Application of telemedicine video visits in a maternal-fetal medicine practice at the epicenter of the COVID-19 pandemic
To identify the factors that affect the patients’ and providers’ desire for future maternal-fetal medicine telemedicine visits in a metropolitan setting at the epicenter of the COVID-19 pandemic. 

Maternal-fetal medicine patients and providers demonstrate high satisfaction with the use of telemedicine. 

The patients’ desires for future maternal-fetal medicine telemedicine visits is significantly affected by their digital experience, the perceived need for physical contact, and the time saved on travel. 

This was a cross-sectional survey of patients who completed telemedicine video visits through the maternal-fetal medicine (MFM) division at the NYU Langone Hospital—Long Island from March 19, 2020, to May 26, 2020. NYU Langone Health, a large academic healthcare system in the New York metropolitan area, expanded telemedicine video visits to all ambulatory settings on March 19, 2020, at the epicenter of the COVID-19 pandemic in the United States. This study was approved by the NYU Institutional Review Board. The waiver of written consent was obtained, and all the patients who completed telemedicine visits with MFM within this time frame were identified using the electronic medical records (Epic, Verona, WI). The survey questions were modified from previously published surveys . , The patients were contacted by healthcare personnel who conducted telephone-administered surveys or provided patients with a Research Electronic Data Capture (REDCap) web-based application link to the online survey after obtaining verbal consent by telephone. The patient demographics were collected from the electronic health records (Epic), which included age, gestational age, gravity, parity, race, ZIP code, faculty vs private obstetrician-gynecologist (OBGYN), diagnoses for requiring MFM care, and the types of visits (new vs follow-up). If the patient had >1 diagnosis for MFM consultation or management, the diagnosis that was first or required the most visits for management was used as the primary diagnosis. The survey was designed to assess the patient's digital experience with the sign-up or check-in process and the technological tools and the overall satisfaction with the telemedicine visits . The survey response scores were converted to a numeric value for quantitation and comparison among survey questions as follows: strongly disagree—1, disagree—2, neutral—3, agree—4, and strongly agree—5. We performed an analysis of the demographics and survey responses of 2 groups on the basis of the response to the following question: “I would like telehealth visit to be an option for future obstetric visit,” which distinguished those who agreed vs those who answered neutral or disagree with the statement. Median scores were then used for these comparisons. A total of 11 physicians and 1 nurse practitioner from the MFM Division at the NYU Langone Hospital—Long Island, who conducted both in-person and telemedicine encounters were also administered the provider survey through a REDCap link. Statistical analysis The differences in demographics according to the survey responses were measured using the Fisher exact test. The Mann-Whitney U test was used to determine the significance between the survey response and the visit types or diagnoses for MFM visits. The Kruskal-Wallis test was used to determine the significance of the survey response in addition to the distance to the closest MFM location, the month of the telemedicine visit (TMV), and the relationship between other survey responses. The comparison of the survey responses for each survey question in relation to the answer choice for question 10, “I would like telehealth to be an option for future obstetrical visits” was performed using the Mann-Whitney U test. When there were 3 pairwise comparisons (agree vs neutral, neutral vs disagree, agree vs disagree), a P value of <.0167 was considered significant. In all other comparisons, a P value of <.05 was considered significant. 

The differences in demographics according to the survey responses were measured using the Fisher exact test. The Mann-Whitney U test was used to determine the significance between the survey response and the visit types or diagnoses for MFM visits. The Kruskal-Wallis test was used to determine the significance of the survey response in addition to the distance to the closest MFM location, the month of the telemedicine visit (TMV), and the relationship between other survey responses. The comparison of the survey responses for each survey question in relation to the answer choice for question 10, “I would like telehealth to be an option for future obstetrical visits” was performed using the Mann-Whitney U test. When there were 3 pairwise comparisons (agree vs neutral, neutral vs disagree, agree vs disagree), a P value of <.0167 was considered significant. In all other comparisons, a P value of <.05 was considered significant. 

