 Hi everyone. First off, I'd like to thank the organizing committee for inviting me to present at this symposium. My name is Nicholas Grubick and I'm a research associate within the Department of Medicine at Queen's University. And today I'll be speaking to you about remote support interventions to improve access to ultrasound services in remote communities, barriers, achievements, and future directions. And I have no disclosures to declare for this presentation. In terms of the learning objectives for this session, I'm hoping that everyone will be able to come away with an understanding of the barriers to access to ultrasound services and education in remote communities, as well as be able to compare the features, workflow, and feasibility of various types of remote support interventions that have been used to deliver ultrasound services. And finally, to understand the Arctica program model and evaluate preliminary findings in two Canadian communities. Before getting into the main objectives of this session, I just wanted to give a very brief overview of cardiovascular health in rural Canada. It's well established that rural residents in Canada have a higher prevalence of numerous acute and chronic illnesses. For example, in a recent population-based study that was conducted in Ontario, it was found that rural residents were more likely than urban residents to have a higher prevalence of common cardiovascular risk factors such as smoking, heavy alcohol consumption, and obesity. It was also found that in general, their overall cardiovascular health, which was measured using a validated health index, was also poor. Indigenous Canadians are also known to be at a heightened risk for cardiovascular disease in comparison to non-indigenous Canadians. In 10-year estimates from 1991 to 2001 demonstrated that the age-standardized cardiovascular disease mortality rate among Indigenous Canadians were 30% higher for males and 76% higher for females in comparison to non-indigenous Canadians. In addition, rural and Indigenous populations also face various barriers to cardiovascular care due to geographical distance, limited health resources, as well as education. When we look further into some of the statistics that have been published surrounding access to care for rural and remote populations, some of the results may actually be quite surprising. What we do know is that approximately 20% of Canadians live in rural and remote regions across the country, and due to the vast geographical landscapes of these regions, providing sustainable access to advanced imaging services, as you can imagine, is quite challenging, resource-intensive, as well as costly. And according to a survey of 336 randomly selected rural hospitals in Canada, although almost all of them had access to an x-ray, only 20% had access to a CT scanner, and only 28% had access to formal ultrasound services. In the event that advanced imaging is needed, 44% and 55% of rural hospitals were shown to be more than 300 km away from a Level 1 or Level 2 trauma center, respectively, which can result in significant delays to patient care as well as additional strain on health teams. Considering the common barriers to ultrasound services, in general, these barriers can be categorized into either system-level barriers or patient-level barriers. At the system level, lack of equipment and funding are two of the most commonly cited barriers to ultrasound services. And it's understandable that, given the high costs and resources required to purchase, ship, as well as maintain formal ultrasound equipment in rural locations, this may be seen as unfeasible from a health system's perspective. And as a result, the use of handheld or point-of-care ultrasound has become an attractive solution for physicians and other healthcare professionals looking to guide management and treatment decisions for their patients in remote communities. However, formal training opportunities, particularly for non-specialized users who practice in remote locations, are quite limited. Outside of established residency programs or expensive commercial courses, few opportunities exist for healthcare professionals to gain practical point-of-care ultrasound skills. And among these opportunities that are available, most tend to be either in-person or lack the time and resource commitments necessary to provide ongoing quality assurance, expert oversight, and longitudinal skill development. These system-level barriers are also further compounded for those practicing in geographically remote regions in Canada, where travel to maintain and learn new medical skills has become exceedingly difficult, particularly during the COVID-19 pandemic. Barriers to ultrasound services can also be observed at the patient level. And according to a recent qualitative study of two northern communities in Saskatchewan, both of which were composed primarily of indigenous inhabitants, geographic isolation was a central barrier to patients accessing ultrasound services. Due to the travel requirements for accessing such services, fear of air travel, isolation from family and friends, financial implications, and unfamiliarity with larger cities also emerged as additional barriers. To address the many barriers to ultrasound services in remote communities, some potential solutions have been proposed. One suggestion is to expand medical school and residency training in ultrasound skills, although this would require substantial curriculum