Recently, the Medical Society of the District of Columbia hosted innovator Juan Pablo Segura, President and co-founder of Babyscripts; and Kathryn Marko, MD, FACOG, NCMP, Assistant Professor of Obstetrics and Gynecology and Residency Program Director at the George Washington School of Medical and Health Sciences, to hear their thoughts on the state of maternity care in the District of Columbia.
Robert Hay Jr., Executive Vice President at MSDC, moderated the discussion, in which Segura and Marko addressed the challenges that exist in DC towards receiving and accessing prenatal care, and how technology can be a conduit to delivering care in areas where it’s otherwise difficult to receive it.
The discussion touched on the country’s current status around digital healthcare, and how it is on the precipice of what looks to be a huge change in the way health technology is paid for and leveraged. It also referenced the exciting developments in how payers are starting to sponsor these innovative care delivery models.
Read the summary below, and watch the full presentation here.
The Current State of Maternity Care
Juan Pablo: It’s widely known that the US has one of the highest maternal mortality rates in the developed world, with minority women suffering the most from these statistics. As a country, we spend millions of dollars on healthcare, but the outcomes don’t even come close to reflecting that investment. Something has to change, because what we’re doing isn’t working.
Technology can’t solve every problem — but I really believe it can be a huge player in solving access to care issues. The smartphone has been almost completely adopted across the board. So how do we address technology in a clinical and scalable way to start addressing these issues of access?
Fifty percent of counties in the US don’t have practicing OBs — that’s an obvious problem. What’s less obvious is that these problems of access exist in urban environments as well as rural. Just because there isn’t a 50 mile distance between a woman and her closest provider doesn’t mean there aren’t issues of access — right here in DC, we have a maternity care desert.
DC’s Maternity Care Desert
JP: There’s a stark divide between East and West in DC in terms of availability of care, and when you start looking at the patients who need the help the most — Medicaid beneficiaries and enrollees — they’re mostly on the East side, where there are no maternity wards and very few care options. The clinical problems, the poor outcomes — preterm birth, infant mortality, maternal mortality — these statistics are coming out of the areas where the facilities and infrastructure do not exist.
Fig. 1: Distribution of DC Hospital and Surgical Services
Obviously we can build new hospitals and train up new providers, but that’s a years-to-decades-long process. The question that led us to create Babyscripts, a virtual solution for maternity care, was what we could do today, right now, to start solving these issues.
The Potential of Technology
JP: What are the specific issues that technology can help address? It can circumvent logistical problems like transportation, for one thing. But it can also help manage complications like preeclampsia. If a woman isn’t attending her prenatal appointments — a major problem in the District where over 30% of women don’t receive adequate prenatal care, and certainly not an isolated problem — she isn’t being monitored for blood pressure complications. At-home monitoring can begin to solve the problems of women slipping through the cracks because they aren’t able to attend prenatal appointments.
Blood-pressure monitoring also holds enormous benefits for the postpartum period, the time when most maternal deaths occur. The majority of these deaths come from blood-pressure related complications that manifest in the 6 weeks before a woman has her postpartum follow-up appointment. Remote monitoring can identify these complications as soon as they surface, and with this, Babyscripts has been successful in eliminating the percentage of readmissions for postpartum hypertension from the national average of 3% to 0%, at client site Cone Health and others.
Beyond Video Visits
JP: We tend to think of virtual care only in terms of telehealth or video visits, but there are in fact many different kinds of virtual healthcare. Video visits are tethered to human contact — there needs to be another person on the other end of the phone. They don’t address the problems of the physician shortage. Supplementing human interaction with remote patient monitoring and mobile digital engagement is a way to circumvent the problem — to provide asynchronous care that doesn’t rely on the presence of the provider.
Any provider that works with Babyscripts gets access to our customized mobile experience, which delivers educational materials and practice-specific content to the patient through the convenience of a mobile app. Depending on the risk of the patient, we also provide Mommy Kits, which include medical devices that allow the patient to capture their biometric data from home. This is a crucial efficiency right now, as providers and patients are trying to limit in-person interaction as much as possible due to Covid concerns.
Babyscripts and GW-MFA
Dr. Kathryn Marko: Our relationship with Babyscripts started a few years ago — we wanted to see how moms engaged with a mobile platform and remote patient monitoring, and our initial pilot studies found that patients had high satisfaction when using the app with remote blood pressure monitoring.
