Editor’s Note: This article was queued up before the Covid-19 situation, but it still gives great insights into the virtual care world coronavirus is pushing us towards.
The following is a guest article by Dr. Nathaniel DeNicola, American College of Obstetricians and Gynecologists Chair of Telehealth
Virtual care has a conflicted reputation in the medical community. Like many innovations, it holds promise and peril, with some providers wondering if the benefits that virtual care delivers are worth the threat that it poses to their job security.
The scare narrative that has risen up around virtual care is an understandable one — digital tools can often seem like the stuff of science fiction where the machines are always one frame away from rising against their creators. But digital tools are just that — tools, not rivals — and we need to start viewing them that way.
Virtual care isn’t doing the work of the doctor, it’s helping us do our work better. Remote patient monitoring and apps that accumulate patient-generated data can be tools to amplify and enhance care by identifying high risk problems before they become high risk; and importantly delivering care to the people who need it most when they need it the most.
As an obstetrician, I’ve seen the impact of digital tools first hand. For example, apps like period trackers have made dating a woman’s last menstrual period much easier — critical information for dating her pregnancy. A due date carries a lot of cultural significance, of course, but it’s also much more than a number to put on a baby announcement. With high-risk pregnancies, the difference of one or two weeks can have a significant outcome on complications like hypertension — the difference between delivering at 37 weeks or 35 weeks, full term or preterm.
Prior to period tracking apps, it was fairly common for a woman not to know the date of her last cycle. Even in the cases where she did have an idea (after all, period tracking wasn’t invented by the smartphone generation), the reliance on recall or manual tracking processes left room for error.
Now with the popularity and easy accessibility of period tracking apps — 100M+ women use menstrual tracking tools available for free in the App Store, and the iPhone comes preloaded with one through Apple Health — women don’t have to rely on recall, and can provide more accurate data about their menstruation.
Of course, without more clinical studies, we have to be judicious about making claims about efficacy, but as I find myself writing “last menstrual cycle unknown” less and less, it seems clear that these digital tools are an enhancement.
Further, with patient-generated data, virtual care enables the development of a patient history that can inform conversations at the doctor’s office and provide vital context for clinical decisions.
For example, in the case of blood pressure related complications — the highest cause of maternal mortality and morbidity — a patient history is crucial to understanding the significance of a blood pressure (BP) reading. A reading of 150/100 might be an improvement for a preeclamptic patient, but worrisome for another woman — one number in isolation will not give a provider enough information. A virtual solution automates the process of data collection to provide a more comprehensive view of an individual patient’s record.
As in the case of menstrual tracking, monitoring blood pressure levels during and after pregnancy is not a new idea. The system that is currently in place, i.e, the 14-visit schedule for prenatal care with a single visit postpartum 6 weeks after delivery, was created to provide readings at increasingly shorter intervals throughout pregnancy — but based mostly on experience and not hard science. This one-size-fits-all approach to pregnancy care leaves a lot of “abnormal” patients falling through the gaps.
Yet sending patients home with a BP cuff to manually track their levels — a practice that attempts to close the gaps in care — doesn’t exactly solve the problem, because human error once again comes into play. Such a system relies on human beings to analyze and communicate their data, not to mention remembering to measure their levels on schedule.
Virtual care narrows the margins of human error. At George Washington, we use Babyscripts, a virtual care solution that reminds patients to check their BP and transmits BP data from patient to provider through a bluetooth-enabled BP cuff in real time.
In three separate cases, Babyscripts identified postpartum patients at GW with elevated blood pressure who were otherwise low-risk. Under the traditional system of care, where postpartum women don’t see their doctor until 6 weeks after giving birth, those elevated levels might never have been caught and might have escalated with dire consequences.
With the continuous monitoring of virtual care devices such as this, interventions can happen in real time. As wearable devices and sensors become more advanced, monitoring is continuously recording — at any given time, we have more data, allowing us to identify signals more precisely as increasingly sophisticated algorithms do the work of data analysis.
It doesn’t take much stretch of the imagination to see the areas where such technology can augment and extend the reach of the doctor. Take the example of glucose monitoring. A traditional glucose test involves fasting — sometimes a full 24 hours of fasting if a woman tests positive — and the process can put a mother out of commission for a half day, an amount of time that few women, especially working mothers, can ill afford to spare. And this is just the test. If a woman is diagnosed with gestational diabetes, she is monitored for a couple of weeks to see if she needs medicine.
Now imagine that we could bypass all of this with remote monitoring of blood sugar. There is no need for invasive tests, no long appointments, no logistical challenges. This is glucose monitoring of the future — still beginning and ending with the doctor, but extending their reach and increasing the impact of each appointment.
This only grazes the surface of the benefits of virtual care — potential and actual. Its facets are many: virtual visits, remote prescribing, secure messaging with a provider through a patient portal — these are actualities that are fast entrenching themselves in the system as consumer demand for them grows. And as actualities that deliver critical information to the people who need it when they need it, we’d do well to lean on, learn, and integrate these new systems into every day practice.