Maternal telehealth: innovations and Hawaiʻi perspectives

Maternal-fetal medicine consultations

Prior to the COVID-19 pandemic, telehealth video conferencing visits or virtual health visits between patients and providers were being used for less than 5 percent of prenatal consultations by the University MFM group. At the height of the COVID-19 pandemic, the University MFM providers had converted over 75 percent of their consultative visits to telehealth visits to prevent the spread of COVID-19 infection while minimizing public transportation and air travel from the neighbor islands. In addition to, routine telehealth consultations from one island to a patient on another island, certified diabetes educators were trained to perform virtual training of pregnant patients to perform self-monitoring of blood glucose (SMBG) and insulin injections. The patients were also instructed on how to use the electronic patient portal on the secure online website to enter their SMBG fingerstick measurements for tracking and glucose management of gestational diabetes and Type 2 diabetes in pregnancy. Telehealth visits were also used for genetic counseling.

Remote ultrasound imaging

A store-and-forward software provides the platform for ultrasound images to be sent to a provider in an efficient manner. The store-forward asynchronous transmission has been implemented to communicate high-quality ultrasound images into cloud-based storage from neighboring islands. The MFM specialist is then connected to the Cloud by logging into a secure internet website to read and interpret ultrasound images (at the remote site) and generate a report. The report will be sent back to the originating health care provider site which can then be made a part of the patient record (at the originating site).

Medcarts

Medcarts support real-time telehealth consultation with two monitors. Medcarts support the real-time simultaneous ultrasound imaging and the live video of the patient and sonographer (at the originating site) and the provider (at the remote site). The remote MFM physician who is supervising the fetal ultrasound and providing counseling to the patient at the originating site, can use a dual monitor system to visualize the ultrasound image and teleguidance to direct the sonographer if necessary (e.g., “Show me the fetal lips and nose; show me the 4-chamber view of the heart again”). This system also gives the MFM provider the opportunity to communicate with the patient simultaneously using the video-conferencing application. This is especially helpful for the MFM physician who is at the remote site to point out and explain preliminary readings, as well as provide consultation to the patient who is receiving news about a newly discovered congenital fetal anomaly while still in the ultrasound suite at the originating site. This virtual teleconsultation that is integrated with live-feed ultrasound improves communication and the patient experience, and allows the subspecialist to have the opportunity to triage which patients need to leave their island home and fly to Honolulu for confirmatory prenatal ultrasound examinations.

Hand-held ultrasound

Live imaging and tele-guidance mobile hand-held ultrasound allow for quick capture of fetal images to assist in triaging the next course of action. The hand-held ultrasound probe works with a mobile computing tablet to transmit images to the remote MFM for triage, as well as teleguidance with live real-time imaging. This is considered a synchronous application and was utilized by a traveling midwife provider who was providing home visitation patient evaluations that was being monitored by the MFM physician during the COVID-19 pandemic. The midwife and MFM were able to succcessfully diagnose pertinent findings such as a post-Cesarean incisional hematoma using the hand-held ultrasound.

Mobile telehealth

The Midwifery-Integrated Home (MI-Home) Visitation Program started in 2021 in Oahu offered home visitation by a certified nurse-midwife in collaboration with hospital-based MFM specialists using mobile telehealth technologies. The traveling midwife carried portable telehealth tools to assist the patient to access subspecialty services from the field. Using mobile telehealth equipment that could be carried in a backpack, the MI-Home midwife could provide increased access to subspecialty care such as substance use disorder, diabetes management in pregnancy, management of women at risk for preterm birth, unhoused pregnant women, and Native Hawaiian, Pacific Islander, Filipino and Black women with multiple social determinants preventing access to primary and subspecialty care.

The lessons and knowledge gained from the MI-home program are numerous. MI-home piloted telehealth, telecommunications, and remote patient monitoring which can be adopted for use in other remote communities to provide services that are unique to pregnant patients. It optimized cell phone and computer applications for arranging confidential transportation to appointments and utilized a Health Insurance Portability and Accountability Act (HIPAA)-secure texting platform. The texting platform allowed a free, confidential communication and allowed for continuity of care between midwife provider, office coordinator and patients.

