The increase in telehealth services has transformed care delivery in America by expanding access for millions. In this conversation, Johnna Nynas, M.D., OB/GYN at Sanford Health Bemidji, discusses the dramatic expansion of maternal telehealth capabilities in Minnesota, as well as an inspiring telehealth program that reaches families in rural areas of the state.

Tom Haederle

The expansion of telehealth services has transformed care delivery, expanding access for millions of Americans who faced barriers to care related to transportation, mobility limitations or geographic isolation. In rural Minnesota, the dramatic expansion of telehealth capabilities, much of it driven by the vision and effort of one passionate physician, has made a tremendous difference in supporting the labor and delivery needs of community residents.

Tom Haederle

Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. Women facing long travel distances for regular visits to their obstetrician are less likely to receive the level of care they need, and more likely to experience serious complications and higher rates of maternal mortality. That's why one OBGYN specialist in northern Minnesota has created the Families First Rural Maternity Health Collaborative program, a telemedicine platform for expectant mothers that she calls "My love letter for my patients and the people that I'm called to serve."

Tom Haederle

Let's join the conversation.

Chris DeRienzo, M.D.

Welcome, everyone to our podcast today. I'm Dr.Chris DeRienzo. I'm the chief physician executive for the American Hospital Association. You are joining us from the Leadership Summit. We are in the Innovation Hall, and you can hear all of the energy and excitement at this incredible meeting here in San Diego. And I am incredibly excited to get to spend a few minutes with Dr. Johnna Nynas from Sanford Health Bemidji.

Chris DeRienzo, M.D.

She is a practicing OBGYN, and the story that she has to share will absolutely blow you away. So Johnna, welcome to the program. Thank you for joining us.

Johnna Nynas, M.D.

Thank you for having me.

Chris DeRienzo, M.D.

You've been recognized recently as one of CNN's champions for change, and that's grounded in the incredibly foundational work that you do. Why don't we just start by talking a little bit about what that recognition means to you personally and professionally?

Johnna Nynas, M.D.

Well, it certainly came as a huge surprise. When you come to work every day, you're doing the job that you're doing because you love the work, and you love the people that you're working with and the type of impact that you have on the community. So to be recognized for something that I love so much is truly an honor.

Johnna Nynas, M.D.

When we set out to create the Families First Rural Maternity Health Collaborative program, we really started with the idea of what were the barriers in our community, because the barriers can never be more than the why. And so when we identified all those barriers and started putting the work together and pulling the ideas together and collaborating with each other, it just became this very passionate project of mine.

Johnna Nynas, M.D.

And the way I looked at it when I submitted the final submission was, this is my love letter for my patients and the people that I'm called to serve.

Chris DeRienzo, M.D.

We can hear it in your voice and obviously touches you deeply, personally. And my understanding is you have some pretty deep roots in this part of rural Minnesota. Would you speak to that a little bit and then you know, why you needed to turn to this groundbreaking telemedicine program to support the labor and delivery needs of the people in your community?

Johnna Nynas, M.D.

So I have background growing up in rural Minnesota as a kid on a small family farm. And realizing that it was 30 minutes one direction just to access medical care, that was standard growing up, I didn't know any different. And as I started to go through my medical training and residency, you started to see some of the disparate impact that that has.

Johnna Nynas, M.D.

And certainly the national data supports that. Women living in rural communities are nine times more likely to die in childbirth than women in urban areas. And that's an unacceptable statistic. Where I'm located in Bemidji, Minnesota, we're very geographically isolated. We're four hours north of Minneapolis, and we are surrounded by three different Native American reservations. And unlike the American population, where 1.3% would be Native American, in my county where I live, 22% of patients are Native American.

Johnna Nynas, M.D.

So that really called into light the need to work on those disparate outcomes and the obligation that we had. I think really looking at how we could break down those barriers is what led us to the work that we were going to do, and kind of leaning in with the communities that we serve and work with daily and hearing from our patients what the barriers were that prevented them from getting care was where we started our work.

