually the referral hospitals are equipped with something called telemedicine cart. So these are, the sophisticated equipment, which Dr. Savani was mentioning earlier. It has a screen and it has mounted cameras, which are the Cisco high-tech cameras, along with the peripherals attached to it, like stethoscope, otoscope and the matter scope. So that cart is vital, in terms of our consultation process. And, that cart gives us the eyes on the baby. We are able to manipulate those remote cameras from our laptops, from our end, so that we can zoom in and look at the baby. And it also allows us to do all the examinations as Dr. Savani mentioned. You know, when the stethoscope is connected to the baby, we can hear the heart sounds, you know, on a live basis, not even recorded, it's like a direct transmission. And once we examine the baby, we discuss the plan with the families, and, with the referral physician as well. And, the consultation is kind of completed at that time and we make a decision whether we need to see the baby here or whether we can keep the baby over there and continue to follow up. And, once the consultation is finished, we document the whole encounter in our charts at Children's Medical Center.
Host: So let's talk more about the technological advances. We heard about the electronic stethoscope, you talked about mounted cameras. Can you tell us more about the state-of-the-art equipment that's used for the remote exams and why is this equipment so important for the program's success?
Dr. Jagarapu: You know, when I joined here five years ago, that was the most fascinating part. When Dr. Savani made the TeleNICU suite. And, so, the telemedicine carts, which I was mentioning, it has something called the high-def cameras, which are mounted on the screen, and the cool thing about them is you can manipulate it from your end, the referring physician doesn't need to touch it. We can manipulate them from our end so that you can have a closer look at the baby. You know, it's like being at the bedside. So, the technology's advanced so much that we can perform those maneuvers. And the other things are the stethoscopes. Again, you can hear the heart sounds and the murmurs very clearly given there's a very good broadband connection, and also the things are, that there matter scope where if we want to look at a skin lesion or, you know, something, a rash, which I think the referral patient is worried about, and they're not. Sure of what it is. I think that also gives us a live, kind of, feed to see them and to see the pictures and otoscopes scopes are where you can, use for, looking at ears and you can even look into the oral cavity to perform a detailed examination. I would say with the current technology available; you can virtually do everything except the only thing we could not do is the hands-on palpation. So, the inspection can be done which is a very vital thing for a newborn examination. It's almost like 70 to 80% of the cases. And, an auscultation can be done with the stethoscope. So, the only thing I could not do is a palpation, which we kind of sometimes rely on the local, referral physicians exam.
Host: So with this equipment, you can virtually replicate an in-office visit. I know nothing will replace an in-office visit, but this is certainly the next best thing. And then can you explain why the TeleNICU is a win for patient families and for the health care system?
Dr. Jagarapu: Yeah, great question, and it speaks to the soul of the program. You know, when Dr. Savani established it in 2013, I think there were like very core objectives, which, you know, one is to extend our specialist care or quaternary care to the rural areas. You know, that was one of the main objectives. And the second thing is keeping the newborn babies closer to their homes, right? Like, you know, we connect to the N-I-C-U, which are 500 miles away from here, or this is one of our centers. I think one of the biggest wins for the families is basically to stay locally at their own hospitals and receive the highest level of care, which they need, without doing a trial of 500 miles one-way trip. And, so, that's one of the things. And, from the study we conducted a review of our program, and we are in process of publication. But, basically, the study showed that no more than half of these babies whom we are doing consultations were kept at the local hospitals. So, in the absence of a TeleNICU program, I think all these babies would have been triaged to phone calls in the past, and they all would have been transferred, because with the phone call system, you can't even see the baby. You can't assess, their status. But, I think the telemedicine gives the leverage of, truly examining them and make the decision confidently, so that we can manage babies locally and, you know, keep them and transfer them whenever it is needed. And for the health care systems, I think it's a huge win, win situation. For Children's Medical Center, which is a Level 4 center, which is a, very busy center. And we are kind of, you know, always, scarce of our beds because of all these referrals for the specialist care, we always, keep it very, tight, but control kind of process. And, so we can decide which babies need to be transferred and you can avoid, some of those, if there is a way to, or some of those transfers can be managed locally. So that would be a perfect idea, and for the local hospitals, the rural hospitals, I think it's a huge win for them because they have 24/7 access to our specialist care. And they can keep the babies locally there. And, you know, that kind of reinforces the family centered care of NICU where we we're trying to benefit the families as much as they can by keeping the babies closer to their homes. So it's a three-way benefit to the local hospitals for the quaternary center like us and for the families, as well.
Host: And Dr. Savani, are there any other benefits of the TeleNICU program that we haven't talked about?
Dr. Savani: The cost of care is lower in a lower acuity center. So, levels one, two, three are cheaper than the care that's provided in the Level 4. And, so, if you retain patients in the outside hospital, you actually save health care dollars. And I think that Dr. Jagarapu’s study actually shows that just the cost of the transport alone saves a huge amount of money. Dr. Jagarapu, can you tell us what your findings were?
