By Matt Skoufalos
Expanding breast imaging access to rural and underserved communities is one of the hardest problems in women’s imaging — and one a growing number of radiologists, vendors and academic health systems are tackling with mobile care, telehealth and cultural competency. For years, Dr. Kimberly Winsor has been working to provide diagnostic imaging services for breast health in Native American populations in rural locations across the American Southwest. As a fellowship-trained breast radiologist at Sedona Diagnostic Ultrasound in northern Arizona and previously with Diagnostic Imaging Associates in Tulsa, Oklahoma, Winsor has identified “a huge disparity in standard-of-care breast imaging” among communities in the Indian Health System (IHS), those organized under Public Law 93-638, the Indian Self-Determination and Education Assistance Act, and the standard of diagnostic care that many other Americans can access reliably.
Winsor described much of the disparity as being rooted in historical attitudes surrounding settler colonialism and the early politics of “managing” the native populations from a Western perspective and later by healthcare being used as a bargaining tool in controversial treaties. In conjunction with chronic underfunding of the IHS, it’s a gulf practitioners still work to overcome to deliver health screenings in a culturally appropriate fashion for communities that are farther-flung from urban or even suburban population centers.
“We talk about the formation of the IHS as a way for the U.S. military and the incoming white settlers to protect themselves from any sort of diseases and trauma that could come from the indigenous population,” Winsor said.
In delivering that promised healthcare, Western-style medicine arrived in native communities on condition of patients abandoning traditional tribal practices, putting them at odds with their own cultural histories. It drove a wedge between the two worlds, creating psychological and emotional barriers that practitioners like Winsor have had to overcome generations later to perform cancer screenings in parts of America that major healthcare institutions don’t reach.
Geographic and Cultural Barriers to Care
The vast expanse of rural reservation lands in the American Southwest present significant geographic barriers to quality care. “Patients can travel for hours to get basic mammography services,” Winsor said. “It’s often difficult for them to get back [to a provider] for different views, ultrasound, a biopsy. For most larger or urban breast imaging centers, if they see something on a screening, a work-up takes a couple of weeks, whereas here, it may take many months.”
Winsor and her partner, sonographer Chilali Vian, began operating a breast ultrasound clinic at Chinle, a community of 4,500 to 5,500 people in the center of the Navajo nation in Apache County, Arizona. She described Chinle as “an extremely remote site” that is richly beautiful in the high desert, but home to significant poverty. Many residents don’t have running water or reliable electricity in their homes, making the effort to deliver imaging services there akin to a domestic medical mission environment.
Mobile imaging units account for a significant part of the screening imaging services provided in the region, but the distributed nature of the work means that when a study results in a finding, follow-up care can be likewise challenging to coordinate. Cancer incidence is lower – but less likely to be identified in the earlier stages of the disease – and health literacy is limited, so Winsor and Vian began spending two days per month there, seeing as many patients as possible for breast ultrasound, biopsies and consultations that make the experience meaningful to the people they treat.
“When we first started going out there, we were seeing people waiting more than a year after being called back for a suspicious abnormality,” Winsor said. “It took us two years to catch up to seeing patients who were having complaints in the last two months.”
“There’s seriously no place for these people to go,” she said. “It’s often too far (3 hours by car) for them to travel into Flagstaff, and a lot of people don’t have the transportation or the resources [to make the trip].”
Cancer detection rates increase in conjunction with an uptick in mammography studies performed; at the same time, mammography screening programs can result in a 30 to 40 percent reduction in patient mortality by connecting patients to services earlier. However, Winsor said that reduction has not been documented in the American Indian population with whom she works for a number of reasons, including a lack of access to advanced imaging modalities, like breast MRI and 3D breast ultrasound, as well as a dearth of skilled staff to conduct those studies and interpret their results.
“A lot of times, imaging technologists are travelers,” Winsor said. “They may have varying levels of experience with the equipment and protocols, and you have to train them again. Even with radiologists’ interpretations, it doesn’t make sense to hire a fellowship-trained breast imaging specialist if you only do five mammograms a week.”
Cultural insensitivity and racism also persist, she said.
“It’s a huge issue with attitudes, first and foremost,” Winsor said. “This isn’t necessarily an expensive problem that can be fixed by technology, it’s a matter of talking to people and understanding where they’re coming from. That patient-centeredness can be really hard to find in this setting.”
DayHawk: Closing the Loop With Telemammography
Winsor’s solution has been to establish a telemammography company called DayHawk. Its objective is to connect underserved rural patients who have abnormal imaging findings with fellowship-trained, offsite breast radiologists for high-quality radiology interpretations. DayHawk also wants to close that care loop with connections to a robust group of nurse navigators and social workers who are versed in the cultural practices of their communities, and who can liaise with staff on the ground for patient next steps.
