New Prenatal Schedule enhanced with technology to deal with COVID-19

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As the President and other officials call for the use of telehealth to help stop the spread of COVID-19, healthcare providers may be wondering how best to implement these solutions at their practices.

We spoke to Dr. Kelly Leggett, an OB-GYN at Cone Health and their Chief Clinical Transformation Officer, about how Cone Health is using Telehealth to support their pregnant population at this time, and her best advice for health systems looking to use solutions like OB Connect.

kelly h leggett md

As an executive leader of a health system, what are your top concerns around COVID-19?

Balancing capacity is a major cause for concern right now. Access to care for patients with respiratory complaints is a primary need — at the same time, people are still getting sick with regular issues and we need to be in a place to support them as well. Using telehealth to keep low risk patients at home helps maximize capacity.

What are your top concerns as an OB-GYN?

Concerns are somewhat relative to the region – for instance, in New York the primary concern is in the hospital setting for inpatient beds and ICU support. Here at Cone Health, our main concern right now is preparing for sicker patients with the Coronavirus and protecting the healthy  — our patients are most frequently coming into the office for checkups and anticipatory guidance.  We’ve stopped all routine and non-urgent visits, yet even as our GYN appointments have been rescheduled, OB patients still want to make contact with their provider because they’re concerned. Delivering information and care to pregnant mothers at home helps manage that anxiety.

How are you using remote patient monitoring to address those concerns?

With blood pressure spikes being the first manifestation of preeclampsia, at-home remote monitoring of blood pressure is an ideal solution for detecting the disease early. BP levels are more reliable as an indicator of preeclampsia than in-office urine dips, not to mention more sanitary — a crucial benefit right now. We long-ago transitioned out urine dips as a part of the routine prenatal care visit.

In the past, depending on gestational age, social determinants of health, and risk factors, we’ve emphasized shared decision-making, and let our mothers on remote patient monitoring decide for themselves if they want to monitor their blood pressure from home and reduce appointments. With the current need to keep pregnant patients out of harm’s way, we are actively enrolling all our mothers.

For low-risk patients, we are implementing a 5 visit (through term), in-person schedule:

9 week viability

15 week genetic screening

20 week anatomy with a possible visit as well if something appears abnormal

28 week glucola

36/37 week GBS cultures, cervical dilation and verifying fetal presentation. After 37 weeks, we are using remote monitoring and/or virtual visit. Between 39-40 weeks, a virtual visit will occur to discuss postdates testing and induction.

This schedule still allows us to capture the global fee for Medicaid patients — in North Carolina, care needs to extend for greater than 3 months with at least 4 visits — and with blood pressure monitoring accompanying the protocol, the need for virtual visits is eliminated for low-risk patients.

How are you supporting high-risk patients?

For mothers who have high-risk factors, we’re implementing a hybrid, adding in-office or virtual visits on top of the 5 visit model above according to risk. We’re walking through the process of remote monitoring of blood pressure with those patients in the office, to ensure that they’re comfortable with using the solution.  If there is still a need to touch base with the patient, she gets an appointment on the schedule, but it will be a virtual video visit — the BP solution delivers the same clinical information that would be captured in the office. If the virtual visit reveals a need for a physical exam, lab test, or fetal monitoring, the patient will be scheduled for an in-person visit.

How are you streamlining implementation?

Consistency is key, so communication is paramount.  We are using Microsoft teams to keep all personnel up to date. Emails with attachments were too cumbersome to manage, especially with the pace of change.  Each office has a team lead who troubleshoots issues and trains staff.

Do you have advice for practices who are looking to implement digital tools quickly?

1. Have a nurse lead and a lead physician managing Telehealth at each office. Write out Standard Work when possible and have lead clinicians help train the office. Don’t worry about integration. Integration can come later — you can build a template to pull data into the record or take a screenshot and put it into EPIC — even just adding a note to indicate that monitoring is happening can simplify the process.

2. Trust the notification system of the solution. The fail safes are in place — women will still call or email with questions just as they always have. The most important thing is to trust that the system.

3. Enroll medical and social high risk patients in person, especially if enrolling mid-pregnancy. Use the office visit to help them understand how the app works, ensure connectivity, and teach proper technique for taking BP at home.

What are the long-term repercussions for telehealth with everything that is happening right now?

What used to seem too risky, the things that scared us about using virtual care — those risks now seem so minimal. Worries over whether a mom would feel less connected to her provider, be anxious because she doesn’t get to listen to her baby’s heartbeat — those are not risks on a level with what we’re facing now. True risk is a pregnant woman who was healthy one minute and in critical condition the next. This situation has encouraged open-mindedness, and the ability to see what risk really exists as opposed to perceived risk, and we’re going to see a huge upsurge in doctors using innovative methods for delivering care.

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