Background
Perinatal regionalization is a system of maternal and neonatal risk-appropriate health care delivery in which resources are ideally allocated for mothers and newborns during pregnancy, labor and delivery, and postpartum, in order to deliver appropriate care. Typically, perinatal risk-appropriate care is provided in-person, but with the advancement of technologies, the opportunity to provide care remotely has emerged. Telemedicine provides distance-based care to patients by consultation, diagnosis, and treatment in rural or remote US jurisdictions (states and territories).
Objective
We sought to summarize the telemedicine policies of states and territories and assess if maternal and neonatal risk-appropriate care is specified.
Study Design
We conducted a 2014 systematic World Wide Web–based review of publicly available rules, statutes, regulations, laws, planning documents, and program descriptions among US jurisdictions (N = 59) on telemedicine care. Policies including language on the topics of consultation, diagnosis, or treatment, and those specific to maternal and neonatal risk-appropriate care were categorized for analysis.
Results
Overall, 36 jurisdictions (32 states; 3 territories; and District of Columbia) (61%) had telemedicine policies with language referencing consultation, diagnosis, or treatment; 29 (49%) referenced consultation, 30 (51%) referenced diagnosis, and 35 (59%) referenced treatment. In all, 26 jurisdictions (22 states; 3 territories; and District of Columbia) (44%), referenced all topics. Only 3 jurisdictions (3 states; 0 territories) (5%), had policy language specifically addressing perinatal care.
Conclusion
The majority of states have published telemedicine policies, but few specify policy language for perinatal risk-appropriate care. By ensuring that language specific to the perinatal population is included in telemedicine policies, access to maternal and neonatal care can be increased in rural, remote, and resource-challenged jurisdictions.
Introduction
Perinatal regionalization, also referred to as “maternal and neonatal risk-appropriate care,” is a risk-based health care delivery system in which resources are ideally allocated during pregnancy, labor/delivery, and postpartum to deliver quality care to mothers and newborns in the most economical and appropriate way. Typically, maternal and neonatal risk-appropriate care is provided in-person in an office, hospital, or clinic. However, with the advancement of technologies, the opportunity to provide health care remotely, or by telemedicine, has emerged. Telemedicine is a heterogeneous concept, defined by organizations that include the American Telemedicine Association, World Health Organization, and Institute of Medicine. Specifically, telemedicine is the delivery of health care services from one geographical location to another–where distance or resources are obstacles to the delivery of care–by health care professionals using electronic communication and exchange to improve a patient’s clinical health status by diagnosing, treating, and preventing diseases and injuries.
Telemedicine is not a separate specialty, but an enhancement to existing services. Studies have demonstrated successful use of telemedicine services such as consultations, diagnoses, and/or treatments to provide adequate perinatal care. For example, Robie and colleagues in 1998 demonstrated the efficacious use of telemedicine in providing accurate diagnoses and guidance for surgical consultation in the intensive care nursery. Similarly, women with potentially poor pregnancy outcomes were given diagnoses and guidance via a telemedicine consultation with a perinatologist. Nores et al in 1997 demonstrated successful interpretation of first-trimester obstetric ultrasound, directed by a perinatologist in a satellite location, and the American Academy of Pediatrics (AAP) recent update of the guidelines for transport of neonatal and pediatric patients includes a chapter on telemedicine for emergency or hard-to-reach locations. For rural or remote settings, telemedicine offers access to specialists and subspecialists, which is an essential need for high-risk maternity and neonatal patients.
The objective of this study is to summarize telemedicine policies of US states and territories and assess how they address maternal and neonatal risk-appropriate care.
Materials and Methods
Study design
A systematic World Wide Web–based review of publicly available information addressing telemedicine care, and telemedicine services specific to perinatal care, was conducted for each US state, territory, and freely associated state (ie, American Samoa, Commonwealth of the Northern Marianna Islands, Federated States of Micronesia, Guam, Marshall Islands, Puerto Rico, Republic of Palau, US Virgin Islands, and District of Columbia) from January through June 2014. All policies and legislation published, to date of the study period, by state agencies, state governments, or territories were examined for inclusion in the study. Federal-level policies for the territories that were not directly mentioned in the publicly available information were excluded (eg, any US military aid provisions). Tribal policies developed for use on federally recognized American Indian/Alaska Native reservations were also excluded, as the focus of this analysis was on state- and territorial-level policies. Last, city jurisdictions were excluded from analysis, as city policies were potentially linked to state policies (eg, New York, NY; Los Angeles, CA). We did not include telemedicine policies specific to pediatric care since it has not traditionally been included in the concept of perinatal risk-appropriate care. A standardized search approach was implemented based on multiple search terms ( Table 1 ). Available policies, rules, codes, administrative laws, licensure regulations, health planning documents, and statewide nongovernmental perinatal health entity publications on telemedicine policies in perinatal/neonatal health were identified for data extraction using search engines such as Google and Bing; we also searched state World Wide Web sites. Results of the initial search were used to further expand the search strategy.