Besides optimizing applications for arranging transportation and a texting platform, the midwife also piloted innovative technologies in the field with support from the MFM physicians. These included remote ultrasound guidance to evaluate abdominal masses, remote fetal monitoring with the commercially available system, the performance of non-stress tests (NST) to assess fetal well-being, and other telehealth systems to assess vital signs from remote locations.

Remote fetal monitoring

During the advent of COVID-19 pandemic, the University Health Partners received a Health Resources Services Administration-sponsored Maternal-Telehealth Access Project grant to pilot a remote fetal heart rate monitoring program and equipment. Tele-electronic, cloud-based remote fetal monitoring with a blood pressure cuff is a physician-prescribed, pregnancy monitoring system. It allows women with high-risk pregnancies to collect their data and review their progress with healthcare providers from home via wearable sensor band, blood pressure cuff and cloud-based digital ecosystem for non-stress test (NST) antenatal monitoring of fetal well-being. The device sends the data to a smartphone to store in a cloud-based database, providing data on heart rate to a provider. During the initial pilot, 15 women participated in a beta-test of the wearable technology as a demonstration of its utility across the Hawaiian Islands. In October of 2021, the remote fetal monitoring equipment received Federal Drug Administration (FDA) approval for the performance of a 20-min non-stress test (NST), a common assessment of fetal well-being that is typically performed in a physician’s office. Hawai‘i Medicaid is required to cover the cost of telehealth monitoring including a storage of patient data, in this case vital signs and fetal heart rate and forwarding to the medical provider equivalent to the same services provided for in person care.

The provider obtains patient consent from the patient to be enrolled into the monitoring system on a secure password-protected website. The patient is issued a written patient electronic consent on their smartphone device with Bluetooth^® capability when installing the application built into the system to participate in the remote monitoring program application and the provider also obtains verbal patient consent. The fetal heart tracing is stored in the cloud and readily accessible by the health center staff and MFM consultants with secure login access to the website.

Home blood pressure monitoring

In 2020 during the height of the first wave of the COVID-19 pandemic, the University MFM division initiated a home blood pressure monitoring program to assess hypertension of pregnant and postpartum patients with a generous donation of free blood pressure cuffs from the Hawai‘i State Department of Health. A foundation grant was subsequently awarded to Kapiolani Medical Center for Women and Children to expand the home blood pressure monitoring to pregnant persons who needed advanced nursing support in collaboration with the MFM physicians. This expanded blood pressure program allows for guided changes in antihypertensive medications. Once a prenatal or postpartum patient with hypertension is identified, an order is placed by the physician for nursing communication with the patient through a secure patient portal. This remote blood pressure monitoring program has been particularly useful for rural or neighboring island patients, patients with exposures to COVID-19 infection, or patients lacking transportation.

Mobile telehealth clinics

As part of a Hawai‘i Department of Health Centers for Disease Control and Prevention (CDC) project, mobile telehealth clinic vans will be stationed at libraries throughout the community for public health campaigns and will be used to deliver telehealth services into the communities on each island. This is part of an overall digital and health equity project that will enable libraries to serve as telehealth access points, by providing places for patients and families to access broadband, computers and support from digital navigators in the libraries as part of the American Rescue Plan Act of 2021 [6]. This is a joint project between the Hawai‘i Department of Health, Hawai‘i State Libraries and the Pacific Basin Telehealth Resource Center.

Robotic ultrasound

Robotic ultrasound has been utilized in Europe and Canada and shows promise for use in Hawai‘i and other remote areas. Following an initiative to close the healthcare disparity gap associated with increased maternal and newborn morbidity and mortality in Indigenous pregnant women in the region, obstetric tele-robotic ultrasound systems were implemented. They are currently used by two northern Canadian Saskatchewan communities to perform prenatal ultrasounds [7]. It has been recently tested successfully Trans-Atlantic between France and Rutgers cardiovascular teams using a 4G network [8]. It is approved by the Food and Drug Administration and the trans-oceanic connection shows promise for Hawai‘i inter-island ultrasonography.