I feel empowered by being able to see my data. I feel more comfortable/relaxed getting to track my stats week after week rather than having to wait for an appointment. -GW-MFA patient
These results directed us forward: how could we use Babyscripts to reimagine prenatal care? What are the redundancies in prenatal care and what would happen if we used the Babyscripts technology to reduce the patient visit schedule? After initial studies and a randomized control trial, we found that not only did patient engagement and satisfaction increase, but that the reduced schedule was successful — there was no difference in patient outcomes from the traditional in-person prenatal visit schedule.
A Solution for the Underserved
KM: We have a lot of patients east of the city (the area that Juan Pablo referenced earlier). We wanted to make sure that this platform would be successfully used by all of our patients — not just a small subset of low-risk patients, but also our most vulnerable patients. We’ve had incredible success with screening for and identifying high-risk patients who otherwise might not have access to care.
Formerly, a lot of our prenatal appointments served as a way to check in with the mom, to provide her with evidence-based resources, and to ensure that she was getting the screening that she needed. Unfortunately, a lot of our vulnerable patients weren’t showing up to those visits. Now with the reduced visit schedule — and these visits are targeted around the main events of pregnancy such as the anatomy ultrasound and glucose screening — these prenatal care visits are more intentional. Because of remote monitoring and the app, we have biometric data at hand and we’ve already shared resources — we can concentrate on more high level conversations with our patients.
KM: As part of our response to COVID-19, we’ve been enrolling all patients onto Babyscripts at the beginning of their pregnancy, regardless of risk. Now, even though we’re not seeing as many patients in person, we can be assured that they’re receiving the right resources, and we’re able to monitor their biometric data to make sure we’re not missing anything like preeclampsia.
Fig. 2: GW enrollment numbers, Jan through July 2020
We’ve also used the app as a means of pushing out new resources related to the pandemic, like information on our visitor policy, which is constantly changing. We’re able to give our patients information about the reduced prenatal care visit schedule and assure them that it won’t affect outcomes. We’re able to discuss the things they need to think about when the baby comes now with Covid. We’ve been able to push out a lot of new information about mental health and resources for domestic violence, as we’ve seen a surge in those issues due to the pandemic.
I think this universal enrollment will continue even after Covid, as both patients and providers have experienced the benefits of keeping a closer eye on the patient through remote monitoring — we’re able to allow the patient to engage in her own care to an extent she couldn’t before.
Patient Case Study
KM: I was sold on the potential of the platform from the very beginning, but it was a patient case study that really solidified my belief in the program. This patient was enrolled very early on in her pregnancy — she was taking at least weekly, sometimes more, blood pressure readings (we ask that patients take at least one a week) — and every reading was normal. She had an uncomplicated, repeat C-section, with a normal discharge. On postpartum day 4, she was noted to have increased swelling and elevated blood pressure. With the elevated blood pressure, a trigger alert was sent through the Babyscripts cloud to the GW-MFA triage center. The patient was instructed to return to the hospital, ultimately diagnosed with preeclampsia with severe features, and received postpartum magnesium for 24 hours and hypertension medication. She was discharged and her providers were able to titrate her blood pressure medication remotely through telehealth and Babyscripts. At 11 weeks postpartum, the patient was normotensive, and her providers were able to wean her off of hypertension medication.
Babyscripts helped me control my anxiety; I knew I had the tools to keep track of my health. Without Babyscripts, I may not have realized I was having serious issues and delayed getting the care that I needed. Babyscripts potentially saved my life.
This is one of several similar case studies that GW-MFA has collected through our research in precision pregnancy care.
Incorporating the Payer to Provide Virtual Care
KM: As we look forward to where we want to go, it’s not only identifying high-risk conditions, but also targeting where in pregnancy patients need interventions — that is, moving towards precision care. We plan to use the Babyscripts platform more extensively to reduce disparities in the District, to ensure access to universal monitoring for high-risk conditions, and anticipate which patients need resources much earlier, which is where the relationship with payers comes in.
JP: GW has committed to solving disparities in care by making technology available to anyone regardless of payer — regardless of commercial, Medicaid, uninsured — but not every health organization has the budget to invest in these initiatives and provide these tools to their patients.