| Individual search terms (“state” was included in subsequent searches and variations of search phrases were subsequently searched) |
| [state] telemedicine policy perinatal |
| [state] telemedicine policy neonatal |
| [state] perinatal transport coordination |
| [state] telemedicine policy obstetric |
| [state] telemedicine legislation |
| [state] telemedicine policy |
| [state] telemedicine |
| [state] telemedicine program |
| [state] telemedicine neonatal |
| [state] telemedicine perinatal |
| [state] telemedicine NICU |
| Categorizing language for telemedicine care |
|
Data collection process
The United States was divided into the 10 Health Resources and Services Administration regions and territories to facilitate a structured search process. Two abstractors independently and simultaneously searched state-level policies within a region. Each state-level policy, within a region, was also cross-referenced and abstractors completed double-entry of all data. Study authors (D.A.G. and A.M.S.) further validated all abstracted information by reviewing and comparing it with source information. Discrepancies were reconciled during in-person meetings among researchers (E.M.O., C.D.K., and D.A.G.) and data abstractors to ensure consistency in search strategy and abstraction.
Data summary process
The primary abstractor (D.A.G.) reviewed and created an initial summary of all abstracted data. The secondary abstractor (A.M.S.) validated abstracted data by reviewing summaries, verifying all summary information in the data, and using his legal training and background to examine, interpret, and categorize statutory language. If the statutory language referred to “direct interaction between patient and/or patient’s primary provider” the telemedicine policy was categorized as consultation. If the language included “interpretation of imaging” and/or “screening,” the telemedicine policy was categorized as diagnosis. Finally, if the language referred to “direct care” or “invasive interventions by a physician” it was categorized as treatment (see Table 1 for detailed search terms). The policy language was also summarized by its specificity for maternal and/or neonatal risk-appropriate care.
Statistical methods
Descriptive statistics were used to analyze the abstracted information. Counts and percentages of US states and territories identified with telemedicine policies, as categorized above, and with telemedicine policies specific to maternal and neonatal risk-appropriate care were described. This study was determined not to need institutional review board approval at the Centers for Disease Control and Prevention because it did not include human subjects.
Materials and Methods
Study design
A systematic World Wide Web–based review of publicly available information addressing telemedicine care, and telemedicine services specific to perinatal care, was conducted for each US state, territory, and freely associated state (ie, American Samoa, Commonwealth of the Northern Marianna Islands, Federated States of Micronesia, Guam, Marshall Islands, Puerto Rico, Republic of Palau, US Virgin Islands, and District of Columbia) from January through June 2014. All policies and legislation published, to date of the study period, by state agencies, state governments, or territories were examined for inclusion in the study. Federal-level policies for the territories that were not directly mentioned in the publicly available information were excluded (eg, any US military aid provisions). Tribal policies developed for use on federally recognized American Indian/Alaska Native reservations were also excluded, as the focus of this analysis was on state- and territorial-level policies. Last, city jurisdictions were excluded from analysis, as city policies were potentially linked to state policies (eg, New York, NY; Los Angeles, CA). We did not include telemedicine policies specific to pediatric care since it has not traditionally been included in the concept of perinatal risk-appropriate care. A standardized search approach was implemented based on multiple search terms ( Table 1 ). Available policies, rules, codes, administrative laws, licensure regulations, health planning documents, and statewide nongovernmental perinatal health entity publications on telemedicine policies in perinatal/neonatal health were identified for data extraction using search engines such as Google and Bing; we also searched state World Wide Web sites. Results of the initial search were used to further expand the search strategy.
| Individual search terms (“state” was included in subsequent searches and variations of search phrases were subsequently searched) |
| [state] telemedicine policy perinatal |
| [state] telemedicine policy neonatal |
| [state] perinatal transport coordination |
| [state] telemedicine policy obstetric |
| [state] telemedicine legislation |
| [state] telemedicine policy |
| [state] telemedicine |
| [state] telemedicine program |
| [state] telemedicine neonatal |
| [state] telemedicine perinatal |
| [state] telemedicine NICU |
| Categorizing language for telemedicine care |
|
Data collection process
The United States was divided into the 10 Health Resources and Services Administration regions and territories to facilitate a structured search process. Two abstractors independently and simultaneously searched state-level policies within a region. Each state-level policy, within a region, was also cross-referenced and abstractors completed double-entry of all data. Study authors (D.A.G. and A.M.S.) further validated all abstracted information by reviewing and comparing it with source information. Discrepancies were reconciled during in-person meetings among researchers (E.M.O., C.D.K., and D.A.G.) and data abstractors to ensure consistency in search strategy and abstraction.
