Maternal Fetal Medicine Telemedicine: Seven Years of Growth and Success in Improving High-Risk Pregnancy Outcomes

UPMC Magee-Womens Hospital conducts more than 10,000 patient consults and visits every year. Since 2011, a growing number of those consults and visits have occurred through the use of telemedicine with patients in distant areas across western Pennsylvania.

Access to a maternal-fetal medicine (MFM) specialist is crucial to achieving good outcomes and preserving and protecting the health of the mother and baby in high-risk pregnancies. Unfortunately, the number of trained MFM physicians in the United States is woefully inadequate to provide these specialized services to all patients who need them. Women who live in rural areas of the country have even less access to this specialized care, and the consequences of a lack of MFM care for high-risk pregnancies are unacceptable levels of morbidity and mortality. Geography should not be a reason that causes any patient to receive suboptimal care. Telemedicine can help to bridge the care gap. Indeed, the Division of Maternal Fetal Medicine at UPMC Magee has shown not only how it can be accomplished but also what success entails. 

Building an MFM Telemedicine Program and Planning for Its Future

The structural design of the program, how it was implemented, and the health outcomes for mothers and babies for the first four complete years of the UPMC MFM telemedicine program were published in June by faculty and staff of the Division in a paper in the American Journal of Perinatology.¹ Analyzing program data for the years 2012 to 2015, the UPMC MFM telemedicine team shows the overall utility of the program on a systemic level, patient satisfaction scores from surveys, and clinical outcomes data from the telemedicine patient cohort (n=455) compared with in-person MFM consults conducted by the Division during the same time period (n = 6,302).

Program Design, Implementation, and Growth

The MFM telemedicine program at UPMC Magee is designed in a hub-and-spoke model. Satellite telemedicine centers are strategically positioned at UPMC community hospitals in distant geographies with UPMC Magee serving as the hub where all the consults feed back to the MFM team who conduct the visits — both inpatient and outpatient. The program began in 2011 with one telemedicine site at UPMC Horizon. During the study period covered in the paper, between 2012 and 2015, four additional telemedicine centers began operation at various points in time, resulting in five total centers active by the end of the data reporting period. Since the end of 2015, two more sites have become operational. 

“It is highly likely that we will add more centers in the future as the larger UPMC system expands into new territories and as the UPMC Magee MFM program expands its reach into new community hospitals,” says Wendy Kalocay, MBA, CMPE, program manager of women’s telemedicine and assistant administrator in the Department of Women’s Health at UPMC Magee.

Obstetrical ultrasound (OB-US) is critical to the maternal-fetal medicine specialty and is a core component of the UPMC MFM telemedicine platform. An OB ultrasound physician at UPMC Magee reads all obstetrical ultrasounds for every UPMC hospital that provides obstetrical services. Regardless of where the patient is treated, their images are transmitted to UPMC Magee and examined by OB/GYN ultrasound physicians who are all board-certified maternal-fetal medicine specialists. 

“All of the ultrasonographers at each UPMC hospital have been specially trained at UPMC Magee. This ensures everyone has the same qualifications and standards as the diagnosticians at UPMC Magee. During telemedicine consults, ultrasound technicians provide guidance and real-time visualization of the imaging coupled with interactive patient discussions of the results,” says Ms. Kalocay.
In addition to the crucial role of standardized OB-US practices built into the MFM telemedicine consults and MFM program as a whole, several other patient services have been added to the UPMC MFM telemedicine program since its inception: diabetes education, genetics testing and counseling, and preconception counseling. Tangential services for MFM patients that are not necessarily part of the current telemedicine program also have been implemented, such as a postpartum remote blood pressure monitoring program for women diagnosed with various forms of hypertension.

MFM Telemedicine Goals and Objectives

• Increase access to specialists
• Reduce travel time and expense for patients
• Improve quality of care
• Eliminate unnecessary procedures and duplicate testing
• Provide timely treatment close to home
• Improve coordination of care
• Allow access to medical history by physicians

Key Outcomes From the First Four Years

During the first four years of the program, 455 unique patients had MFM telemedicine consults. Compared to other, in-person MFM consults across the UPMC system during the same period, these individuals were predominantly Caucasian, younger, and more likely to have public insurance coverage. The most prevalent conditions for which consultations were conducted included diabetes, prior history of preterm labor, hypertension, and preeclampsia.

Caesarean-section rates were comparably high for both groups; fetal mortality was rare for both cohorts as well. Patients who had telemedicine consults showed lower rates of both premature delivery and NICU stays.

Across all telemedicine patients and facilities, 84.4 percent of patients were able to deliver their babies at their local hospital.

In addition to these and other metrics analyzed and reported in the paper1, the study also examined the cost-savings to patients associated with telemedicine visits in avoidance of lost time at work and travel expenses. In total, the analysis estimates total savings across all patients of $90,103.90, approximately $90.28 per telemedicine consult.

Patient satisfaction surveys were captured from 465 individuals (86.27 percent response rate based on 539 consultations) in 2014 and 2015. Eighty percent of respondents reported being very satisfied with their telemedicine experience, and 83 percent expressed strong confidence in the physician’s telemedicine care.

Additionally, “Having a telemedicine visit as opposed to an in-person consult saved 56 percent of the patients over two hours in round-trip driving time. Seventy-four percent said that the telemedicine visit allowed a family member to be present who would not have been otherwise able to attend the appointment. The telemedicine consultation center provided access to 11 percent of patients who would have otherwise forgone care. Ninety-five percent of respondents indicated that they would be interested in participating in future telemedicine visits.

“Our findings provide continuing encouragement that our programs are on the right track, providing needed care to some individuals who otherwise would not receive it. This may be our best approach to providing high-quality MFM care to at-risk mothers and babies who would otherwise not have access. There are few to no downsides to this kind of program that we can discern from our historical perspective,” says Ms. Kalocay.

New Services and Future Expansion Plans

Since its inception, the MFM telemedicine program has expanded its services for patients in various areas. One such area is genetic testing and counseling. Samples are drawn at the patient’s local provider office or hospital and then are sent to UPMC Magee for analysis. First-trimester screening, noninvasive prenatal testing, and multiple marker screening are available, along with requisite telegenetics counseling sessions with the patient to discuss the results of their testing and help them understand what the information means and what things they likely need to consider if there are adverse findings.

Diabetes management is offered for those with gestational diabetes and includes nutritional counseling and glucose meter education in both one-to-one and group sessions. One-to-one consultation for patients with either type 1 or type 2 diabetes also is a part of the program.

Preconception counseling is another service available for patients, linking them directly with specialists in the UPMC Magee Center for Fertility and Reproductive Endocrinology where they can discuss such options as fertility preservation, in vitro fertilization techniques, early embryo viability testing, and preimplantation genetic screening and counseling.

“Our MFM services will continue to grow and expand their reach. We have gone from having to convince our community doctors and hospitals to use the services to a point now where we are at maximum capacity covering the demand. Our approach to co-managing MFM patients with their local doctors has made acceptance and use of the services easy to replicate as we add new sites,” says Ms. Kalocay.

References 
¹ Leighton C, Conroy M, Bilderback A, Kalocay W, Henderson JK, Simhan HN. Implementation and Impact of a Maternal-Fetal Medicine Telemedicine Program. Am J Perinatol. 2019 Jun; 36(7): 751-758.