From March 19, 2020, to May 26, 2020, 253 patients participated in 433 TMVs with MFM providers. The average patient age was 33 years (±5 years), and the median gestational age was 26 weeks and 5 days (14 weeks and 5 days, 30 weeks and 5 days). The 3 most common MFM TM visits were for maternal comorbidities, poor obstetrical history, genetics, and preconception counseling. The types of visits included the following: 37% consultations (new patient visit), 48% follow-up visits, and 15% genetic, preconception, and nutrition counseling. Of the 253 patients who participated in TMVs, 165 patients participated in the survey, resulting in a 65% survey response rate. Besides the gestational age and marital status, there were no other significant differences in the responders vs the nonresponders. The responders had a slightly earlier mean gestational age of 25 weeks and 6 days vs 28 weeks and 1 day for nonresponders ( P =.03) and were more likely to be married at 83% vs 73% ( P =.04) (data not shown). The response rates to each patient survey question are detailed in . Overall, there was a high rate of patient satisfaction in the areas assessed. More than 80% of patients agreed that sign-up and check-in for their TMVs was easy, with no issue regarding the internet connection or the ability to see and hear their provider. Similarly, 90% of patients agreed that the lack of physical contact was not an issue. The patients also reported that TMVs saved travel time and made it easier to see providers 95% and 87% of the time, respectively. In accordance with the overwhelmingly positive response to the ease and applicability of the TMVs, 73% reported that they would like telehealth to be an option for future obstetrical visits. To identify factors that contribute to the patient's desire for future telemedicine visits, for further analysis, we used the survey responses from patients who answered that they desire future TM vs those who answered neutral or disagree. The comparisons of demographic data and visit characteristics are shown in . Age, gravidity, parity, and ethnicity had no association with the desire for future TM visits. There was no difference in marital status, type of insurance, primary OBGYN, distance to MFM office, number, or type of TM visits. Although there was no statistical difference in the distribution of diagnoses necessitating MFM services, there was a trend for patients with poor obstetrical history to desire future TM ( P =.05) . Furthermore, there was no difference in agreeability based on when the TMV took place from March to May (data not shown). No significant differences were found when similar comparisons were evaluated between those who agreed that they desired future TM vs those who disagreed alone (data not shown). A detailed classification of how patients answered the remaining survey questions in relation to whether they desired future TM vs answering neutral or disagree was performed and is shown in . The patients who desired future TM had significantly increased agreeability that they were able to see and hear their provider easily (5 [4.5, 5] vs 5 [4, 5]; P =.014) and that lack of physical activity was not an issue (5 [4, 5] vs 5 [4, 5]; P =.032). They were also more likely to agree that TMVs are as good as in-person visits (4 [3, 5] vs 3 [2, 3]; P <.001). In addition, they had higher agreeability scores that telehealth visits saved them traveling time (5 [5, 5] vs 4 [3, 5]; P =.001) or that telehealth made it easier for them to see doctors or specialists (5 [4, 5] vs 3 [2, 3]; P <.001). Although some median scores were similar, the distribution of scores for those who desired future TM were typically less broad than other patients . The assessment of providers in MFM practice who participated in TM visits was also surveyed and provider survey responses too demonstrated high levels of satisfaction . More than 83% of the providers agreed that telehealth is an acceptable and convenient method to provide healthcare and it improves access to patients. There were no significant technological barriers identified, with 83% agreeing that they could see and hear their patient without difficulty and 100% of providers felt that the technology was secure. All providers agreed that remote patient monitoring enhances telehealth visits and 75% agreed that the lack of physical examination was not a problem. Thus, 67% of providers agreed that telemedicine visits are an adequate replacement to in-person visits and 83% agreed they would like telehealth to be an option for future obstetrical visits. 