Obstetric outcomes

Several studies prior to the COVID-19 pandemic showed similar perinatal outcomes compared with traditional care without compromising the patient-physician relationship. The majority of these studies examine the use of telehealth virtual visits and other than a home-blood pressure cuff or blood glucose monitor, no other medical devices. A cohort study in 2016 analyzed maternal and neonatal outcomes in 117 patients who chose a hybrid model of nine in-person prenatal visits and five virtual prenatal visits to 941 women who received 12 in-person visits. There were no significant differences in rates of cesarean birth, preterm birth, neonatal intensive care unit admissions, or birth weight. Despite a higher rate of preeclampsia in the virtual visit cohort, the above outcomes were not significantly different [13].

Likewise, in February 2020 a systematic review of Clinical Trials, Cochrane review, and medical literature database concluded that telehealth reduced in office-visits for patients requiring blood pressure or glucose monitoring without a change in maternal and fetal outcomes [14]. One study noted by the systematic review found reductions in diagnosed preeclampsia among women with gestational hypertension. Though two subsequent large randomized control trials (RCTs) in England published following the systematic review showed no significant reduction in preeclampsia diagnosis and no improvement in control of chronic hypertension in pregnancy [15, 16]. Nevertheless, the RCTs and systematic review both found that home blood pressure monitoring via telehealth did not incur an increase in maternal or neonatal morbidity or mortality, and few adverse events were noted [14], [15], [16].

The same 2020 systematic review concluded that telehealth use was associated with improved some obstetric outcomes including perinatal smoking cessation, increase in breastfeeding rate, earlier access to medical abortion services, and schedule optimization for high-risk obstetric patients requiring multiple appointments. Telehealthcare was effective for compliance with oral and injectable contraception methods. Medication abortion services had similar clinical outcomes compared with in-person care and improved access to early abortion. Addressing gynecologic needs was noted to be improved earlier notification of sexually transmitted infections via telehealth notifications and app-based urinary incontinence bladder training [14].

Antenatal testing

Remote ultrasound reading by an MFM has been shown to improve diagnostic accuracy when an in-person MFM specialist is not available. The potential for missed diagnoses was 34.5% in one recent study where MFM-trained sonographers, general OBGYNs and general practitioners all called the scan “normal.” There were significant differences in the rate of the potentially missed diagnoses by organ system, with the highest rate for cardiac anomalies^. [17]. In a study of remote fetal monitoring in low-risk pregnancies utilizing OB Nest, a Mayo Clinic protocol developed with phone-application communication of fundal height, blood pressure and hand-held doppler, adherence to ACOG’s guidelines for prenatal services was similar in both groups [18]. Maternal and fetal outcomes were similar between groups. Total reported nursing time was higher in the OB Nest group.

Patient satisfaction

The 2016 cohort study results mentioned prior noted hybrid in-person/virtual patients’ satisfaction was significantly higher but had a non-significant absolute difference between their rating of virtual compared to in-person visits [19]. In a cross-section study of 332 patients, a 90% response rate found that most patients reported comfort with home monitoring skills in the categories of measuring weight, taking blood pressure, and monitoring fetal heart tones. It should be noted that fetal heart tones were the lowest at 68% of survey respondents who felt comfortable taking their own fetal heart tones [10].

Home monitoring devices, such as blood pressure cuffs and handheld Dopplers have been controversial given concern for overutilization of acute care if erroneous measurements are taken [20]. Despite this, survey studies have suggested that these devices may increase both patient and provider comfort and satisfaction with virtual care [10, 21]. In a study conducted by researchers at the University of South Florida in 2020, a standardized obstetric protocol for pregnant patients was developed using a virtual care schedule model (OB Nest) to reduce in-person visits and incorporate telehealth into the schedule of prenatal care. Patients were provided with blood pressure cuffs and fetal dopplers, and followed a schedule consisting of a combined virtual and prenatal care protocol combining eight in-person visits with six virtual nursing visits, an asynchronous online portal for questions and education, and an online community moderated by nurses. Compared to the control group, participants in the OB Nest group had higher patient satisfaction and lower stress levels [22].

