From high-definition video to mobile health applications, high-risk obstetrical telehealth employs technologies similar to any clinical telehealth endeavor; however, some technologies are unique to this clinical field and deserve special attention.
First, it is essential to identify the technological building blocks of a high-quality, secure, high-risk obstetrical telehealth practice (see Figure 6-3). At a minimum these include,
High-definition video cameras – Cameras are required at both the remote and local sites that can achieve at least 720p (1280 × 720 px or HD Ready) to ensure high-quality images.
Video screens – A screen size of no less than 20 inches diagonal is recommended with at least 1280 × 720 pixel resolution.
Software – Must have the ability to dial H.323 via Internet Protocol (IP) or E.164 and be connected to transverse firewalls of participating sites.
Broadband – At least 1.5 Mbps download, with 6 Mbps download and 1 Mbps upload speeds recommended to ensure real-time, live video transmission without significant delays.
Security – HIPAA-compliant firewalls and encryption are required.
Essential technology used in high-risk obstetrical telemedicine.
The use of high-definition video in obstetrics is implemented in a variety of ways. Primary care physicians may use it to consult with maternal-fetal medicine specialists or other specialists who may not be available locally or in remote locations where access is not feasible. Specialists can also remotely examine patients, giving them the ability to directly observe and assess the patient. It can also be used as a tool to provide continuing education to health care professionals or to disseminate information through teleconferences or discuss high-risk obstetric cases in the form of grand rounds. High-definition video can educate patients on topics such as birth, breastfeeding, or nutrition. The use of high-definition video in high-risk obstetrics provides a conduit for a multidisciplinary approach and comanagement to coordinate and provide treatment options for women with heightened medical needs and/or a diagnosis of a fetal anomaly or genetic or chromosomal abnormality.
Currently, live, real-time video level 2 (“targeted”) ultrasounds (“teleultrasounds”) represent the gold standard of high-risk obstetrical telemedicine delivered in the clinic. Traditionally conducted face to face in a hospital or clinic, a targeted ultrasound provides women in their second trimester of pregnancy levels of scanning detail not possible through a level 1 ultrasound, making it possible for physicians to determine the sex of the fetus along with a range of other valuable pieces of information for expectant families. However, this type of ultrasound can also detect potential fetal anomalies and complications that may prompt the involvement of maternal-fetal medicine specialists, geneticists, and other specialists to determine how to ensure the best obstetrical outcome for high-risk pregnancies. Should an obstetrician, family medicine provider, or other medical provider detect a potential problem with a pregnancy—whether based on patient history or the imagery derived from an ultrasound—a targeted teleultrasound can enable distant specialists to view the ultrasound imaging in real time through high-definition video, while also conversing with the patient and her provider in real time over secure video and audio. This clinical exchange, in effect, provides all parties the opportunity to explore the pregnancy and its potential benefits and complications and to collectively formulate a plan of care based on best practices.
Specialists may also analyze teleultrasounds through store-and-forward technologies through the collection and transmission of still images and/or video for later analysis. 13 Store-and-forward teleultrasounds are typically less costly and more feasible in low resource settings, which include countries and regions that have underserved populations and difficulties accessing specialty care. Store-and-forward teleultrasound also allows less need to coordinate schedules of patients and specialists, which can be a great benefit in such low-resource settings. Whereas synchronous teleultrasound allows for immediate consultation between specialist and patient, asynchronous teleultrasound has been cited as a useful tool in low-resource settings and has demonstrated its clinical usefulness, sustainability, and cost effectiveness. 14
One might wonder why targeted teleultrasound is so important in the care of high-risk pregnancies. Complicated pregnancies occur everywhere, rural and urban, yet access to specialty care does not occur everywhere. Most importantly, rural areas without the means to employ maternal-fetal medicine specialists, geneticists, or even obstetricians within their community hospitals or clinics do not have equal access to high-risk obstetrical care. Therefore, even if a community provider can perform a targeted ultrasound in his or her clinic, the means to accurately interpret such images with specialty obstetrical knowledge may not be readily available to that provider, nor may the knowledge of best practices be as readily available as at academic medical centers.
This is how telemedicine revolutionizes high-risk obstetrical care—using teleultrasound technology, HIPAA-compliant broadband connections, and high-definition video, a patient need not leave her hometown hospital or clinic to receive the expert advice and care offered by obstetrical subspecialists. Before teleultrasound technology, such pregnant patients had no choice: travel to town for subspecialty care. The alternative was to receive no subspecialty care at all, which only further endangers a complicated pregnancy. With the stress of traveling to receive care, the costs of hiring babysitters or missing work, the psychological toll of a problematic pregnancy, and the countless other barriers to making such a journey, high-risk pregnant women too often may elect to receive no subspecialty care at all, with potentially disastrous outcomes on the lives of the family and the health care system. Telemedical comanagement of patients also provides a protective legal barrier for rural providers by giving the best possible collaborative care to complicated pregnancies.