Chris DeRienzo, M.D.

It's the exactly right place to start, and it's fitting that we're sitting here in the Innovation Hall at the AHA's Leadership Summit, because we know that the challenges that America faces with high quality and safe labor and delivery of care, there's never going to be one solution for those. And so we need the kinds of local innovations that you've been able to drive up in Bemidji as examples that we can then replicate across the country.

Chris DeRienzo, M.D.

So talk to us a little bit more about those key initiatives within the Families First Rural Maternity Health Collaborative, how you sought the funding, how you built those pillars and then what they actually do to bring care in such a unique and innovative way?

Johnna Nynas, M.D.

Sure. We applied for funding through HRSA's Our Moms program around maternity obstetric management strategies program, and we were awarded $3.67 million over four years to do this work. And when we broke the work down, we kind of have some basic pillars that are focused on excellent obstetric care coordination and management, transportation services, prenatal care and education services, support services related to other factors from childbirth, from lactation to home visiting nursing programs.

Johnna Nynas, M.D.

And then lastly, our virtual care program to try to bridge the gap that exists due to distance and transportation. Within the program, some of the things that we're seeing is we've created a very strong partnership with our collaborative partners, which includes Red Lake and Cass Lake Indian Health Services, Scenic River's health system, which is our local FQHC. And then we also have partnership with Primus, which is our Medicaid servicer, and then Beltrami County Public Health and then Sanford Medical Center, Fargo, to provide some maternal fetal medicine outreach for those additional services that we don't have locally.

Chris DeRienzo, M.D.

And how far is that from where you are in Bemidji?

Johnna Nynas, M.D.

So our nearest tertiary care center is Sanford Fargo. That's three hours to our west.

Chris DeRienzo, M.D.

Goodness. Three hours.

Johnna Nynas, M.D.

Johnna Nynas, M.D.

So what would it look like if, instead of expecting my patient who lives in a geographically isolated area in Red Lake, and asking her to come to my clinic 2 to 3 times a week for monitoring for management of her diabetes and her chronic hypertension and or other chronic medical conditions that contribute most to severe maternal morbidity and mortality.

Johnna Nynas, M.D.

What would that look like if I brought that care to her? So one of the ways we're doing that is by really expanding our use of OB telemedicine visits. These can be used for really any visit that doesn't require an in-person appointment for either labs or ultrasound or imaging. Patients are given a low tech kit, including a blood pressure cuff and fetal heart rate monitor that they can use at home for their visits, and then they connect with their medical provider via a digital platform through the My Sanford Health app.

Johnna Nynas, M.D.

The nice thing about this is from a provider standpoint, we made very sure that we didn't limit this to just low risk women. Because the reality is where we're located, if women aren't coming to us to seek care then they're just not getting care at all. And that's unacceptable. So we opened it up to anybody. And what we found is not only are patients very accepting of that telemedicine platform and doing visits themselves, it's also better engaging women in understanding their care.

Johnna Nynas, M.D.

And as a physician, you can appreciate how important it is to have patients who really understand the why behind what we're asking them to do. One example of that is monitoring patients with hypertension in pregnancy. When they come into my office, it's a passive process. Someone's checking their blood pressure, someone's telling them the number of the day and is it good or is it bad?

Johnna Nynas, M.D.

Whereas if a patient's at home and she's monitoring her own blood pressure, I've had to give her some education and some guidance on: this is what I worry about. This is what I don't. These are your parameters for coming in and following up for care. Yeah. So now that patient not only has some insight into her condition, she's taking ownership and responsibility for that.

Johnna Nynas, M.D.

She's reaching out and saying, I am having these symptoms. And I took my blood pressure. I noticed it's high. I think I need to come in, what's my next step? And that takes on a step further within the communities that we serve. So by educating women on these conditions during pregnancy, we're seeing an impact where patients have been cousins or aunties or relatives or friends of other pregnant women who have said, I don't feel good today.