Data summary process
The primary abstractor (D.A.G.) reviewed and created an initial summary of all abstracted data. The secondary abstractor (A.M.S.) validated abstracted data by reviewing summaries, verifying all summary information in the data, and using his legal training and background to examine, interpret, and categorize statutory language. If the statutory language referred to “direct interaction between patient and/or patient’s primary provider” the telemedicine policy was categorized as consultation. If the language included “interpretation of imaging” and/or “screening,” the telemedicine policy was categorized as diagnosis. Finally, if the language referred to “direct care” or “invasive interventions by a physician” it was categorized as treatment (see Table 1 for detailed search terms). The policy language was also summarized by its specificity for maternal and/or neonatal risk-appropriate care.
Statistical methods
Descriptive statistics were used to analyze the abstracted information. Counts and percentages of US states and territories identified with telemedicine policies, as categorized above, and with telemedicine policies specific to maternal and neonatal risk-appropriate care were described. This study was determined not to need institutional review board approval at the Centers for Disease Control and Prevention because it did not include human subjects.
Results
Telemedicine policies
Of the 59 jurisdictions studied (the 50 states; District of Columbia; and 8 territories), 36 (61%) had policy language referencing at least 1 topic of telemedicine care. The 36 jurisdictions were composed of 32 states, 3 territories (Guam, Puerto Rico, and US Virgin Islands), and the District of Columbia ( Table 2 ). In all, 29 (49%) referenced consultation in their policies, 30 (51%) referenced diagnosis, and 35 (59%) referenced treatment.
| State/territory | Telemedicine care, consultation b | Telemedicine care, diagnosis c | Telemedicine care, treatment d |
|---|---|---|---|
| Totals, n = 59 | 29 (49.2%) | 30 (50.8%) | 35 (59.3%) |
| Alabama | Yes | Yes | Yes |
| Alaska | Yes | Yes | Yes |
| American Samoa | – | – | – |
| Arizona | Yes | Yes | Yes |
| Arkansas | – | – | – |
| California | Yes | Yes | Yes |
| Colorado | – | – | – |
| Commonwealth of Northern Mariana Islands | – | – | – |
| Connecticut | Yes | Yes | Yes |
| Delaware | Yes | Yes | Yes |
| District of Columbia | Yes | Yes | Yes |
| Federated States of Micronesia | – | – | – |
| Florida | – | – | – |
| Georgia | Yes | Yes | Yes |
| Guam | Yes | Yes | Yes |
| Hawaii | Yes | Yes | Yes |
| Idaho | – | – | Yes |
| Illinois | – | Yes | Yes |
| Indiana | Yes | – | Yes |
| Iowa | Yes | Yes | Yes |
| Kansas | – | – | – |
| Kentucky | Yes | Yes | Yes |
| Louisiana | – | – | – |
| Maine | Yes | Yes | Yes |
| Marshall Islands | – | – | – |
| Maryland | – | – | Yes |
| Massachusetts | Yes | Yes | Yes |
| Michigan | – | – | Yes |
| Minnesota | – | – | – |
| Mississippi | Yes | Yes | Yes |
| Missouri | Yes | Yes | Yes |
| Montana | Yes | – | Yes |
| Nebraska | – | Yes | Yes |
| Nevada | – | – | – |
| New Hampshire | Yes | Yes | Yes |
| New Jersey | – | – | – |
| New Mexico | – | Yes | Yes |
| New York | Yes | Yes | Yes |
| North Carolina | – | – | – |
| North Dakota | – | – | – |
| Ohio | – | – | – |
| Oklahoma | Yes | Yes | Yes |
| Oregon | – | – | – |
| Pennsylvania | Yes | – | – |
| Puerto Rico | Yes | Yes | Yes |
| Republic of Palau | – | – | – |
| Rhode Island | – | – | – |
| South Carolina | – | – | – |
| South Dakota | Yes | Yes | Yes |
| Tennessee | Yes | Yes | Yes |
| Texas | – | – | – |
| US Virgin Islands | Yes | Yes | Yes |
| Utah | Yes | Yes | Yes |
| Vermont | Yes | Yes | Yes |
| Virginia | Yes | Yes | Yes |
| Washington | – | – | – |
| West Virginia | – | Yes | Yes |
| Wisconsin | – | – | – |
| Wyoming | – | – | – |
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