changes and resources. And as a result, it's unlikely to make an immediate impact on access to care in remote regions. Others have also advocated for additional funding to integrate point-of-care ultrasound training into practice for rural physicians and allied healthcare professionals. Although the geographical distances required for both learners and educators to travel for these in-person trainings could be quite difficult. A promising solution that has been evaluated and tested over the past few decades involves providing remote support to ultrasound users. Through technological developments in ultrasound technology, ultrasound machines have become increasingly portable, allowing imaging services to be available in the most remote locations across the globe. And recently, many ultrasound providers have also integrated the necessary technological infrastructure to facilitate remote support applications such as tele-ultra sound. Tele-ultra sound allows healthcare professionals to perform bedside ultrasound at one location with any images or videos transmitted and interpreted by an expert provider located in a distant location. And uniquely, this process can be conducted either asynchronously by capturing, storing and transmitting media for interpretation at a later point in time or synchronously by performing the scan at the same time as expert interpretation takes place. And given technological advancements in image quality, evidence has shown that ultrasound images acquired in resource limited settings and transmitted using an online platform to an expert interpreter are of satisfactory quality and value for clinical diagnosis and management. Although tele-ultra sound is a relatively new technology, there has been some literature to date which has described some of the various features and modalities that have been evaluated in resource limited settings. So this recent systematic review found that pocket and other portable ultrasound machines were the most commonly used devices when performing tele-ultra sound in resource limited settings. And to transmit images for expert interpretation, certain studies used cameras or smartphones to record images of the ultrasound machine screen while others used telemedicine software to automatically send ultrasound images during or after performing the scan. It is also important to note that there is quite substantial diversity in the specialty and level of expertise of ultrasound performers. So in this review, some studies evaluated the use of tele-ultra sound performed by primary care physicians while others evaluated the use of tele-ultra sound by nurses, residents or more specialized healthcare professionals such as sonographers. As I mentioned before, the use of tele-ultra sound software has become increasingly popular as a modality to deliver expert care to under service regions. One example of telehealth software is known as REACS, which can be currently used by connecting a Philips ultrasound probe to any smartphone. The image on the right shows a screenshot of the REACS platform from the perspective of a remote expert interpreter. So as you can see, the expert interpreter can simultaneously visualize the probe and patient positioning as well as the ultrasound screen. Colored pointers on the ultrasound screen can also be used by the learner or the interpreter to highlight certain structures. And with the capabilities of this software, an expert interpreter can provide real-time remotely delivered feedback by directing probe angles, pressures, as well as guiding window acquisition. Over the past decade, point of care ultrasound has emerged as a crucial tool for the cardiopulmonary assessment in all tertiary centers, and its use has been particularly important during the COVID-19 pandemic. However, as I mentioned previously, a major challenge facing healthcare professionals today is the limited educational opportunities to develop focused skills. And these issues are further compounded for those practicing in geographically remote regions in Canada, where travel to maintain and learn new medical skills has become exceedingly difficult. And these disparities in education have led to parallel disparities in care within remote areas, which are already susceptible due to the lack of imaging access, training, technology, and infrastructure. To address this national issue, our group has proposed the use of novel point of care ultrasound streaming technology to firstly, accelerate virtual teaching of point of care ultrasound, and secondly, to provide ongoing expert guided live imaging consultation services for continuous quality maintenance. And this is particularly useful in remote and northern communities, where on-site supervision and expertise may not always be available. To integrate the power of telepoint of care ultrasound or telepocus and provide real-time mentorship and feedback to remote communities in Canada, our group designed and piloted the Arctica program at Queen's University, which provided telepocus consultation services to communities within the Weenie-Baco area health authority in northern Ontario. The overall goal of this program was to implement, evaluate, as well as optimize a telepocus training and workflow program for local non-expert users in geographically remote facilities. And since our initial launch in 2020, we've now expanded our network to a total of five expert hub sites in Kingston, Halifax, Toronto, Winnipeg, and Calgary, together servicing