The anatomy of a teleultrasound setup is made possible through the following technologies and partnerships:
To forge a high-risk obstetrical telemedicine partnership that utilizes teleultrasound or any other in-clinic services, a specialist should ideally unite forces with a community provider. This may be more difficult than it sounds. As with any clinical application of telemedicine, a partnership must be built on the idea that such specialist support will not steal patients from community providers, but instead support them so they may reinforce their available care with supplemental specialty support. In effect, instead of losing a patient, the community provider is actually gaining a clinical ally with whom she or he can comanage complicated pregnancies leading up to delivery. Because evidence shows pregnancy outcomes fare better at tertiary hospitals, 15 this comanagement must agree that in the interests of the patient and her baby, complicated deliveries should be transported and/or arranged at the nearest tertiary centers, otherwise known as perinatal regionalization. Emphasizing that this partnership balances on the contribution of both the specialist and the community provider to provide the best possible care will better ensure that the telehealth partnership lays the ground rules for collaboration.
Next, an ultrasound unit with an output display, ultrasound software, and computer is needed at the patient site to make real-time teleultrasound possible. For real-time encounters the ultrasound device can be integrated with a telemedicine cart that manages the transmission and other aspects required for real-time interaction. For store-and-forward of an ultrasound, the equipment should include an ultrasound unit and Picture Archiving Communications System (PACS) or other dedicated storage and transmission software. Alternatively, the operator may use the ultrasound unit and a CD or other storage device to copy and send the images to the consulting site. These computers and/or telemedicine carts must be connected to secure broadband, as noted earlier. With the necessary broadband and technology in place, next comes technology training.
Teleultrasound training is key to success of any new high-risk obstetrical telemedicine program, and retraining is necessary whenever new personnel join an existing program or the skills of existing personnel need updating and further refinement. The sonographer controlling the teleultrasound equipment and performing the actual ultrasound on the patient should receive orientation to introduce him or her to the new roles of teleultrasound. Training should be conducted sonographer to sonographer, including an introduction to the equipment, shadowing during a normal ultrasound and teleultrasound, and the reinforcement of best practices in ultrasound and how they apply in full to teleultrasound. A technologist can aid the process by explaining and troubleshooting telemedicine technology to new users.
The increase in remote monitoring in obstetrics has led to the development of a number of systems and devices to enable the patient to be monitored from the convenience of her own home. The Sense4Baby system was developed specifically to remotely monitor high-risk pregnancies for real-time fetal heart rate and allows the provider to access data directly on their smart phone or tablet. 16
High-risk obstetrical fetal heart remote monitoring devices have flooded the “at home” market, with some devices being dedicated solely to the collection of specific obstetrical readings or advice and others being used on smart phones through apps. Although these at-home Dopplers may provide the patient with a new tool, they may not be accurate when it comes to fetal heartbeat detection, thus creating unwarranted patient anxiety, worry, or even false reassurance. 17 Such a case in Great Britain occurred in 2009 when a woman 38 weeks pregnant used a home monitor to listen for the baby's heartbeat when she no longer felt movement. Having thought she heard a heartbeat, she delayed medical help, unfortunately losing the baby. 18 Currently, this is a rapidly evolving telemedicine technology, and further testing for safety and clinical reliability is needed before such monitoring can replace clinical monitoring.
M-health has also assisted pregnant women in tracking their personal health at home, empowering patients with advice and data never as easily accessible to any patient prior to the advent of such technology. This technology is constantly evolving as developers are continually devising apps that address obstetrical issues ranging from fertility advice based on individualized menstrual cycles, to patient-directed abdominal scanning to detect fetal heart rate. This technology is as exciting as it is concerning due to its need to be thoroughly validated to ensure the data generated are reliable and valid before patients can rely on the technology's ability to accurately address complicated monitoring, such as fetal heart rate. M-health will undoubtedly provide patients unique tools never before available in their home. It will take time and scientifically based testing to ensure these tools provide accurate and trustworthy advice to expectant families. Patient education and training on how to use this technology are advised for any complex collection of patient data to help prevent false-positives through inaccurate reading techniques.
Mobile Health Applications
Because over half of American adults own a smart phone, mobile health applications are increasing in popularity. In fact, one in five smart phone users have at least one health-related app on their phone, 19 and the Apple App Store has at least 1,800 obstetrics and gynecology apps currently available for download. 20 Moreover, industry estimates predict that by 2018 half or more of 3.4 billion smart phone and tablet users worldwide will be using a health care application. 21 The money spent by digital health companies specifically for women's health has been rapidly increasing, with an estimated $2 million spent in 2011 to $111 million spent in 2015 before year end, a development that has resulted in an influx of women's health apps. 22 Women are more invested than ever in taking charge of their health and need ready access to trustworthy educational resources. M-health apps that provide educational, reliable, and trustworthy information are in high demand among pregnant women. 22 Although many apps are available, their reliability and trustworthiness must be further scrutinized before clinical endorsement is possible. Some apps transcend patient education to provide actual one-on-one clinical consultation. Some apps host virtual clinics specifically designed for women that provide visits with doctors including pediatricians and OB/GYNs, lactation consultants, nurse practitioners, doulas, and nutritionists. Apps such as these are predicted “to make a visit to a women's health professional affordable and easy” considering such resources are available on any smart phone. 23 The U.S. Food and Drug Administration (FDA) has taken a lead in reviewing and regulating certain moderate-risk and high-risk mobile medical apps, which include “apps that are intended to be used as an accessory to a regulated medical device or transform a mobile platform into a regulated mobile device.” 21 This regulation helps identify FDA-approved apps, which are accessible through an online searchable database. 24