In Colorado, maternal health telehealth improves quality and patient experience
Colorado is densely populated in the Front Range of Denver and Colorado Springs. After leaving the Denver Metropolitan Area and the I-25 corridor, you quickly enter areas that are sparsely populated, where people are accustomed to traveling many hours to access specialized healthcare expertise.
THE PROBLEM
Even in some areas with larger populations, some medical specialists may not be readily available in person. That can be complicated by Colorado’s terrain, with snowy mountain passes, road closures in the winter, and mudslides and traffic jams on the roads in the summer.
Maternal fetal medicine providers work in partnership with local gynecologists to provide women with high-risk pregnancies with all the obstetric and maternal medicine expertise needed to manage any complications a high-risk mother may face during her pregnancy.
With 24 MFM providers, the Maternal Fetal Medicine Division at Children’s Hospital Colorado/Colorado University School of Medicine is one of the largest in the country. The division has 21 clinics in the Denver metro area, Greater Colorado and Wyoming. They offer comprehensive prenatal care, maternal-fetal disease consultation, prenatal diagnosis and genetic counseling.
An MFM physician is a health care provider who has completed additional training after completing his or her training as a gynecologist and obstetrician. This additional training focuses on high-risk pregnancies. This includes additional training in maternal medical conditions (e.g., diabetes, hypertension), fetal imaging (e.g., ultrasound), and procedures (e.g., amniocentesis, fetal blood transfusions).
“While some MFM physicians provide full prenatal care (e.g., prenatal visits and deliveries), most MFMs provide consultative care,” said Dr. Nicholas Behrendt, a maternal-fetal physician at the Colorado Fetal Care Center at Children’s Hospital Colorado and an associate professor at the University of Colorado School of Medicine.
“This means they join a patient’s care team to provide their expertise on high-risk issues, but the patient continues to receive prenatal care and ultimately delivery with their OB/GYN physician,” he continued. “This is beneficial because it combines the continuity of care of the OB/GYN provider with the high-risk expertise of the MFM.”
There are many reasons why a patient may need an MFM specialist, and this number continues to increase for a variety of reasons.
“One of the challenges we faced as an organization was being able to meet the growing demand without our patients or caregivers having to travel hundreds of miles across Colorado, Wyoming and the region,” Behrendt explained.
“Avoiding these trips has significant benefits for patients, including reduced time off from work, need for childcare, cost of travel, etc.,” he continued. “In addition, it helps providers by not taking them away from their families, their Denver-based clinical practices and patients, and other academic activities. Importantly, this telemedicine program also allows experts in the care of these patients to be readily available.”
The healthcare institution aims to ensure that patients receive care through their local midwife and in their local hospital.
“Enter telehealth,” Behrendt said. “This technology allows our MFM providers to care for a pregnant parent using telemedicine. Along with During a telemedicine consultation, the pregnant parent can also have an ultrasound and other tests performed on site, under the supervision of the local gynecologist.
“The MFM provider can review the ultrasound or tests and then meet with the patient virtually to provide counseling and develop a plan of care,” he added. “The MFM provider works closely with the patient’s local gynecologist to provide the highest level of care for both the parents-to-be and the baby.”
Many high-risk MFM patients require frequent visits and ultrasounds to monitor the pregnancy. Without telehealth, these expectant parents would have to travel far to see an MFM subspecialist, or they would not receive the care they should.
“Approximately 60% of the patients we treat via telehealth are either Medicaid patients or patients with financial need, and this patient population has significant difficulty traveling significant distances outside of their home community for care on a regular basis,” Behrendt noted. “Traveling to Denver is expensive, a significant time drain, takes patients away from work, and is difficult for these families who have other children or family members at home who need care.
“Sometimes a patient needs to deliver in a specialized facility, like Children’s Hospital Colorado,” he continued. “Telemedicine allows those patients to meet and communicate with the providers who will be caring for them before they have to relocate, if necessary. Delaying the relocation and creating a care team that is familiar to the patient is a very important way that we can support these patients and reduce the cost of care.”
PROPOSAL
Several areas were considered when Children’s Hospital Colorado explored how to solve the problem of providing MFM specialists to communities in Colorado and Wyoming via telemedicine.
“We had to identify a technology that would allow us to share protected health information with multiple providers, including sonographers, gynecologists, maternal fetal medicine and other maternal and fetal subspecialists, as needed,” Behrendt said. “This technology had to have three different points of connection.