Challenges to implementation of telehealth

Lack of access or digital literacy with smart-phone and computer technology is can limit access to modern healthcare services. To promote digital equity and reduce delays in maternal healthcare in rural communities of Ghana, telehealth solutions were implemented to reduce delays in seeking care and discovered the potential to reduce maternal mortality as well as cultural and financial barriers to utilizing telehealth [23]. In order to mitigate low internet and broadband penetration in rural areas, some studies suggested relying on the use of community volunteer mobile phones, which incidentally have been shown to increase skilled birth attendance [24, 25]. In order to minimize the burden of cost, mobile financial services were provided to pregnant women to help them access financial services for maternal healthcare [23]. A United States-based study compared barriers encountered by MFM practices in the majority Medicaid and majority non-Medicaid insured patients [26]. Both groups received care at University-based practices and showed no significant differences in the rate of barriers faced between the differing types of insured patients. The two most common barriers faced by both groups were patient access to the internet or data plans and “soft-ware/hardware usability” [26].

Additional challenges have been noted. Waivers for reimbursement for telehealth may vary by state, as the extension was not granted following the initial phase of the COVID-19 pandemic. Payment can be less for FQHCs for in-person compared to telehealth encounters and issuing standardized equipment, a medical device or a pharmacy item and training a patient on how to use a device can be difficult to trouble-shoot initially for providers [27].

COVID-19 pandemic contributions

Since the advent of the COVID-19 pandemic, current telehealth literature has increased substantially due to the necessity of isolation. Studies noted benefits to patients and providers as well as some barriers to telehealth access. A recent review of 25 published reports aimed to analyze how obstetric care systems responded to the COVID-19 pandemic concluded that protocols developed replaced some in-person visits with telehealth visits when no testing was required [28]. Common reported benefits were minimizing exposure and the continuity to provide safe care. Lack of access to high-speed internet and hardware and inaccessibility to patients were the most reported barriers [28].

Several expert opinions and templates for obstetric care have been published by various obstetric health care groups across the globe reflecting their experience with telehealth during 2020 and onward [29]. Examples include a group at the University of Michigan that proposed a Michigan Plan for Appropriate Tailored Health Care in Pregnancy (MiPATH), a constellation of expert recommendations for more flexible prenatal care for patients with average risk with 4 in-person visits, 1 ultrasound visit, and 4 virtual visits (the 4-1-4 prenatal plan) [11].

Pregnancies requiring genetic counseling were shown to overall adapt to the telehealth format. The University of North Carolina at Chapel Hill described its workflow well for transitioning genetics consults to telemedicine during the pandemic [30]. Their program decreased in-person resources to be mostly utilized for ultrasound and prenatal diagnostic procedures while providing safe and effective patient care for genetic counseling and psychosocial support after a difficult diagnosis with virtual visits with genetic counselors [30]. Telehealth appointments for low-risk patients or patients with only specific needs such as genetic counseling or preconception counseling have become more commonplace since 2020.

High-risk pregnant patients who require an MFM’s care, still faced the same risk of exposure in the era of the early pandemic as low-risk patients but had even more complex medical and psychosocial needs. Thus the medical community was driven to adapt. Columbia University Irving Medical Center’s report of this time period shows well-outlined, evidence-based protocols for specific high-risk conditions including patients with increased risk of still-birth, cardiovascular conditions, hypertension, pregestational diabetes and fetal anomalies. These high-risk patients were provided services and coordination through a hybrid telehealth format [29]. Antenatal testing such as non-stress tests and ultrasounds were still performed in person and the report concludes that telehealth virtual visits did not fully replace in-person prenatal care, but offered a means of reducing potential exposure to COVID-19 while providing consolidated in-person services. For patients requiring care by a MFM, one recent study showed patients’ preference for telemedicine when available though the implementation actually decreased patient adherence to the appointment schedule [31]. ACOG recommends that each region assesses and decides the number of inpatient and telehealth visits appropriate for their unique population [32].

Consensus on some aspects of telehealth still remain to be widely established such as ensuring patients’ internet or data-plan access, patient comfort with home monitoring devices, and provider reimbursement for telehealth visits and remote monitoring systems. Current literature is promising that a more patient-centered telehealth prenatal format can benefit the accuracy of care, increase patient satisfaction and reduce the need for in-person visits. Community/patient needs assessment, adherence to evidence-based guidelines and strict protocols are commonly cited by experts in the field as important components for telehealth implementation. Evaluation of telehealth use in remote and global regions with successful telehealth services may inform better practices for telehealth in remote areas worldwide.