Johnna Nynas, M.D.

I feel like I have a headache, my vision's really blurry. And my patient has said, you know, my doctor talk to me about preeclampsia. We should probably check your blood pressure. That's really impactful if you think of what that can do for communities.

Chris DeRienzo, M.D.

It's impactful and it effectively flips the challenge that we face around maternity care in this country on its head. And we have all heard about the shifts in demographics and changes in the kinds of people living in communities. And we know there's a massive workforce crisis, and that you need several thousand people living in a community just to be able to support one OBGYN.

Chris DeRienzo, M.D.

But what you've done is taken the strength in those rural communities, which we know is a tight knit fabric in this country. And by projecting specialist expertise into those communities, you've tapped into the power of that fabric. It's incredibly inspiring. And at the same time, I know it's got to have been challenging.

Johnna Nynas, M.D.

Certainly has been challenging. Some of the initiatives that we haven't even begun to realize yet is we still need to implement satellite clinics, which are going to be regional hubs where there's already a preexisting clinic. One example is in Panama, Minnesota, which is in Red Lake Nation. They have a medical assistant, but not necessarily a provider.

Johnna Nynas, M.D.

So our next steps are to build out the infrastructure. So there is telemedicine equipment and broadband. Because the reality is not all rural patients have access to a smartphone or broadband. So now instead of expecting a patient to have those tools, that patient can just go down the street to their local clinic and receive that care virtually. And we're working to outfit everything from remote antenatal testing and non stress tests, consults with diabetes educators, nutritionists, potentially maternal fetal medicine all from the comfort of the patient's own community.

Johnna Nynas, M.D.

They can come in and they can upload their continuous glucose monitor so we can see exactly how their blood sugar control is, so we can better manage those chronic medical conditions that contribute most to severe maternal morbidity and mortality. But as you can imagine, it's a simple idea. Right. But implementing it is a completely different story. We have definitely run into some barriers when it comes to working between different agencies, and especially with a government agency that we're unintended not realized prior to starting our work.

Johnna Nynas, M.D.

And it's delayed some of the implementation that we want to do, but we're still making forward progress, and we're really excited about that. I think one of the things that we've certainly learned from this is when you're implementing a new mode of delivery for care that's going to be shared across different entities, is to have those conversations with IT

Johnna Nynas, M.D.

teams and legal teams early on in the planning process. Absolutely. Instead of springing it on them at the end.

Chris DeRienzo, M.D.

That is a spectacular recommendation. And we always run into this when we're breaking new ground in health care. But you folks at Sanford have been so incredibly innovative, recognizing that you serve frontier communities, that you've got to innovate in order to get these folks who live in you know, less than seven people per square mile to the kinds of outcomes that you're able to.

Chris DeRienzo, M.D.

Chris DeRienzo, M.D.

And so that's part of this innovation workstream. And in just the last couple of minutes that we have, I'm wondering for all of the folks listening in today, by hearing your inspirational story and the incredible work that you're doing up in in rural Minnesota, what advice would you give to people, say, in rural Mississippi or in rural Massachusetts who are facing the same challenges and saying, gosh, I just need to take that first step to get the momentum going.

Johnna Nynas, M.D.

I think one of the most important steps to realize, if you're looking to implement some programming is the time to solve the problem is actually not now. We're not solving today's problem. We're creating the infrastructure to solve the problems that will be in existence to support the communities that we will be 20 years from now. Well, so that's what we're looking to do.

Johnna Nynas, M.D.

And really having that forward thinking mindset.

Chris DeRienzo, M.D.

Again, this has been an absolute privilege, Johnna. Thank you so much for joining us again. This is Dr. Chris DeRienzo, we've been with you live from the AHA Leadership Summit Innovation Hub. And thank you for joining our podcast.

Tom Haederle

Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.