Rapid Implementation of Telehealth Services During the COVID-19 Pandemic

Background

Telehealth can be defined as any health-related service that utilizes electronic and communication technology to remotely deliver health or medical information.¹ It has the advantage of providing comprehensive care to those in remote or resource-limited settings.² Considering the current global public health emergency of the novel coronavirus disease of 2019 (COVID-19), telehealth is increasingly gaining traction to safely deliver essential, timely, nonemergent ambulatory obstetric and gynecologic (OB/GYN) care to decrease exposure risk for providers and patients. The Centers for Disease Control and Prevention (CDC) has released recommendations for health care providers to increase the use of telehealth systems to assess and care for patients.³ In addition, there has been a call for relaxed prior authorization requirements for telehealth as long as systems comply with Health Insurance Portability and Accountability Act (HIPAA) and security rules.^4,5

The American College of Obstetrics and Gynecology (ACOG) published recommendations for telehealth use in February 2020 in response to COVID-19.⁶ Potential uses include consultation with specialty services, remote observation of fetal monitoring by maternal fetal medicine and reproductive endocrinology specialists, bladder diary tracking with smartphone applications, postpartum blood pressure monitoring with synced Wi-Fi and data connection, remote provision of medically induced abortions, and fertility tracking with patient-generated data. These applications can be delivered through two modes: (1) asynchronous, also known as store-and-forward, where patient’s medication information is stored and reviewed later by a medical provider, and (2) synchronous, also known as live interactive consultations, where patient and physician interact remotely in real time to preserve physical distancing.⁷

Previous telehealth programs designed for OB/GYN patients have yielded high satisfaction rates and produced comparable, if not better, patient outcomes that in-person visits.¹ In 2003, the Antenatal and Neonatal Guidelines, Education and Learning System telehealth program founded by the University of Arkansas implemented a statewide telehealth network that includes educational programs, case management, 24/7 calls, and evidence-based guidelines for perinatal and neonatal care. A case series of eight women enrolled in this program demonstrated reduced feelings of anxiety and intimidation with virtual visits.⁸ Another initiative in 2010, the Text4baby Program, run by the National Health Mothers Healthy Babies Coalition, provided free weekly text messages with health information and education for mothers about their pregnancies throughout the babies’ first year of life. As a result, patients demonstrated increased health literacy and missed fewer appointments.⁸

As we adapt to the current medical landscape, specific procedural guidelines for development and implementation of an OB/GYN telehealth service in the setting of a public health crisis have yet to be delineated. Our guideline streamlines a process to appropriately screen and deliver timely ambulatory care through telehealth for low- and medium-risk prenatal care and nonemergent gynecologic complaints. This was successfully implemented in our academic urban health care system serving a primarily low-income patient population. We offer our work as a valuable insight into other institutions with a need to accelerate initiation of their own telehealth system during the COVID-19 pandemic. In the words of Portnoy et al., “the only infection that one can catch while using telehealth is a computer virus.”⁹

Procedural Guidelines

The “COVID-19 Emergency Telehealth Procedural Guidelines” were created by the Department of Obstetrics and Gynecology at the University of Illinois at Chicago (UIC). The aim of these guidelines is to limit physical patient and provider contact while still delivering essential, timely, and ambulatory OB/GYN care. We illustrate how to triage patient candidacy for telehealth and deliver telehealth while meeting OB/GYN care standards.

Determining Appropriate Telehealth Candidates

A detailed set of guidelines outlined in Table 1 is used to determine telehealth eligibility for obstetric, postpartum, and gynecologic patients. A team of attending and resident physicians triage scheduled visits to either in-person visits, telehealth visits, or visits that should be temporarily canceled and rescheduled for a time after the cessation of physical distancing recommendations. The providers assigned to clinic differ weekly and are responsible for triaging the schedule a week in advance. Clinic schedulers then communicate with patients and adjust their appointments accordingly. The resident physicians primarily identify visit types and conduct the visit itself, whereas the attending physicians supervise, communicate with staff, and bill for each visit.

Of note, in our routine practice, patients are scheduled for postpartum follow-up at 2 and 6 weeks. In addition, elective gynecologic surgery has been currently suspended during the COVID-19 pandemic, so preoperative visits are not included here. Postoperative visits noted are for patients who underwent surgery before suspension of elective surgical services or who needed an emergent procedure (management of ectopic pregnancy, ovarian torsion, incomplete miscarriage, etc.).

Visit Spacing

In addition to transitioning patients to telehealth when appropriate, our practice also evaluated visit frequency for obstetric care, to promote less-frequent physical engagement with ambulatory centers. This schedule was created after careful consideration of the frequency of visits relative to usual practice at our institution. These encounters were timed to ensure patients present for an in-person visit at least once per trimester, or when due for laboratory testing or imaging.