“In most developed places, that patient would show up in a breast imaging facility and be able to see a breast radiologist onsite,” she said. “I think it will take a large network of people in a remote capacity to provide that basic level of care to these underserved areas.”
Winsor said the most successful interventions she’s seen in working to bring diagnostic imaging to women in remote regions of Arizona and Oklahoma have come from patient word-of-mouth endorsements. Her outreach efforts in Chinle began with two-thirds of her calendar slots being no-shows; now, after two-and-a-half years of consistent outreach, every appointment she offers typically is filled. That turnaround was built by forming multidisciplinary connections with local staff and medicine men, and by delivering on the services that she promised.
“You can’t force and you can’t expect it,” Winsor said. “When patients feel comfortable, they bring imaging to other family members.”
A Vendor’s Role in Community Outreach
Christie Devine, women’s health product manager at Siemens Healthineers North America, said that supporting community health outreach through mobile imaging services partnerships – such as those connected with Winsor’s work – is “a huge undertaking, but one we’re happy to do.”
The most successful health screening outreach initiatives turn on community partnerships with the patient populations they serve. Although Siemens Healthineers can facilitate pop-up events by sourcing imaging technologists to conduct the studies themselves, finding practitioners who can loop patients into a continuum of care after the results are delivered is a heavier lift. Devine praised Winsor for conducting her work in a culturally significant way that benefits the people served by it.
“The first thing we do need to ask is that our partners are able to find a radiologist to read them,” Devine said. “That’s one thing we’re not able to provide due to licensing. We need to make sure they’re capable and willing to take on the follow-up care as well.”
The logistics of hosting an outreach event also involves working with partners in the study area to identify the best time, place and manner of delivering services. Sometimes the most ideal opportunities for doing so may be in off-hours or weekends, to facilitate the schedules of women who work multiple jobs, provide caregiving or other responsibilities.
“We’ve done things to be able to get patients screened at a time that works for them that may not be the typical open hours,” Devine said. “People work with the organization to understand the challenges in this area. Karen Anderson, our key opinion leader, scientific manager, mammographer, and breast health advocate, has a great way of developing these relationships.”
Once such partnerships are identified within the communities where screening initiatives are to be conducted, Siemens Healthineers assigns a dedicated team of outreach professionals to advertise their events, promote them within the community and coordinate those efforts with the partner organizations.
When it comes to the imaging modalities involved, Siemens further works to account for any disparities in technologist training with equipment advancements like 50-degree, wide-angle tomosynthesis technology, a 3D mammography format that can help identify cancers sooner and more definitively.
Thereafter, Devine said, Siemens breast imaging pop-ups are designed “to help create a relationship that can lead to more appropriate care once a mammogram has been completed.”
“Once you can get someone to the room, that patient’s going to have the best experience that they can, and we want people to return, even if they don’t have a finding today,” she said. “When you have an expert like Dr. Winsor, the care is right there.”
Telehealth as a Bridge in Appalachia
Similar to the challenges of reaching women in distributed communities across the American Southwest, pediatric cardiologist Dr. Karen Rheuban, director of the University of Virginia (UVA) Health Center for Telehealth, has overseen the development of a telemedicine blueprint for the Appalachian community utilizing networks and partnerships across the state.
Rheuban, who calls herself the “chief cheerleader” of such technological outreach, said that remote healthcare options allow physician providers who’ve long traveled to remote locations across the state to deliver services to remote parts of Virginia that would otherwise require patients to travel hours to the nearest clinic.
“We host subspecialty clinics in distant community settings across Virginia one or two days every month. Before we had established telemedicine partnerships in these communities, if we were not physically present, our patients needed to either travel many hours to see us, or receive no subspecialty care for considerably complex conditions,” Rheuban said.
Rheuban said it’s been “gratifying to see our telemedicine program blossom as we approach nearly 1 million telemedicine encounters supported by federal and state grants, philanthropy and local partnerships across Virginia.” She’s testified before U.S. Congressional and Virginia General Assembly committees multiple times, urging elected officials to expand coverage in Medicare and Medicaid in support of telehealth options for patients in rural and urban areas. Rheuban points to federal and state waivers and flexibilities, and Federal Communications Commission and U.S. Department of Agriculture programs approved during the novel coronavirus (COVID-19) pandemic, as “transforming” how care is delivered.
“Prior to the issuance of COVID flexibilities, with a few exceptions, in order to be reimbursed for providing a telemedicine service to a Medicare beneficiary, patients had to travel to an eligible healthcare facility in a rural area,” she said.
By statute, Virginia chose to continue many of the COVID-era waivers that expanded telemedicine coverage for Medicaid beneficiaries and for those covered by commercial insurance plans. Medicare has extended those flexibilities, enabling patients to be seen at home, whether from rural or urban locations, through December 31, 2027. Now, as much as 11 percent of the ambulatory visits conducted by UVA Health are provided via telemedicine, and because patients don’t have to drive, pay for parking or gas, or account for long travel times in their appointments, they’re returning the highest levels of satisfaction scores.