nine spokes in remote and northern communities across Canada. To facilitate ultrasound education as part of the Arctica program, physicians with imaging expertise at hub sites were able to provide guidance and mentorship to learners located at remote spoke sites through telepocus consultations. At this point in the presentation, I'd like to highlight some of the pilot results from our Arctica program. And for those of you who are interested in reading more about the program as well as our initial results, the final manuscript has recently been published in ultrasound quarterly. For our proof-of-concept study, we piloted the Arctica program locally at the Kingston Health Sciences Centre in Kingston, Ontario, and remotely at the Weenie-Baco General Hospital located in Moose Factory, Ontario. For context, the Kingston Health Sciences Centre is Southeastern Ontario's largest acute care academic hospital, supporting the city of Kingston, which has a population of approximately 120,000 people. In comparison, the Weenie-Baco General Hospital is located 830 kilometres northeast from Kingston in the isolated island community of Moose Factory, which has a population of about 3,100 people and is composed mainly of Indigenous inhabitants. The Weenie-Baco General Hospital is also considered fully staffed with 12 family physicians, 6 to 8 medical residents and students, as well as a rotating group of surgeons and anesthetists to ensure full-time coverage. In this pilot program, we recruited 12 physicians, 7 local physicians from Kingston, as well as 5 remote physicians from Moose Factory, all of which participated in our Arctica program. And overall, a total of 10 physicians were able to complete the program in the allotted three-week training window. As part of the Arctica program, all physicians were enrolled in a three-week learning track that was compartmentalized into three blocks. For the first week, learners were provided with a suite of POCUS eLearning modules, which were designed and curated by our institutional education team, providing basic knowledge in cardiac and lung pleuripocus concepts, image acquisition, and image interpretation. Participants were also provided with telepocus equipment to practice image acquisition on consented volunteer models. At the end of week one, all learners participated in a one-hour virtual workshop to review technical skills and receive feedback, as well as had a pre-training assessment with a POCUS evaluator to assess baseline knowledge. For the following two weeks, learners were then instructed to initiate telepocus calls to experts in Kingston during their own clinical encounters. To facilitate these calls and on-call telepocus consultation service was continuously available throughout the study period. When a call was made, the expert received real-time POCUS recordings to their personal device and were also able to interact with the learner. A mini-evaluation was also performed during each call to assess for improvements in image quality following remotely delivered guidance. And lastly, at the end of the three-week program, all learners performed a post-test with a POCUS evaluator to quantify knowledge retention and skill development. Here is a quick example of a telepocus consultation that occurred between an expert physician at the Kingston Hub and a remote physician practicing in Moose Factory. I've got a patient here and we'll be able to do this POCUS right now. So Dr. Walton, can you remind me where you're practicing again? Yeah, this is, so we're up here at Moose Factory. This is Northern Ontario near the James Bay community. It's a remote location, so far away from you guys, and so we relish this opportunity to get in touch with you kind of directly like this. This device and this program has really helped the rest of us here get a little more comfortable with POCUS techniques and very comfortable with getting in touch with you. So we got your face and other cardiologist faces, the names, and we can kind of build rapport there. And it's just been excellent. I've enjoyed this program so far. Me go from someone who has never really touched POCUS to sitting a lot more comfortable with some quick bedside evaluations with some introductory cardiac ultrasound and some introductory long ultrasounds. It's been really great. Yeah, it's been our pleasure to see you progress with your bedside cardiac and lung ultrasound skills. And as you mentioned, the idea is to get that probe in your hands, give you some support, and continue to support you in the long term so that we can continue to see progress over the future. So we're really excited to do that. And thank you for participating to you and your colleagues. And so what we're going to do today is I understand you'd like me to provide a little bit of tele mentorship with a patient that you have right now at the bedside. Yeah, yeah, if you don't mind. Yes, that sounds good. So here's a patient room and the patient right here. And so I'll set you up. Okay, great. And at this point, the expert physician would be able to guide the learner while seeing the visual orientation of the probe, as well as the view from the POCUS device. Over the study period, a total of 76 telepocus consultations between learners and experts were performed, of which 37 were focused on cardiac focus and 39 were focused on lung pluripocus. And on average, each learner had a median of three cardiac and lung pleura telepocus consultations. And in terms