At the end of the day, these virtual tools help deliver care but also reduce cost and dramatically improve outcomes, at a huge benefit to the payer. So we’ve involved large MCOs, like Amerihealth and Amerigroup in DC, that work with our provider customers to subsidize or sponsor the cost of Babyscripts for their members.
Babyscripts created a program that we call joint deployment, which pulls the payer, the provider and the patient onto the same tech experience. We think this is the future of how digital health gets integrated into the delivery of care, and that care coordination is one of the best things that can happen to move outcomes. There are many resources out there, but right now they're not delivering the impact that they should because they're functioning in siloes. The insurance companies have social workers and people on the ground, but they're not talking to the provider teams and getting the point of care data and insight that they need to really address patient risk.
Through the joint deployment program, our payer partners have subsidized the cost of
- High-risk remote patient monitoring to identify and triage complications
- Bi-directional chat to screen for social determinants of health
- Mental health surveys and depression screening
- Connection to community resources (provided by the payer) to address environmental risk
- Substance use disorder experiences focused on opioid addiction, with connection to community support and interventions.
The benefits of these social, clinical, and mental health risk identifications are immediate and obvious -- better attendance to prenatal care appointments, identifying at least 2 social risks or barriers to care, improving outcomes, and so forth. When you empower a patient with a program like this, you give them more ownership over their care.
JP: The importance of innovative solutions such as ours and others is becoming increasingly clear across the country, and policy-makers are starting to wake up to what they can do to accelerate adoption. Here in the District, the DC Council just passed the Postpartum Expansion Act — a really big step for our space. The bill expands the coverage possible in the postpartum time period beyond the one visit, six week timeframe to really give moms more support after they deliver. One of the other innovative approaches — and I haven’t seen this in any other state — is a digital health mandate that mandates reimbursements for digital interventions at the point of care.
This is a huge step for those who have been waiting for the day that telemedicine would have parity with in-person visits — ACOG, for example, has long specified that giving women options in their care is incredibly important, especially during the postpartum time period. Now these changes aren’t just happening on the innovative practice side as at GW, but also legislators are recognizing that digital health tools can impact outcomes and solve many disparities in their respective geographies. It’s a really exciting time for our space, and an encouraging move forward for the wellbeing of mothers around the country.
Data privacy is always an issue with new tech. How do you make patients feel comfortable, on the provider and tech side, with using technology to navigate their pregnancy?
JP: Babyscripts is a clinical tool, so we sign some pretty robust business agreements with our health system clients. We don’t sell data — we’re not allowed to under our BAA. We don’t make any money off of marketing or ads, the app is fully owned and administered by the health system and Babyscripts makes no additions. The IT risk assessment and review processes are very robust from the health system. Many consumer-oriented apps have hidden clauses in their end-user agreements that allow data-sharing, but again, as a clinical tool, Babyscripts is contractually not allowed to share data.
KM: I’ve only had a handful of patients express concerns over privacy issues. I direct them to customer service at Babyscripts and they have had their concerns met. Patients know this isn’t like other apps you can use with ad pop-ups. I’ve read (and written some!) of the content myself, so it’s all provider approved.
How is the information sent back to the provider team?
JP: I’m assuming this is about triggers/alerts, in addition to the educational resources. We have two ways of sharing info back to the clinical team. We prefer to integrate directly into the EMR which is our standard practice now. We do what’s called HL7 integration so that patients can be automatically rolled onto Babyscripts — the data points that are captured at home can be fed into the flow sheets automatically. That’s not what we do at GW, because GW is a legacy account. We created a workflow around them that works really well and so we haven’t needed to integrate.
KM: Babyscripts has a searchable provider platform called DIANA that allows providers to see every single patient on a panel: you can search by name, who enrolled them, etc., and you can see all the data points. If someone has a trigger we have an internal prompt in the app that asks the patient to recheck their BP in 20-30 minutes — if it’s still elevated it will send a message to the provider. The app also has symptom checkers, so if necessary you can log symptoms and if someone has an elevated BP plus symptoms that would trigger to our triage system. This goes to the triage nurses or the on-call provider during the day if there’s critical levels. If there’s no critical levels or the blood pressure normalizes, it sends what are called “tasks” to our inbox — that is, it will go to the provider or the triage inbox so that it can addressed the next day.