Dr. Jagarapu: Yeah, I think the transport costs savings itself, you know, just because we are ordered a transfer, more than 50% of the babies, the transport cost savings itself is up to like point $9 million. It's not even taking into the equation families who are able to continue with their jobs because the baby is able to stay closer to their NICU. And there are some other studies which looked at loss of pay and everything because the families had to take time off from work and also the travel savings, you know, they have to travel all the way, 500 miles away from their center to the quaternary care. So there are some of the other significant cost savings as well. But, from our study, it's just from the transport cost savings for the health care system up to like zero point $9 million.
Dr. Savani: Over two years.
Dr. Jagarapu: Yeah.
Host: And this is such a remarkable program. Dr. Savani, what advice would you give to other systems who may be looking into the possibility of offering a similar program?
Dr. Savani: So, absolutely. I think that this kind of approach will save money and keep families closer to their geographic locations, and should be shared with multiple other centers that are interested. In fact, we've had four or five centers call us to say, well, how did you do this? And they're very methodical steps and we've actually helped University of Minnesota, Johns Hopkins and others that have asked us. And you have to be very, very methodical in the way you approach it. You have to have the right people at the table. So, in the same way as I told you about the hurdles, we have to have legal at the table. We have to have compliance at the table. We have to have the IT technology gurus at the table. And it's important to have the physicians at the table, too, that can speak to how would we deal with an emergency situation versus the scheduled situations and so on. You also have to have program managers, so that what is the workflow here? The phone call comes into the access center. What are the questions that the technician on the access center is going to ask? How do we get the neonatologist to tell the NICU doctor on the line as quickly as possible to the outside center. And while we give 15 minutes, we actually, most of the time can connect with the TeleNICU doctor within two minutes. So we try and get that outside facility connected to the TeleNICU doctor as quickly as possible. So, all of those hurdles, you have to have the right people there. And each person has their own job to do, which is, then coordinated in a sort of committee that met, when we set it up, we met every two weeks and everyone had homework to do. And, you better have your homework done by the time you get to the next meeting, otherwise you would be blamed for delaying the onset of the progress. So everyone held everyone else to account, and I think that, looking at all the applicable regulations is important. So I think having a very, very organized, thoughtful, check-the-box kind of approach is very important so that you don't drop the ball, and you know, you've set it up so that when you actually go live, it just goes so smoothly and so seamlessly. And for the users now, who do telemedicine consults, you just press a button and it works. But behind that one press of a button is a whole series of things that were put in place to make sure that that was seamless and without hassle. And, of course, the last thing I will say is you've got to have a technical crew available 24/7 in case things go wrong. Sometimes the outside hospitals have had difficulty remembering which club to put the stethoscope in, and, so there's a technical crew available to them to say, no, no, no, no, no. The black wire goes in the black socket, you know, that kind of thing. So that the telemedicine concepts can happen flawlessly, seamlessly and quickly.
Host: And is there anything else we should know about the TeleNICU program?
Dr. Savani: The one thing I will say is that it demonstrates the partnership extremely well. So, Children's Health and UT Southwestern partner to put this program together and we're fully committed to advancing that partnership. I think that being the only academic center for children in North Texas is a really important attribute, and I think it allows us to do things together that the individual parts couldn't do on their own. And I think that that partnership is something that we are to use to further advance care for children, and you know, really reach all the rural and remote parts of Texas so that we can help every baby get the care that they need without having to travel a whole huge distances to get that care. So we're very proud of it, and we're very proud of that connection that we have between Children's Health and UT Southwestern.
Host: And then lastly, Dr. Savani, I do want to talk about COVID-19. How has COVID-19 impacted the TeleNICU and how has it benefited you through the COVID-19 pandemic?
Dr. Savani: Right. This is such an important question. As you know, the world is grappling with an incredibly, serious and devastating disease, and I think that telemedicine has really taken off and really been given a sort of shot in the arm, if you will. So the idea that you can provide care from a distance decreases the chances of health care workers and consultants and others from actually contracting the disease. And, so, we have now set up a consultation service even within the Children's Medical Center where a subspecialist can provide consultation remotely using the system TeleNICU so that they don't have to go in and examine the patient physically. They can actually be at a safe distance and provide the same level of consultation that they could otherwise. And I think that's going to significantly help folks from actually catching disease while they're providing care. As you know, health care workers have been affected dramatically by COVID and taking care of patients with COVID. The other thing that's happened, of course, is that ambulatory appointments have almost completely gone virtual.
And I think that that sort of portends to how it's going to be in the future. We won't ever not have in-person, outpatient visits, but I think the advent of COVID has really, galvanized us to say that we can provide care virtually and if the outcomes are exactly the same as if we did it in person that allows us to triage patients properly, not have backlogs of outpatient visits and continue to provide the high level of care that we want to.
Host: Well, this was such an important tool before COVID-19 and who would have thought how instrumental it's use is right now. Dr. Savani and Dr. Jagarapu, this has been fascinating. Thank you so much for your time today. That's Dr. Rashmin Savani and Dr. Jawahar Jagarapu. Thank you for listening to Pediatric Insights. For more information, please visit childrens.com/teleNicu and if you found this podcast helpful, please rate and review or share the episode. And please follow Children’s Health on your social channels.
This is Pediatric Insights: Advances and Innovations with Children's Health. Thanks for listening.