Dr. Mike (Host): This is Pediatric Insights: Advances and Innovations with Children's Health, where we explore the latest in pediatric care and research. I'm your host, Dr. Mike. And today, we're discussing a new study comparing telemedicine with in-person neurological exams for neonates with suspected hypoxic ischemic encephalopathy.

We're joined by Dr. Lena Chalak, Division Chief of Neonatology at Children's Health, and Dr. Jawahar Jagarapu, neonatologist at Children's Health. I want to thank you both for coming on today. And by the way, congratulations on your publication in Pediatrics this year. Dr. Lina, let's start with you. This is kind of the why behind this study. What motivated you guys to compare telemedicine with in-person Sarnaa exams specifically for this type of patient.

Lina Chalak, MD: Yes. Hello, Dr. Mike and all. I think it's a critical point to be able to do a detailed accurate exam within a very timely manner. We have six hours to start a neuroprotective intervention that's cooling babies at-risk to protect their brain. So thereby, the word time is brain. So, the sooner you do the exam, the sooner you're confident whether the baby needs to be transferred or not or needs to be initiated on a treatment, the best the results. For babies that get cold closer to that six hours or after, we don't get the same benefit. So, it is a time-sensitive manner. The exam can change. It is not always straightforward. And practice makes perfect. So, we have high volume places that get to do it with certified examiners, et cetera. And then, you have regional community practices and other places that don't get the full opportunity to practice those skills, and to do them as often. And therefore, the ability to kind of bypass space and time and be able to connect by tele to do those assessments with a specialist can be lifesaving to the baby's brain.

Host: If this were to be implemented across the country, which based on the study, it looks like that's where we're headed, this is mainly going to be used in those rural areas that don't have the specialist on hand like you guys, right?

Lina Chalak, MD: It would be used anywhere where the physician is not comfortable doing that quick assessment that is neuro-intensive, it doesn't have the volume to support doing it, nor the expertise, and where there is decisions about transporting that would be imminent. So yes, it would be mostly used in rural community practice, but can also be used in busy settings where it's a small level 2 or a level 3 hospital that is in Dallas, for example, for us, but doesn't do enough of those to make those imminent decisions in a critical time-sensitive manner. It can also be used by the transport team when they're deployed on site. So, multiple different practices to get to the key concept, which is time is brain. And as a neonatal neurointensivist, that is a fundamental principle.

Host: Dr. JJ, can you walk us through how you ensured that telemedicine, the exam itself, was standardized and clinically robust?

Jawahar Jagarapu, MD: Sure, Dr. Mike. And we designed this study in a rigorous, blinded comparison manner so that we can accurately measure the telemedicine efficacy against a gold standard in-person exam. We trained our nurses to be bedside presenters using training sessions. And both the exams were done on the same infant, both telemedicine in-person within a very short timeframe.

But each of the examiners didn't know each other's findings. So, it was completely blinded to give extreme validity to this question. And we use like very standardized workflows. So, it, this is just not like a FaceTime, but it was more like a structured clinical system. And one more thing is, if we had to implement this in real-time in clinical practice, we have like a workflow, which we kind of created.

Host: Yeah, it's really awesome that we're at a time and place nowadays where we have the innovations and the technology to do this. Dr. JJ, I want to stick with you for a second. So, I went through the study and noted that HIE classification, cooling treatment, those kind of aspects of this study, those were almost a hundred percent in agreement with in-person. But certain exam elements like tone and level of consciousness, even reflexes, kind of fell into the fair to moderate in agreement. Why were those exam elements so challenging?

Jawahar Jagarapu, MD: That's a good question. As you know, I think the Sarnat exam itself has like six components and four of them are inspection based. That makes it very, very appropriate for telemedicine use. But two of the six components need more hands-on, like tone, measuring tone of the infant, reflexes and, you know, pupillary exams, which require like direct physical interaction.

Actually, those were the challenging ones. But I think we kind of try to overcome those challenges by training our nurses very effectively doing certain maneuvers so that whoever is watching on the telemedicine side can accurately identify the findings. And there were some technology limitations, like pupillary exams. I think we use the general camera. I think in future we might see, you know, more dedicated pupillary exam cameras. You know, that might help. But I think at the end of the day, I think, what the interesting finding was the telemedicine performed best where it mattered the most, like actually the decision to treat the moderate to severe encephalopathy cases.

Host: Yeah. At the end of the day, you were getting these kids into treatment faster, right? At the end of the day. So, Dr. Lina, you know, looking at this, can this be expanded to the outcome that you saw, really expedite cooling initiation in those community hospitals that you had mentioned? Like, where do you see this going from here, I guess, is the question.

Lina Chalak, MD: Yes. So as Dr. JJ mentioned, this is the first time with the accuracy of the procedure itself. So, you have two physicians, one on tele, one in real life, doing their separate assessments within that 10, 15-minute time, okay? And you are comparing the accuracy and the rigor. That by itself has not been done before. The premise of the sooner cooling can lead to improved outcome, we don't have to reprove it. Animal studies, clinical trials have shown this over and over and over. So, we know that the sooner exams lead to better outcomes and is brain protective.