Principal findings We present the results of a large patient and provider survey study administered to an obstetrical population who completed MFM telemedicine video visits in one of the epicenters of the COVID-19 pandemic. We demonstrated high levels of satisfaction and indicated that more than 70% patients and 80% providers would like obstetrical telehealth visits in the future. Through our analysis comparing patients who desire future TM visits compared with others, we found that the patients’ digital experience, perception of need for physical contact, time saved on travel, and ease of accessibility to their healthcare provider were the drivers for desiring future TM visits. Results Before the COVID-19 pandemic, the use of TM in obstetrics had been described in a rural setting as providing specialized care such as MFM consults to patients geographically distant from specialized clinics with great satisfaction rates. With the restraints of social distancing during the pandemic, TM was implemented widely and rapidly within the metropolitan and surrounding suburban settings. Despite this rapid implementation, our results demonstrate high overall satisfaction rates with TM visits among both patients and providers. This is in line with previous studies evaluating telehealth in obstetrics and gynecology. , No differences in the sign-up or check-in process are likely owing to both groups reporting high levels of satisfaction with the use of a mature technological system as previously reported. A patient's desire for future TM obstetrical visits was also significantly influenced by their perception of the importance of physical contact during the visit, easier accessibility to providers, and time saved from travel. Demographic characteristics did not influence the patient's desire for future telemedicine obstetrical visits. The types of visits, both new consults and follow-up MFM visits, were amenable to TM as well as the diversity of diagnoses that are typically seen in common MFM clinical practice. Interestingly, for patients being seen for fetal indications for MFM care, they were more likely to disagree that TMVs saved them time. This is likely because they still require in-person fetal monitoring services that are not available in current mainstream telehealth modalities. Clinical implications COVID-19 poses a significant health risk to both pregnant women and neonates. , The COVID-19 pandemic is a debilitating and frightening time for all patients, including patients and physicians in the field of obstetrics. Given that obstetrics has a uniquely defined system for prenatal care, often incorporating at least 8 to 10 visits with additional ultrasound and fetal monitoring, the field had to quickly modify a majority of this program into telehealth. Aziz et al describes the implementation of telehealth in a New York City (NYC) hospital and clinic system during the pandemic and provides recommendations on how to structure in-person and telehealth prenatal care during times requiring social distancing. NYU Langone Health rapidly implemented the shift to telemedicine quickly and efficiently in many different specialties, and here we see that the patients’ and providers’ digital experiences correlate with high satisfaction with telehealth in obstetrical visits. Although TMVs have been critical in the setting of the pandemic, especially in metropolitan areas such as those where our study was performed, we demonstrate that the majority of obstetrical patients desire future TMVs. Although COVID-19 may be the stimulus for the rapid transformation of telehealth, both the patients’ and providers’ desire for telemedicine services after the pandemic need to be anticipated. In today's obstetrical clinical care model, TM can continue to provide access to obstetrical care and allow for an easier method to see a provider through increased flexibility for both patient and provider. Although a majority of the patients in our study population lived within 10 miles to an ambulatory office, even those <5 miles away had a similar perception of saved time and desire for future TM visits. The trend for patients with poor obstetrical history to desire future TM indicates that easier access to the provider through a telemedicine visit does not only save time but also offers a convenience for patients to access providers without needing to be surrounded by other obstetrical patients; this may serve as a reminder of the hardships these patients have experienced. Another facet to telehealth use is the concern for access and availability for patients of all socioeconomic levels. The study by Chunara et al identifies health disparities as an important aspect of telemedicine that should be addressed as it becomes more integrated into routine medical practice. A recent study from our institution assessing health disparities and telemedicine demonstrated that although there was an increase in the number of Black patients accessing TM, they were still less likely to access TM compared with White patients (0.6 Odds Ratio). This emphasizes the need to focus efforts to increase accessibility to telemedicine services to minimize health disparities and increase telemedicine usage. Our study demonstrates that when a TMV is conducted, there is an equally high degree of satisfaction or agreeability to the telemedicine features between White and Black patients. Research implications There are limited studies of substantial quality on the implementation of telehealth