Delivering Telehealth Services

During the COVID-19 pandemic, our practice has created a temporary rotating provider schedule with teams assigned to cover in-person care for 1 week or to provide telehealth services while sheltering at home the alternating week. Attendings and resident physicians have separate schedules that are subject to change depending on whether there are providers under quarantine. Fellows, nurses, and ancillary staff are not included in this schedule. Attending and resident physicians are assigned to a team and have specific roles with the goal of minimizing clinical contact and maintaining wellness. Providers in their “work-from-home” rotation oversee the telehealth clinic and conduct visits through a secure HIPAA-compliant video platform such as WebEx or InTouch. A staff member contacts the patient, obtains consent for a telehealth visit, schedules a visit time, and sends the meeting link to the patient’s phone or e-mail address.

Before initiating these telehealth procedural guidelines, remote training sessions were held with all stakeholders, including attendings, residents, and schedulers, to review the schedule changes and planned implementation of telehealth services. In addition, separate webinars were available to receive training on the various video platforms. The authors of this guideline acted as super users and were available for immediate help throughout the telehealth sessions. Given the rapid cycle implementation of this system, the guidelines document has evolved through feedback to what is presented in the guidelines.

The provider conducts the telehealth visit, first discussing the patient history and review of systems. Although the physical examination cannot be conducted in its entirety, certain methods can be used to collect important information. For example, vital signs can be conducted in the following ways: a provider can teach a patient through video and visualize them taking their pulse, their respiratory rate can be visualized through video, and patients can be requested to take their blood pressure and weight with home equipment as available. Obstetric patients can be instructed through video to do fundal height measurements and, if the patient has one, an at-home Doppler can be used to obtain fetal heart tones. The provider can also assess skin lesions and surgical sites through visual inspection.

Laboratory tests and imaging are ordered as clinically indicated. Our department developed a partnership with four local CVS pharmacies for self-swab kit pickup for sexually transmitted infection screening. This was done to reduce clinic foot traffic while providing patients with the necessary testing and care. The locations were chosen based on the geographic distribution of patients in our practice. At present, patients complete the self-swab and return the sample to the laboratory for testing. We are currently developing a mail-in option to further facilitate physical distancing and are working with our ambulatory laboratory to extend self-collection to complete vaginitis testing, group B strep (GBS) testing, and possible even primary human papillomavirus (HPV) screening. The authors of this document coordinate with the pharmacies on a weekly basis to ensure an adequate stock of supplies. Obstetrical laboratory tests and ultrasounds are completed in alignment with in-person visits to decrease exposure risk.

The provider completes charting and billing in the electronic medical record with the appropriate telehealth billing codes. Detailed guidance on telehealth billing and coding is available on the ACOG website.¹ After completion of the encounter, the ambulatory schedulers are messaged to arrange next indicated in-person and/or telehealth follow-up visit(s).

Discussion

These procedural guidelines have been instrumental in our department’s rapid transition to telehealth services. Amid the continuously evolving clinical milieu created by the COVID-19 pandemic, establishing these procedural guidelines has ensured timely, safe, and high-quality care for our patients. It has been particularly important in ensuring continuity of prenatal care. Early in the implementation, we also held a weekly virtual meeting that was vital in applying feedback to improve workflow and patient outreach. In addition, implementation of these telehealth procedural guidelines has facilitated OB/GYN care for low-income patients who typically experience transportation challenges in accessing our clinics. We plan to collect visit types and patient satisfaction data as our telehealth services continue and anticipate that a permanent addition of some telehealth access may benefit this marginalized population. Finally, patients have appreciated the ability to utilize self-swab testing. Although our laboratory at present does not process self-swab testing for vaginitis, HPV, or GBS, expanding self-collection options into these areas could improve patient satisfaction and further reduce the need for in-person visits.

One challenge has been patient engagement with video-based telehealth. Although the barrier is occasionally logistic (i.e., the patient is unable to access a computer or smart device to utilize the software), some patients have also expressed a desire for telephone-only encounters. We hope to gain more insight into this preference through patient satisfaction assessments. Another limitation of our current telehealth system is our weekly rotating provider schedule. Although vital for physician wellness during a time of high risk for clinician burnout,¹⁰ this consistent provider turnaround has altered patient continuity in the ambulatory setting.

Overall, patients have been very receptive as our clinics have transitioned to telehealth, particularly the younger obstetric population. They have been willing to learn this new method of outpatient care and are appreciative of efforts to minimize their exposure risk. Implementing telehealth at a busy academic OB/GYN practice has been a unique challenge requiring flexibility from both providers and patients. Although our guideline is a living document, it has been vital in adapting and shaping OB/GYN ambulatory care for our health care system during this pandemic. Furthermore, it has opened an exciting door to explore avenues for future applications of telehealth to meet the needs of our ever-changing health care delivery system.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.