1. Perinatal Telemedicine
DEXTER M. PAGE, MD, FACOG
ATLANTA PERINATAL ASSOCIATES
PAGEMED, LLC

2. OBJECTIVES
 Why there is a need?
 Challenges
 Advantages
 Possibilities
 Perinatal assessment
 Scope of service

3. Why a NEED – Disparities
APA experience
 Access
 Quality
 Geography
 Continuity
 Morbidity
 Prevention
 Awareness

4. Why Bother?
 Infant mortality rates 10% higher
 Rural child death rate (ages 1-14) 29% higher
 Poverty rate 58% higher
 Percent of population living in poverty is higher
 Percent of the population that is uninsured is higher

5. Why Bother?
 Receiving inadequate prenatal care (<or =4 physician
visits) 47% higher
 Cancer death rate 33% higher
 Deaths from motor vehicle accidents 68% higher
 Educational levels < ninth grade are two times higher

6. “Cure” Growing Needs
 Inadequate Prenatal care late or infrequent
 Rural neglect
 minimizing the travel
 physician back-up/support
 Stopgap - Provider shortages
 Encourage partnerships
 Escalating costs
 Increasing demand for care

7. Quality Deficiencies
 Experts - 200 MFM graduates nationally
 2/year in GA
 Marginalized care does not = managed care
 Outdated tools

8. Infant Mortality Rate
Critical measure of access to healthcare services
 Georgia ranks 48th in the nation
 Rate in rural counties is 11.4/1,000
 Infant mortality rates are 10% higher
 Rate in 10.1/1,000 in urban counties
 Rural child death rate (ages 1-14) is 29% higher
 Without adequate medical infrastructure 33% higher
infant mortality

9. GOALS
Decrease the Disparity in Infant Mortality
 Objective 1: Decrease  Baseline of 15.5 to 13.0 per
African American infant thousand live births by
mortality rate 5/31/14
 Objective 2: Increase first  Baseline of 85.2% in 2004-
trimester initiation of 2006 to 87.0% by 5/31/14
prenatal care among
African American women
 Objective 3: Decrease the  Baseline to LBW = 10.3%
percent of Low Birth and VLBW = 2.5 % of live
Weight (LBW), Very Low births by 5/31/14.
Birth Weight (VLBW)
African American

10. Balancing the Scales
 Convenience
 Patient-friendly
 Long appt wait times  Technology
 Limited resources  Real-time results
 Outdated  Cost-saving measures
 Patient anxiety  Provider efficiency
 Consolidation  Accuracy
 Regionalization  Timeliness
 Patient compliance

11. Rural Healthcare
Core problems facing rural health care providers
 Declining population
 High percentage of the elderly
 Poorer health status indicators
 Retaining medical and administrative staff

12. Rural Healthcare
Core problems facing rural health care providers
 Maintaining sufficient inpatient occupancy and outpatient
volume to cover costs
 Inability to achieve economies of scale
 Difficulty securing capital to renovate old physical
structures and to replace outdated medical equipment
 High percentage of Medicare/Medicaid and
indigent/CHARITY

13. Rural Healthcare
Core problems facing rural health care providers
 Lack of planning
 Inability to adapt
 Problems can be traced to Medicare and other third
party payment practices, including managed care
 Result
 Providers’ inability to shift costs
 Changes in reimbursement have decreased LOS
 Shift resulted in more outpatient treatment

14. Challenges
Lead a horse to water….
 Infrastructure
 Not a real “Trekkie”
 Cost of equipment
 Regulatory concerns
 Reimbursement issues
 Lack of standardization
 Reimbursement
 Credentialing of Providers
 High administrative cost
 Interactive video

15. Perinatologist
 Definition of a Subspecialist in MFM
 Is a subspecialist in obstetrics and gynecology
 By virtue of additional education
 cares for
 provides consultation
 women with complications of pregnancy
 Requires advanced knowledge of complications of pregnancy
 Obstetrical
 Medical
 Surgical
 The effects on both the mother and the fetus
 Requires expertise in the most current approaches to
 diagnosis and treatment of women with complicated pregnancies
 practice in a setting in which such modalities are available.

16. Perinatal Services
 H&P
 Counseling
 Genetic
 Imaging
 Lab interpretation
 Share info
 Manage the Risks, AND Transfer liability

17. Active Assessments
 Fetal well-being
 PTL
 Cervical compromise
 Glucose monitoring
 Fetal development
 Fetal arrhythmia

18. Advantages
 Face to face
 Accurate
 Coordinate proper referrals
 Manage, Diagnose Image, Monitor
 Patient/Provider satisfaction
 Decreased LOS
 Reduced anxiety
 Increased compliance

19. Telemedicine
Advantages
 Providing immediate access to specialty consultation
 Retaining the patient at the rural community hospital
 Reducing delays in providing acute care
 Maintaining continuity of care with the patient’s
primary care physician
 Providing effective continuing medical education
(distance learning)
 Expanding medical capability as well as the ability to
supervise non-physician healthcare personnel
 Decreasing healthcare costs.

20. Telemedicine
Advantages
 Providers want to reside in/near metropolitan areas
 Remove the feel of isolation from the medical community
 Most of the population in the rural areas are
Medicare/Medicaid recipients and/or are uninsured
 There are fewer opportunities for on-call coverage and time
off
 Rural docs work longer hours for same $$ urban MDs
 State-of-the-art equipment and technologies are often
unavailable
 Patient referrals and transportation in emergency cases
may be difficult

21. Requirements
 live or interactive;
 Service provided through the use of camera, video, or audio
conference equipment on a real-time basis
 store-and-forward
 transferring information by sound, images, or images on
videotape
 must be provided through the transference of digital
images between locations
 allow quality consultation to referring provider
 obtain information
 analyze
 report back diagnosis and management

22. Challenges
 Perception
 Acceptance
 Compliance
 Lack of understanding
 Buy-in
 Reimbursement
 Documentation

23. Pregnancy complications
 Prenatal diagnosis
 Amniocentesis
 CVS
 PTL concerns
 RPL
 Multiples
 Fetal anomalies

24. Pregnancy complications
 Maternal medical conditions
 Teratogenic concerns
 Counseling
 Procedures
 2nd opinion

25. Build relationships
 help local providers
 detect and manage maternal and fetal complications
 congenital anomalies,
 oligohydramnios or polyhydramnios,
 maternal medical disorders
 diabetes,
 hypertension
 autoimmune disorders

26. Build Relationships
 Hospitals
 Community centers
 OB/GYN
 Families
 Referrals

27. Telemedicine Services
 Ultrasound
 Level I, Complete: Interpretation (Store & Forward) CPT: 76801, 76802, 76805,
76810
 Level II, Detailed Complete: Interpretation (Store & Forward) CPT: 76811,
76812
 Transvaginal Ultrasound: Interpretation (Store & Forward) CPT: 76817
 Follow-Up (Single item or AFI): Interpretation (Store & Forward) CPT: 76816
 Limited Ultrasound: Interpretation (Store & Forward) CPT: 76815
 Nuchal Translucency: Physician to co-sign with certified sonographer CPT:
76813
 Real time/online participation of Perinatologist for all ultrasounds can be
scheduled in advance. CPT 76811, 76812, 76817
 For all ultrasounds, the remote site will bill for the technical/facility
component, and the referral site will bill for the professional component.

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