“First, it had to connect diagnostic tools like ultrasounds from one clinic to another in real time for providers as they encounter patients,” he continued. “Then, providers had to have access to each other’s notes and care plans. Finally, the technology had to connect the patient in one location to the MFM provider in another location.”
This was followed by training and education of the staff.
“We had to make sure that the local obstetric sonographers were comfortable and competent in performing high-risk ultrasounds so that the MFM provider could diagnose and treat the patient,” Behrendt noted. “In addition, we had to train the local team on the process of using the telemedicine equipment and how to troubleshoot when technology issues arose.
“Then the patient experience,” he continued. “Quality and family-centered care are at the heart of everything we do. It was paramount that patients receive the same level of care locally as they would in a larger center. We have a telehealth process that puts the patient and their care at the center, giving the patient a high-quality experience with the MFM specialist, feeling like they are getting the care they need and that the technology is just another modality through which they receive care.”
TOOK UP THE CHALLENGE
The organization believes that where a person lives should not determine the level of health care they receive. With telemedicine, the organization ensures that expectant parents who live far from MFM expertise have the same access to care as those who live closer to these providers.
“MFM teams have built a robust telemedicine network that supports rural communities in caring for both maternal and fetal conditions that result in high-risk pregnancies,” Behrendt said. “By bringing adult and fetal subspecialty services to these communities, Children’s Hospital Colorado’s Colorado Fetal Care Center is enhancing the care provided locally in more rural communities.”
“The process for a high-risk MFM telemedicine visit is well-defined and consistent across all of our partners,” he continued. “The MFM can toggle between seeing the patient and reviewing the ultrasound in real time to make care plans and decisions. These providers can communicate with the sonographer and the patient in real time to review the ultrasound images as if we were there in person.”
Once imaging is complete, the MFM provider consults with the patient and shares the findings with the patient’s local obstetrician. Electronic health records have made these consultations easily accessible to both the patient and provider, regardless of distance.
“This telemedicine technology is integrated in many ways, including: our photo archiving and communication system; ultrasound report software; and Epic EHR for documenting and conducting in-person appointments,” Behrendt explains.
RESULTS
“Telemedicine is a bridge from a baby developing from a fetus to a newborn,” Behrendt said. “With this in mind, we know that telemedicine improves outcomes for the high-risk MFM patient through earlier diagnosis. This has a positive outcome during pregnancy and for the baby after delivery. Additionally, telemedicine can help close a troubling gap in fetal care in Colorado and the region.”
“Telemedicine saves mothers and families the time, expense, and physical and emotional discomfort of travel,” he added. “Based on a study we conducted at our center, we know that telehealth patients have saved over 200,000 miles of driving and over $30,000 in gasoline costs over the course of a year.”
Based on a minimum wage of $10.20 per hour, families saved between $32,636 and $65,272 in missed workdays. Most fetal abnormalities are detected during fetal anatomy ultrasound between 18 and 22 weeks of pregnancy.
““If telemedicine weren’t available, patients would have to travel to Denver for appointments for at least half of their pregnancy,” Behrendt said.
“Our telehealth families complete a patient satisfaction survey,” he added. “Based on the results of 50 surveys, all patients who completed the survey would prefer telemedicine locally rather than traveling to Denver for their care. Telemedicine has proven to be a huge patient satisfaction driver. Patients did not feel like they were receiving a lower level of care because of a telemedicine visit versus an in-person visit.”
Finally, telemedicine enhances the capabilities of local providers. The MFM providers train local providers to help them identify fetal abnormalities earlier. This is evident in the steady increase in referrals since the provider organization started the program.
ADVICE FOR OTHERS
“Ensure that the technology used at each location is compatible with the technology used for image review and documentation,” Behrendt advised. “Creating a strong technology plan prior to implementation should minimize the challenges that may arise.
“Reliable internet connections, secure communication paths, and high-quality hardware make this process comfortable for everyone involved,” he continued. “We have protocols in place for providers and team members that make troubleshooting relatively easy and minimize complications that may arise. For example, each provider has a document with key contacts in case communications outside the the hardware/software for telemedicine.”
Technology has improved tremendously in recent years, making this process as smooth as possible, he added.
“Also important, you need to make sure that all of the provider’s privileges and liability policies are up to date and applicable to the program,” he concluded. “There were certainly challenges in setting up the process, but creating a clear plan and executing on that plan made this achievable.”
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