Many parts of the United States are considered “maternity care deserts.” Thirty-six percent of U.S. counties have no obstetric providers or labor and delivery units in hospitals. In New Mexico, which has the second highest maternal mortality rate in the country, Michael Ruma, M.D., M.P.H., a maternal fetal medicine sub-specialist at Perinatal Associates of New Mexico, is using a combination of telehealth and ultrasound to reach patients in rural parts of the state.
Albuquerque-based Ruma is using a remote access ultrasound tool, Philips EPIQ Ultrasound System with Collaboration Live, to connect with patients and staff in real-time. This tool has helped Perinatal Associates of New Mexico with over 8,000 pregnant lives scanned in 2023.
Much of obstetric ultrasound has traditionally been done in hospital facilities, Ruma explained. “In general, radiologists are not keen on pregnancy. They do very basic approaches to it. They definitely don't talk to the patient about what's going on. And that is why we have an advantage in reaching out to these small communities if I can put my sonographer there, use Philips ultrasound equipment, and communicate with those people,” he said. “Amazingly, that integrates all these small towns into a much more sophisticated, safer perinatal environment, so that's really been the crux of our strategy and growth.”
Jennifer Law, maternal health leader at Philips, said the company is focused on using technology to improve access to care. “The average or normal pregnancy will have 10 to 15 prenatal care appointments, which is a lot to ask for a mom, and if that is a high-risk pregnancy, and 25% of pregnancies are high risk, then you could be doubling the number of prenatal appointments you're doing,” she said. “Prenatal care is so important. Studies have demonstrated that we need to be doing better prenatal care. But if a mom has to take off a half day from work to drive to the next county over, find childcare, find transportation, she may not make it to all her appointments. There have been some high-risk pregnancy clinics that have reported that their no-show rate is as high as 28%, so it can really vary all across the United States.”
In 2016 one of the first places Perinatal Associates started to do telehealth was in Farmington, in the northwest corner of New Mexico. They went from doing about 70 visits in 2016 as an experiment to about 750 visits by telehealth office to office in 2019, focused on genetics and diabetes, mostly. Once the pandemic hit, the number of telehealth appointments jumped to 5,500 visits in 2020; 9,500 in 2021; 12,500 in 2022; and 16,523 in 2023.
After initially focusing on genetic counseling and perinatal pregnancy diabetes management, the practice started doing real-time ultrasound by telemedicine. “We've done a lot of collaborative industry research with Philips over the last 10 years, and we had just finished an FDA submission trial with them in February of 2020, on this device called Collaboration Live,” Ruma said. “I can call in to an actual ultrasound machine and communicate using the microphone and the speakers on the machine, and put my video face right next to the patient's baby, so the mother is looking at the monitor, and she's seeing her baby, but she's also seeing me, which is exactly the way we do our in-person visits. In person, I knock on a door, open the door, and introduce myself. Now my face pops up, and we immediately start talking. And the sonographer and I can communicate. I can ask her to give me control of the machine. I can take pictures; I can turn different aspects on, which has its own additive benefits.”
Most ultrasound is traditionally done with a sonographer collecting images and then sending them remotely via computer program to a physician such as Ruma, who reviews them a few hours later. “But Collaboration Live has allowed us to develop this comfort level where we are making very complicated diagnoses via telehealth and we're not making patients drive to us,” Ruma explained. “The patients know they're getting better care through the computer; they can understand that I'm talking differently than their local doctor. We can help pull those people into the big city when we find abnormalities. If their kid has a heart defect, we don't want them born in Roswell or Farmington. You want the baby born where there's a pediatric heart surgeon, and I can tell the mother that we're going to make that happen. When we make a diagnosis, we inform them about it right away, and we get the wheels in motion to get the outcome to be better, so that has been really been hugely beneficial for us and the patients.”
Ruma said his practice also started offering mental health treatment as part of perinatal pregnancy care, which he called “super eye-opening. I knew we had a need, hired a part-time person and filled up her schedule in two months, hired another person, filled her up in six months, hired another person, and last year, we did 2,500 mental health visits via telemedicine,” he said. “The patient acceptance is 100%.”
Despite the value of reaching out to provide prenatal care in rural areas, the reimbursement picture is still unclear. Ruma said that payers have told him that reimbursement for telehealth should be less because their expenses are lower. They aren’t paying for additional brick-and-mortar facilities. “We quickly tell them that there is a significant IT infrastructure, too. We pay subscription services to Philips so that we can have the benefits of this technology for our patients,” Ruma said. “I have four IT individuals who work full-time with us. So we're not leasing buildings, but we are paying for the technology, which helps our patients. I think the feds and the states likely will keep telehealth around, but that is always a lingering concern. The first payer I negotiated with for mental health rates wanted to pay us 70% of what Medicare rates are. Medicare is like the basement.”
Ruma described another way they are trying to expand the use of this tool. “We find a lot of heart defects in babies and refer them to pediatric cardiologists. There's one big group in New Mexico. We find the patients in small towns, but the pediatric cardiologists still make them drive to the city for appointments. In the next year we are trying to develop a program where we're doing the fetal ultrasound and inviting the pediatric cardiologist on to Collaboration Live. They have to get comfortable with the tool as well, but we have a small grant from state Medicaid dollars, and hopefully we can bring that to fruition.”