And now that we've shown that there is a method that is accurate that allows you to do an exam sooner, all what we have to do in future testing is confirm the time to exam in these regional practice. Like when you deploy this with the transport team and in community areas, confirm that the time to doing their assessment compared to prior, before the implementation of tele, is going to be cut by half, for example, would be a good way to move this project forward, integrated with the workflow of a transport team, and look at decreased time to cooling, decrease time to do that first examination, even things like do serial examinations. So, you could do it for that first exam and you could do a follow-up exam to make sure that it has not changed. And the way I see it also for important metrics that are not measured currently, which is increasing collaboration, increasing patient satisfaction. I mean, the anxiety that those patients have when they're born at a remote site, the families, what they're having to go through and being able to see a physician on tele and to know that this is a collaborative team decision. So, I see lots of important metrics in future studies, the impact on the education of the community providers, the impact on provider satisfaction, parent satisfaction, and this collaborative spirit are also qualitative important metrics, other than decreasing the time to cool and the time to do that first exam. All those are important to integrate in future workflow and dissemination of this important seminal work that we have been able to do at UT Southwestern.

Host: Dr. JJ, Dr. Lina touched upon some like workflow changes that might come from this. I'd like to get your opinion on this. How might adoption of a telemedicine model change regional neonatal care workflows in your opinion?

Jawahar Jagarapu, MD: Yeah, I agree with Dr. Lina a hundred percent. I think most of the barriers, I think, we might see in this space is more the training and the adoption, and not the technology per se. I think the technology is mature enough that, you know, we're able to conduct these exams and everything.

But whenever you create new models of care, there is always some cultural resistance, the staff level and even in the confidence for the physicians. I think once we standardize those protocols, we show that, you know, this is effective, I think, you know, they might be more amenable to future adoption.

So, I would say I think, you know, some of the barriers would be more like a people problem rather than a technology problem. And as we see with any innovation, adoption is the harder one. And it needs a lot of change management processes.

Host: Yeah. So, training and medical legal aspects, how do you see those as barriers here?

Jawahar Jagarapu, MD: Yeah, absolutely. I think, you know, for us, we are lucky enough, I think, we were able to train dedicated folks like what we call resuscitation nurses at both the hospitals where we did the study and using video sessions, in-person sessions, so that they are able to do those maneuvers. I think even in future, if you're able to do this in transport settings, I think, we have a handful of transport nurses whom we have to teach, and it could be done very well.

From medical-legal standpoint, you know, as Dr. Lina mentioned, I think time is brain. I think, you know, the earlier we are able to assess these babies and initiate interventions, the much likely the good outcomes are. And in the past, I think when we didn't have this technology where the baby had to travel all the way in a state like Texas, they're so far away, they have to come to Children's Medical Center, and then get assessed, and then initiate the interventions. But with this technology in place, I think once our transport team gets into community, we are able to assess, make the assessment, and they're able to cool and route to the Children's Medical Center, that has a significant impact. So, I think if I had to risk the medical legal, I think the benefits outweigh the risks.

Host: What about AI assistance? Because everybody's talking about that, remote EEGs. How do you see those things being integrated into this technology?

Jawahar Jagarapu, MD: Absolutely. I think we are seeing a wave of technologies, especially AI, which could completely change the way we take care of, you know, babies. For example, AI could in real-time assist in, you know, neurological assessments, you know, things like vision-language models, we could analyze the video exams in real-time.

I think we are heading towards an exciting front in care for the newborns. And Dr. Lina has more experience with, you know, remote EEG and those things as well, I think. But overall, I think the technology is so rapidly advancing and mature enough that, you know, we are able to apply these to improve newborn care in future.

Host: Dr. Lina, you've touched on this a little bit, but I kind of want to dive into this a little bit more with you. Where do you see this going in terms of research? Like, what's next that needs to be studied in your opinion?

Lina Chalak, MD: I think that dissemination and implementation is going to be important. And I think that as we do dissemination and implementation, looking at these qualitative things, the satisfaction of the providers, the ability of the parents to feel reassured, their anxiety is addressed, the time to cool is shorter. All those are very important.

I also see another aspect of potentially helping with the difficult cases. So right now, there are situations where we do not know if it's safe or optimal to cool, like the late preterm babies, those that are born a little bit before their term age, the mild asphyxia babies. They're not totally, totally, depressed on the exam, but they have some features. Those are gray areas where even in a level 4 hospital with certified neonatal neurology providers like our teams. It can be very difficult to discern the best line of management.

And I think having the ability to offer telehealth assessments and evaluations for those gray line situations, having interdisciplinary team available, so that the community provider does not feel unsupported or alone. I mean, when the practices themselves are gray, the protocols can change from month to month or year to year with new data; and the exam nuances, like the late preterm, what's normal in a late preterm? Are they developmentally appropriately hypotonic? Because tone progresses from having the strength, you know, in a certain progression way. Or is it abnormal pathologically? So, I think these are future domains where dissemination and implementation, in those gray area also could be very, very helpful for the community provider in using tele.

As we wrap up, I just think it's important to emphasize how grateful we are for the nurses that actually carried those iPads and tried to help the physician that was doing the remote assessment do their proper assessments. And I also want to thank the parents without their participation in such important research, we would not be able to make these discoveries that help implementation of new methodology to advance the way we provide care for those babies. So, both JJ and I are extremely grateful for the parents. And for the nurses and for the sites that participated within our network to show this proof of concept accuracy and rigor of telemedicine neuro assessments.

Host: Dr. Lina and Dr. JJ, this was fantastic information. Really insightful, and I'm excited to see where the research goes and the technology goes and to see how this is adopted by many other institutions. So, thank you again for your time. To explore more topics, you can visit childrens.com.

If you found today's discussion valuable, please share this episode on your social media channels and check out our entire podcast library for more topics of interest. I'm Dr. Mike. And this is Pediatric Insights: Advances and Innovations with Children's Health. Thanks for listening.