Colorado is densely populated across the front range of Denver and Colorado Springs. After leaving the Denver Metropolitan Area and the I-25 corridor, one is quickly in areas that are sparsely populated, where people are accustomed to traveling many hours to access healthcare specialty expertise.

THE PROBLEM

Even in some larger population areas, certain medical specialists are not immediately available in person. That can be complicated by the terrain of Colorado, with snowy mountain passes, road closures in the winter, and mudslides and traffic-congested roadways during the summer.

Maternal fetal medicine providers are partners to local obstetricians and provide women with high-risk pregnancies the full range of obstetric and maternal medicine expertise necessary to treat any complication a high-risk mother might face in her pregnancy.

With 24 MFM providers, the Children's Hospital Colorado/Colorado University School of Medicine Maternal Fetal Medicine Division is one of the largest in the country. The division has 21 clinics across the Denver metro area, greater Colorado and Wyoming. They provide full prenatal care, maternal and fetal disease consultation, prenatal diagnosis, and genetic counseling.

An MFM physician is a provider who has undergone additional training after their obstetrics and gynecology residency. This extra training focuses on high-risk pregnancies. This includes additional training in maternal medical conditions (for example, diabetes, hypertension), fetal imaging (for example, ultrasound) and procedures (for example, amniocentesis, fetal blood transfusions).

"Although some MFM physicians offer full prenatal care (for example, prenatal visits and deliveries), most MFMs offer consultative care," said Dr. Nicholas Behrendt, a maternal fetal physician at Children's Hospital Colorado's Colorado Fetal Care Center and an associate professor at the University of Colorado's School of Medicine.

"This means they join a patient's care team to lend their expertise in high-risk issues, but the patient continues prenatal care and eventual delivery with their OB/GYN physician," he continued. "This is beneficial in that it combines the continuity of care of the OB/GYN provider with high-risk expertise of the MFM."

There are many reasons a patient may need an MFM specialist, and these reasons continue to grow because of a multitude of reasons.

"One of the challenges we faced as an organization was our ability to meet the growing demand in a way that didn't have our patients or providers traveling hundreds of miles across Colorado, Wyoming and the region," Behrendt explained.

"Avoiding this travel has significant benefits to the patients, such as less time off from work, child care needs, the cost of travel, etc.," he continued. "In addition, it helps the 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 caring for these patients to be readily available."

The healthcare organization strives to have patients get care through their local obstetrical provider and at their local hospital.

"Enter telehealth," Behrendt said. "With this technology, our MFM providers can care for a pregnant parent utilizing telemedicine. Along with the telemedicine visit, the pregnant parent is also able to get their ultrasound and other testing done locally under the supervision of their locally based obstetrician.

"The MFM provider is able to review the ultrasound or tests and then meet virtually with the patients to counsel and craft a plan of care," he added. "The MFM provider collaborates closely with the patient's local obstetrician to provide the highest level of care to both the expecting parents and baby."

Many high-risk MFM patients require frequent visits and ultrasounds to monitor the pregnancy. Without telehealth, these pregnant parents would have to commute far distances to see an MFM subspecialist, or they do not receive the level of care they should.

"Approximately 60% of the patients we treat via telehealth are either Medicaid or patients with financial needs, and this patient population has significant hardships in regularly commuting far distances outside their home community for care," Behrendt noted. "Traveling to Denver is expensive, a significant time burden, takes patients away from their jobs, and is difficult on these families who have other children or family members at home who require care.

"On occasion, a patient requires delivery at a specialized facility, such as Children's Hospital Colorado," he continued. "Telemedicine allows those patients to meet and interact with the providers who will care for them before they have to relocate, if needed. Delaying relocation and creating a care team familiar to the patient is a very important way we can support these patients and reduce the cost of care."

PROPOSAL

There were several areas considered as Children's Hospital Colorado explored how to solve the problem of bringing MFM specialists to communities across Colorado and Wyoming via telemedicine.