of consultation times, the median cardiac consultation time was around 15 minutes, whereas the median lung pleura consultation time was about 10 minutes. During each telepocus consultation, experts conducted a mini assessment which evaluated the image quality of common cardiac and lung focus views before guidance and after the delivery of remote guidance. Each testing component was scored on a five point Likert scale with one as the lowest score indicating poor image quality and five as the highest score indicating excellent image quality. So comparing pre guidance, which is shown in blue and post guidance scores, which are shown in orange, we observed significant improvements in image quality for all cardiac and lung pleura focus views as assessed by our expert interpreters. And these findings were also consistent across both geographical settings. General surveys were also conducted at the end of each telepocus consultation and scored on a similar five point Likert scale. Among physician learners, the mean scores for ease of use clinical relevance utility and continued use indicators range from 4.03 to 4.72. And this suggested that learners found telepocus to be easy to use clinically relevant for their clinical encounter and beneficial for the clinical workup of their patient. Learners also generally agreed that they would be likely to continue their use of telepocus throughout their practice. Similarly, experts found telepocus appointments to be efficient were comfortable in providing remotely delivered guidance through telehealth software and found the physician learners easy to instruct. Based on our preliminary findings, we observed that all physicians demonstrated significant improvements in image acquisition, image quality and image interpretation for cardiac and lung pleura focus following completion of the article program. The quantitative evidence and box box shown on this slide demonstrate the change in average score for each testing component from the pre-training assessment completed at the end of week one to the post-training assessment completed at the end of week three. And it's important to note that these improvements were made without the need for any in-person contact with experts. Given that this was a proof of concept study, there are various limitations that we're hoping to address in future work. Firstly, since physicians were only recruited at two centers in Ontario, this potentially limits the generalizability of our findings. Although we are hoping to validate these findings on a larger scale by incorporating the evaluation data from other hub and spoke sites that are participating in the article program. Secondly, there were some baseline characteristics and evaluative data missing, and this was mainly due to telepocus consultations that ended prematurely as a result of poor internet service and limited device battery capacities. And although we attempted to provide a continuous on-call consultation service throughout the study period, there were instances where learners were unable to connect with expert interpreters. Measurement consistencies among the three independent experts who score training assessments may have also occurred, although there is prior work suggesting that there is excellent interator and test retest reliability for focus image quality using an ordinal scoring system like the one that we used in our study. And then finally, experts were not blinded to learners during consultations or assessments, which may have led to detection bias. Overall, through the article program, we were able to successfully implement a longitudinal and fully virtual focus training program in a real-world clinical setting. And without any need for face-to-face contact with instructors, participation in this program led to significant improvements in focus skills following a three-week program which incorporated both asynchronous e-learning and synchronous telepocus consultations. And the findings of our study support the feasibility of telepocus to educate learners in resource-limited settings and really sets the stage for further evaluation and opportunities in telepocus education. The future of the ARCTICA program is aimed at continued implementation at our nationwide hub and spoke sites. And overall, our end goal is to provide remote learners, particularly those practicing in low resource settings, an opportunity to develop critical skills in image acquisition and interpretation while providing ongoing expert feedback and quality assurance. Ultimately, the ARCTICA training model allows learners to become focus leaders at their respective institutions, thus establishing in-house expertise for them to directly enhance the cardiovascular care of their patients as well as facilitate knowledge transfer to other providers in their communities. Although I am the face of the ARCTICA program today, I'd also like to take the time to recognize and acknowledge our amazing leadership team, research and clinical staff and trainees for their crucial work and dedication to the progress of this program. Our various funding, supporting organization and collaborating hub and spoke sites have also played an integral role to the success of the ARCTICA program. With that being said, I'd like to thank you all for listening to this presentation, and I'd like to also thank the organizing committee again for inviting me to give this talk, and at this point I'd be happy to take any questions from the audience.