We’re able to set those trigger parameters and workflow very easily in order to make sure that the appropriate follow-up is happening for each patient. The patient doesn’t necessarily need to come in with their BP log or sugars or whatever they’re tracking, because you as the provider can see all the levels at once, and ask about abnormal readings to clarify whether there were areas of concern or if it was an aberration.
JP: I’ll add that every provider is a little different in the way that they handle triage, etc., so all of that is mapped out for the particular provider — the solution runs turnkey, which is very important.
What info is going directly to the payers and how are they using it?
JP: In a joint deployment, the patient is tagged with their payer, and the patient acknowledges that they’re okay with the Babyscripts terms and conditions and also with sharing that data with their provider. It’s not just physiological remote patient monitoring, but social and behavioral risks that are captured through monitoring and risk surveys — they’re flagged so the care management team can follow up on them. Babyscripts confirms what the provider wants to follow up on vs. the care management team.
KM: All of this used to be on paper and mailed or faxed into the office. This tool has created the ability to access these resources in real time: resources for food insecurity or mental health support, etc — things that we don’t necessarily have as providers because we don’t have an in-house social worker at all of our sites. This has been a benefit to identify high-risk early.
What about patients who have financial insecurity/lack a smartphone?
KM: We currently are using the app for patients who have access to a smartphone (in English and Spanish). It’s an unfortunate reality that an app is not the most useful tool for a patient who doesn’t have access to a smartphone.
JP: Babyscripts does have web-based application for educational materials, to deliver that enhancement to patients even without a smartphone, although that is a very small margin of patients. One of the unfortunate exclusion criteria for Babyscripts’ remote monitoring is the necessity for a smartphone. Fortunately that is a very small number — about 94% of patients have smartphones.
Is there a way to monitor blood sugar?
JP: We do have gestational diabetes monitoring, and use the same mechanics as the BP monitoring.
KM: In addition to the possibility to monitor for blood sugar, we also have patients monitor their weight gain through manual entry into the app, and we’ve just deployed blood pressure monitoring for our postpartum patients. We’ve discussed a more rigorous survey to monitor for mental health risk. The possibilities for a platform like this are really endless.
JP: The whole realm of digital/virtual can be really overwhelming — what populations/conditions should we focus on? A lot of our providers start simply by digitizing education, and get comfortable with the app before they make workflow changes. Then they might start with a low-risk population, or postpartum population for hypertension, for example.
Ten years from now, what are we looking at in terms of taking care of and treating pregnant women?
KM: Ten years from now, virtual care will be more of the norm. It’s going to allow us to identify patients at risk early, and allow us to intervene at the right time, and that’s going to create really personalized care. I envision a time where an app or whatever we’re using will automatically push out extra resources. There’s not a lot of data out there right now, but in ten years there will hopefully be a substantial amount of data to guide us toward effective interventions for things like weight gain, gestational diabetes, and other issues. Not only will this improve outcomes, but we’ll also see the penetrants into rural and limited-access communities be much easier, and the moment a woman becomes pregnant she can get care and still connect to her provider in a meaningful way. We love the face-to-face connection, and we’re utilizing this technology to enhance the moments when we do see patients in-person.
JP: In ten years, the 14-visit schedule as we know it will be completely innovated out of the standard of care. Care will be totally personalized based on risk and preference and delivered in an environment where the woman is comfortable. Right now what women are doing, and the process of what women are doing in terms of receiving care, is a very uncomfortable and inconvenient process. Think of taking a couple hours off in the middle of the workday to battle traffic or deal with public transit, maybe paying for parking. You wait in a waiting-room that’s never the right temperature, for 30 minutes to an hour, and then you see your provider for only 10 minutes — that’s not the kind of patient experience you want to create.
Whether it’s detecting risk better or more appropriately, or reallocating provider time so that the doctor can focus on the patients who are higher risk and need more care or need more attention, I think you’re going to see a whole system of obstetrics that’s completely reinvented, from standardization to personalization. And the only way to really do that is through an end-to-end virtual tech experience — you can’t do that just through templates in an office — you need to have some level of constant connectivity between the patient and the provider. GW is doing some of it for patients and providers and you’re going to start seeing more of it — not as an option but as a starting point.