By Tanya Mack, Women’s Telehealth
On March 11th, the World Health Organization declared COVID-19 a worldwide pandemic. As our understanding of COVID-19 expands and our social distancing and separation requirements extend, the need for safe access to care for all, and the protection of pregnant women has become critical. Although we do not yet know if pregnant women have an increased chance of getting sick from COVID-19 compared to the general public, we do know there are changes in their bodies that may increase the risk of infection. We are now seeing indiscriminate and sustained spread across patients in all three trimesters. Within the past month, telehealth has risen to the forefront worldwide as a means to provide quick and safe access to medical care – and the pregnant patient and their obstetric providers are no exception.
Telehealth Enters OB Practice in a Widespread Way
Prior to the COVID-19 pandemic, the use of telehealth was minimal in obstetric practice in the US. Despite its growth in other healthcare areas, few healthcare facilities or providers were set up to provide OB telehealth services. However, in the short span of 4-6 weeks, this has changed dramatically. We have seen ACOG and the Society for Maternal Fetal Medicine (SMFM), hospitals and OB practices quickly respond with broad adoption of telehealth as a means to protect pregnant patients from viral exposure, OB clinical protocols adjusted for telehealth and “pods” of providers during delivery admissions to avoid cross-contamination. As we are learning together, telehealth use can be crucial in meeting healthcare needs during disaster relief.
How Telehealth Works in General and in Obstetrics
Telehealth can be used in many settings such as hospitals, outpatient clinics, doctor’s offices and in patients’ individual homes. Telehealth visits can occur by using satellite, cellular or broadband transmission. Prior to COVID-19, in the US, broadband (internet) was the most common method of transmission. However, cellular transmission is quickly providing access, as it is the most available means for the patient to connect from home via their Smartphone. Clinical standards follow the same guidelines and flow as face-to-face visits. Generally, the connection requirements include: a camera, a microphone and either a cellular or internet connection between the parties.
OB Telehealth visits can occur in the following ways:
- Live: Two-way, synchronous visit (patient and provider connect same time/ different location (for patient to provider consultation, screening, triage)
- Store and Forward: Data/ image (like an ultrasound) is captured in one place and time and received and evaluated by a provider at a different time/different location (sometimes used for remote diagnosis of a fetal anomaly where there is no local MFM doctor)
- Hybrid Visit – blends live AV call with concurrent store and forward data/image transmission (MFM or other specialist consultation in pregnancy with U/S imaging)
- Remote Patient Monitoring – Home OB visit checks with patient/provider (for blood pressure monitoring for hypertension, insulin management for gestational diabetes, medication adjustments, etc.)
Regulatory and Reimbursement Changes in Telehealth During COVID-19 Crisis
Reacting to and being flexible with the current situation, the federal government has greatly relaxed prior barriers to telehealth in recent weeks. Although few pregnant patients have Medicare as a payor, the Centers for Medicare and Medicaid Services (CMS) has set standards that many state Medicaid and commercial carriers are following as well. Some of these temporarily “relaxed” guidelines for telehealth use and payment during this crisis are:
- The use of AV equipment to connect patients to providers does not currently require HIPAA compliance (platforms such as Skype, Zoom, FaceTime on devices are now allowed to provide easier access for the majority of patients)
- Telehealth may now be used for new and established patients (prior to this, many states required a face-to-face visit to establish a doctor-patient relationship prior to the payment of telehealth visits)
- The originating site requirement has been waived (the patient’s home is now acceptable)
- Geographic restrictions have been relaxed (patients are not required to live in rural areas)
- Services covered for payment have been expanded and are not limited to patient diagnosis or the patient having COVID-19
For reimbursement, although CMS and Medicare have lifted restrictions for payment nationwide and temporarily, each state controls their Medicaid coverage and each commercial healthcare payer determines their telehealth coverage. Patients are encouraged to follow and check with their own carrier and state, but an overwhelming majority are covering telehealth during this public health emergency. In general, although the use of telehealth and reimbursement for it are changing daily, preventing the spread of COVID-19 in pregnant patients remains the #1 priority in obstetrics.
Obstetric Protocol Adjustments for Low and High-Risk OB Patients Using Telehealth
Obstetric professional organizations such as delivering hospitals, ACOG and SMFM are adapting clinical guidelines for telehealth. The idea is to have OB patients come in for critical antenatal appointments such as the 11-13 weeks dating scan and labs, 20-week anatomy ultrasound, and the 26-18 week GTT testing and end of pregnancy visits. Telehealth antenatal visits can be used for <11 weeks initial assessment visits, blood pressure checks for pre-eclampsia and glucose monitoring for gestational diabetes, and kick counts/telehealth follow-up versus in-person nonstress tests (NSTs), etc.
As there is no vaccine for COVID-19 yet, limiting risk for pregnant patients during this pandemic remains a priority. Worldwide organizations are sharing COVID-19 pregnancy information at a rate we’ve never seen before, to ascertain how the virus affects mom and the fetus, whether vertical transmission occurs between mother and fetus, what treatments are effective and more. In the interim, the benefits of using telemedicine in obstetrics are clear. Telemedicine provides easier access to specialty care, is consistent with the social distancing policies, is often cheaper than an in-person visit, and decreases unnecessary travel.
Prior to the COVID-19 pandemic, Women’s Telehealth provided over 34,000 high-risk OB visits 100% by telehealth. As providers and patients grow accustomed to using this modality in obstetrics, many for the first time, Women’s Telehealth is available to help. Contact Tanya Mack, Women’s Telehealth, 404-478-3017 or visit www.womenstelehealth.com.