"We needed to identify a technology that would allow for sharing of protected health information across multiple providers, including sonographers, obstetricians, maternal fetal medicine, and other maternal and fetal subspecialists, as needed," Behrendt said. "This technology needed to have three different connection points.

"First, it needed to connect diagnostic tools, such as ultrasound images from one clinic to another in real time for providers when they were meeting with patients," he continued. "Next, providers needed to have access to one another's notes and plan of care. Lastly, the technology needed to connect the patient in one location with the MFM provider in another location."

Then came staff training and education.

"We needed to ensure the local obstetrician sonographers were comfortable and competent at administering high-risk ultrasounds to enable the MFM provider to diagnose and treat the patient," Behrendt noted. "Additionally, we needed to train the local team on the process of utilizing the telemedicine equipment and on how to troubleshoot if technology problems arose.

"Then, patient experience," he continued. "Quality and family-centered care is at the core of all we do. It was paramount that patients received the same level of care locally that they would in a larger center. We set up a telehealth process that put the patient and their care at the center, ensuring the patient would have a high-quality experience with the MFM specialist, that they felt they were getting the care they needed, and that the technology was simply another modality by which they were getting care."

MEETING THE CHALLENGE

The organization believes that where one lives shouldn't define the level of healthcare they receive. With telemedicine, the organization makes sure that expecting parents who live remote from MFM expertise have the same access to care as those who live closer to these providers.

"The MFM teams have built a robust telemedicine network supporting 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, the Colorado Fetal Care Center at Children's Hospital Colorado 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 our partners," he continued. "The MFM has the ability to switch between seeing the patient and reviewing the ultrasound in real time to making care plans and decisions. These providers can interact with the sonographer and patient in real time to see the ultrasound images as if we were there in person."

Once the 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 readily available to both the patient and provider no matter the distance.

"This telemedicine technology is integrated in many ways, including: our picture archiving and communication system; ultrasound reporting software; and Epic EHR for documenting and executing during the face-to-face visit," Behrendt explained.

RESULTS

"Telemedicine provides a bridge from a baby forming from a fetus to a neonate," Behrendt said. "With this in mind, we know that telemedicine improves the outcomes of the high-risk MFM patient through earlier diagnosis. This has a positive outcome during the pregnancy and for the baby post-delivery. Further, telemedicine can help close a troubling fetal care gap 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 performed in our center, we know telehealth patients have been saved more than 200,000 miles of driving and more than $30,000 in the cost of gas over the course of a year."

Based on a minimum wage salary of $10.20 per hour, families saved between $32,636 and $65,272 in missed work days. Most fetal anomalies are diagnosed at the time of the fetal anatomy ultrasound between 18 weeks and 22 weeks gestation.

"If it wasn't for telemedicine, patients would have to travel to Denver for at least half of their pregnancy for appointments," Behrendt reported.

"Our telehealth families complete a patient satisfaction survey," he added. "Based on the results of 50 surveys, all the patients who completed the survey would rather have telemedicine locally than travel to Denver for their care. Telemedicine has proven to be a huge patient satisfier. Patients did not feel like they received a lower level of care by having a telemedicine visit, rather than an in-person visit."

Lastly, telemedicine enhances the capabilities of local providers. The MFM providers educate local providers to help them identify fetal anomalies earlier. This has been seen in the steady growth of referrals since the provider organization began the program.

ADVICE FOR OTHERS

"Ensure the technology being used at each site is compatible with the technology being used for image review and documentation," Behrendt advised. "Creating a strong technological plan before implementation should minimize the challenges that can be faced.

"Reliable internet connections, secure communication pathways and high-quality hardware makes this process comfortable for all those involved," he continued. "We have set up protocols for providers and team members that makes troubleshooting relatively easy and minimizes complications that can occur. For instance, each provider has a document of key contacts in case communication is needed outside of the telemedicine hardware/software."

Technology has advanced significantly over the last several years making this process as smooth as possible, he added.

"Also important, you must ensure any provider privileging and liability policies are up to date and are applicable to the program," he concluded. "There were definitely challenges setting up the process but creating a clear plan and executing that plan made this attainable."

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