“We’ve proven to our leaders that their investment in telehealth has borne fruit, improving access and patient engagement. We partner with community hospitals, federally qualified health centers, free clinics and other entities across the state,” Rheuban said.
In addition to offering mobile mammography, the UVA telehealth program is working on a proposal to house a mobile van within a federally qualified health center (FQHC) network serving Appalachian women, which would deliver the technology to those brick-and-mortar sites to serve patients closer to where they live. The proposal would cover screening and diagnostic mammography, with locally provided care that loops in their comprehensive cancer centers. It would also offer patient navigation services, affirming trust in the capabilities of remote outreach, “and an understanding that we’re here to help,” Rheuban said.
“A lot of our work has been grant-supported, but our goal is to remain in the community, be a valued and trusted partner, and support patients where they are,” she said. “Through telemedicine distance does not have to mean destiny.”
The Academic Health System’s Responsibility
Dan Wassilchalk, MHSA, recently retired as chief operating officer for the department of radiology and medical imaging for UVA Health, said that academic medical institutions like UVA have a significant responsibility to support patient care, teaching, research and community outreach in all areas they serve.
“The issue of access to care, to me, is the social-economic challenge of taking high-end, advanced imaging equipment, and reaching far-rural parts of the country,” Wassilchalk said. “How are we able to use IT as a connector to those communities, but also, how do we tie it to an electronic patient record, where advanced specialists are able to determine the next best steps for care?”
Patients in the Appalachian region are challenged to find the time to break away from daily activities like work, child-rearing or homesteading tasks for a diagnostic health exam, he said – particularly one inviting follow-up care that also takes them away from home for extended periods of time.
“Urban and suburban opportunities have access to this care more conveniently,” Wassilchalk said. “It’s not always the economic challenges of affordability and insurance coverage; it’s also the social logistics of being able to have the exam and follow up accordingly. Decisions have to be made, or prioritized, and women in particular will often put themselves on the back burner in favor of taking care of the family.”
“All of these challenges come into play as social determinants that need to be considered. Access to care needs to be as convenient as possible and as affordable as possible,” he said. “Early cancer detection saves lives and also costs less in the long run in terms of treating a patient that may be at Stage 1 versus a latter stage of the disease.”
Wassilchalk believes that it’s also important for academic, integrated health systems to deliver the level of care and follow-up that is necessary for those patients because such institutions also bring the kinds of outcomes-driven research found in an academic setting.
“If research can enable us to evaluate these healthcare disparities and identify these social determinants, then something can be done about making it easier, simpler, more accessible for these patients in rural regions, and then state dollars can be made available as evidence-based outcomes are demonstrated that justify these types of grant dollars being spent,” he said.
Training Local Talent — and Respecting Local Culture
One such example of that intersection of public health priorities, community partnerships and the resources of a federally supported academic institution is a proposed Rural Health Transformation grant to provide sustained breast cancer screening wraparound services. Rheuban and UVA Health Director of Teleradiology Debbie King are working to move that application forward in partnership with Tri-Area Community Health, which operates “in a part of Appalachia that’s home to one X-ray technologist who covers multiple clinics,” Wassilchalk said.
The linchpin of the program? A single X-ray and ultrasound-trained tech who said she would undergo mammography training to perform those women’s breast imaging exam in the community if the grant is awarded.
“On the spot and in front of the radiology tech, I called back to UVA Radiology, and spoke with one of my key counterparts who oversees tech training and said, ‘Can we provide training for this individual?’ ” Wassilchalk said. “Would we be able to not only accommodate her in terms of room and board, but provide the training as well, for free? My counterpart said, ‘Absolutely.’ The tech was shocked and thrilled, while the clinic staff immediately started to clap.”
“That’s what it takes sometimes,” Wassilchalk said. “When you’ve got the ability to provide patient care, the ability to teach and the ability to conduct evidence-based research that can not only justify and validate the outcomes but then spread the service as well, it kind of gives the advantage to the academic provider.”
Beyond building that capacity in its vocational staff, however, Wassilchalk further underscored the need for continued outreach that respects local culture and the needs of the population the program aims to serve.
“If we come into a culture saying, ‘Here we are; we’re coming to save the day,’ that is not going to work,” he said. “The approach needs to be humble to understand and appreciate the culture, and to teach, most importantly, the benefit socially, clinically and, of course, economically, so that the community can actually help us by spreading the word, making themselves available and going through the process. That’s a huge component to determining the success of this opportunity.”
Across the Navajo nation and the hollows of Appalachia, the throughline is the same: expanding breast imaging access takes more than advanced equipment. It takes mobile units and telehealth links, yes — but also local talent, patient navigation and the cultural humility to earn a community’s trust. That combination is what turns a one-time screening into a care relationship, and, as Rheuban puts it, keeps distance from meaning destiny.
