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.^1–3 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.⁴ 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.^4–6

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.^7–15 For example, Robie and colleagues ⁹ 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. ¹⁰ Nores et al¹² 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.⁷ 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.

The combination of increasingly affordable and powerful computing and communication technology, along with continuing nationwide concerns about health care access and costs, has propelled telemedicine from an innovative way of practicing medicine to a practical and necessary tool in addressing the health care needs of the nation.¹⁶ Our findings represents the first summary of how state and territory telemedicine policies address maternal and neonatal risk-appropriate care. We found that while the majority of states/territories had policy language for telemedicine care, only 3 states and none of the territories had language specific to maternal and neonatal risk-appropriate care. The paucity of telemedicine policies among the territories, and lack of specificity to perinatal care among those with policies, was unexpected because telemedicine is an effective mechanism for improving medical access in jurisdictions without an advanced care facility, otherwise citizens are required to travel long distances for specialty care.

Despite the fact that the American College of Obstetricians and Gynecologists ¹⁷ and AAP^7,18 have policies advocating the use of telemedicine to expand access to health care services, these policies do not explicitly address the perinatal population, instead they provide guidance on the shortage of providers, health equity, liability, and logistics of telemedicine.^7,17,18 With such ambiguity, it is understandable that we found only 3 jurisdictions (New York, Ohio, and North Carolina), with telemedicine policies specific to maternal and/or neonatal risk-appropriate care. Although these states have telemedicine language specific to the perinatal populations within existing policies, we found limited evidence of statewide telemedicine program development for regionalized perinatal care. For instance, the North Carolina statewide medical board recognizes telemedicine as a useful tool in increasing access to health care; however, it released a position statement cautioning that practitioners utilizing telemedicine be held to the same standard of care as those who conduct in-person care, a position with potential to adversely affect development and expansion of telemedicine programs. ^19,20 In January 2014, the Ohio Senate passed a bill that required Medicaid, and not the state itself, to develop standards for billing and reimbursement for telemedicine services, affecting the state health department’s ability to fully implement statewide telemedicine programs.^21,22 Even though these challenges increase the complexity of developing statewide telemedicine programs for the perinatal population, some changes are occurring. On January 1, 2016, the state of New York implemented a new statewide law that better defines telemedicine and mandates reimbursement coverage by private insurers and Medicaid for telemedicine services, including obstetric care.^23,24 Such changes may occur in other jurisdictions to improve clinical and national guidelines, policies, and reimbursement mechanisms, and ultimately, patient outcomes.

In jurisdictions without telemedicine policies specific to perinatal risk-appropriate care, individual hospitals and/or regional centers have implemented telemedicine programs for the benefit of their perinatal populations. For instance, in Florida, Iowa, and Idaho, regional centers extended maternal-fetal medicine services to women in underserved rural areas to include genetic counseling and other neonatal services.^25–29 Since 2003, the Antenatal and Neonatal Guidelines, Education, and Learning System (ANGELS) program in Arkansas has empowered local providers through telemedicine support, consultations, and best practices development to utilize the expertise of the state’s only board-certified maternal-fetal medicine specialists located in Little Rock.³⁰ ANGELS’ long-term goal is for all pregnant women in Arkansas to be no more than 20 miles from an interactive consultation, via compressed video, with high-risk pregnancy specialists.³¹ Multiple studies have demonstrated the benefit of this innovative program.^3,32–34 For instance, Glen et al³² in 2006 found that this distance-based obstetrical management system can increase maternal transports to tertiary centers, allowing for proper coordination of high-risk pregnancies. Similarly, Kim et al³ in 2013 demonstrated that a telemedicine collaborative program such as ANGELS improves level of care provision and services received, and decreases infant mortality among very low-birthweight neonates.

In other areas of medicine, states are moving forward with statewide telemedicine programs. From 2011 through 2012, 10 hospitals in North Carolina began participating in the Albemarle Hospital/Duke Endowment Telepsychiatry Network. The early results of the project found a 47% reduction in length of stay and a 35% reduction in 30-day readmit rates. During the 2013 session, the North Carolina General Assembly approved and funded a statewide telepsychiatry program for hospital emergency departments, modeled largely after the efficacious Albemarle Hospital Foundation telepsychiatry program. By 2014, this statewide Telepsychiatry Program (NC SteP) had saved the state approximately $7 million, and a growing number of hospitals were requesting inclusion in the program.^35,36

If all states and territories implemented similar statewide telemedicine programs for perinatal care in remote and resource-challenged areas, access to maternal-fetal medicine specialists would expand. For instance, Sullivan et al³⁷ in 2005 concluded that if an area increased the number of available maternal-fetal specialists to 5 per 10,000 live births, a reduction of approximately 27% in the risk of maternal death can occur. Nevertheless, further research to understand perinatal outcomes associated with the implementation of statewide telemedicine programs are warranted.

Our study was limited by the use of publicly available information; researchers did not directly contact jurisdictions to confirm or obtain additional information regarding telemedicine policies. Additionally, policies and regulations that were not published or publicly available were not incorporated into this review, precluding inclusion in the overall sample. Furthermore, since we did not include federal-level polices for the territories that were not directly mentioned in the publicly available information, we may have underestimated the number of telemedicine policies available in the territories. Finally, changes that may have occurred in jurisdictional policies following the data collection phase of this review were not included. Regardless of these potential limitations, including language on maternal and neonatal risk-appropriate care in existing telemedicine policies would have an impact on overall cost of care provision in states because it would improve access to care and increase risk-appropriate care provision and services received among this population.

In conclusion, the majority of states and territories have the infrastructure for perinatal telemedicine implementation through established policies addressing the topics of consultation, diagnosis, and treatment. By including language specific to perinatal risk-appropriate care in these existing telemedicine policies, states and territories can better manage current challenges to appropriate care coordination and utilization of heath care services facing their maternal and neonatal populations and potentially realize cost-avoidance, increase care coordination, and improve the provision of medical care.