in obstetrics and gynecology. A review by Lassens et al  assessed 9 randomized controlled trial studies for quality and bias indicators, revealing intermediate-to-high bias in a majority of the studies. The evaluation of only low bias studies demonstrated a significant decrease in low birthweight births and a reduction in neonatal intensive care unit admissions in pregnancies managed with telemedicine. Thus, evaluating the pregnancy outcomes of patients who participated in TM during their obstetrical care through the COVID-19 epidemic would be an informative future research. In our study, we found that patients are less likely to desire TM for future obstetrical visits when they feel that lack of physical examination is an issue. In addition, our data suggests that patients with a fetal indication were less likely to agree that telehealth saved them time traveling to medical offices. Although conclusions cannot be made from this small sample of patients, it does highlight aspects of telemedicine that require optimization, such as increased surveillance and fetal monitoring required for fetal indications. Currently, a physical visit for ultrasound and fetal testing is required to safely assess both maternal and fetal well-being. However, there are evolving enhancements to telehealth that may address these issues. Mhajna et al has shown comparable performance of remote fetal and maternal monitoring systems within 8 beats per minute compared with standard of care cardiotocography. In addition, the utilization of technological tools to allow providers to conduct a physical examination virtually and more comprehensively is becoming increasingly more available. The implementation of telehealth applications such as integrated physical examination devices equipped with video and auditory aids, remote patient monitoring of vital signs and blood glucose, or fetal monitoring such as electronic fetal monitoring or even ultrasound may help augment and improve patient outcomes and satisfaction. For instance, a prospective cohort study using telehealth for postpartum blood pressure monitoring in a rural setting demonstrated 95% retention rate, 0% hospital readmission rate, and 86% patient satisfaction rate. Similar applications are being suggested for antepartum blood pressure monitoring and glucose management in pregnancy. Strengths and limitations This is a large patient and provider survey for obstetrical telemedicine visits conducted in the New York metropolitan and surrounding areas, which is an epicenter of the COVID-19 pandemic. The surveys were performed no more than 7 weeks from the initial telehealth visit, thereby decreasing recall bias. The greatest strength of this study is our detailed analysis distinguishing patients who desired future telemedicine vs those who were neutral or disagreed with the option. This led to the identification of both modifiable and perceived factors that drive a patient's desire for future telemedicine visits. There are also limited provider satisfaction assessments of telemedicine applications in obstetrics and gynecology. Similar to previously described studies, we also find that our provider-administered survey demonstrates a similarly high degree of satisfaction in all areas reviewed, which correlates with a desire for future telemedicine visits. Furthermore, this study is not without limitations. Survey studies have inherent levels of bias at varying levels, including response decline, question design, and extremes in patient opinions, which can skew survey answering. With a response rate of 65%, it is unclear whether the patient responses represented in this study could be skewed more negatively or positively. However, we found only minor differences in the gestational age and marital status in our responders compared with nonresponders, indicating a good overall representation of the target population. Our survey did not include open-ended questions for suggestions from patients on what would improve the telemedicine experience, which is one suggested approach to reduce bias. This was not done because of the extensive time and resources needed to further analyze this type of information. Most of the patient surveys were completed over telephone calls. Therefore, the patients may have felt the need to answer more favorably, which may be another potential bias. To minimize this bias, telephone surveys were not conducted by the provider who conducted the telemedicine visits, and some patients chose to complete the survey through the provided survey link on their own. Indeed, we assessed a large obstetrical cohort. However, we did not have adequate numbers in some of the subgroups to provide robust statistical analyses. Therefore, future studies may attempt increased numbers in some of the groups such as patients with fetal indications for MFM care to further improve this modality for their care. Finally, although this study assesses the satisfaction and implementation of TM in obstetrical care, it does not assess quality and safety. Future studies on maternal and fetal outcomes based on those included in this study may help to elucidate the safety and future of TM in obstetrical care. Conclusions The COVID-19 pandemic initiated a rapid increase in the use of telehealth in all areas of medicine. We assessed the patient and provider satisfaction with telehealth use within a large suburban region surrounding the NYC metropolitan area from a MFM practice during the height of the COVID-19 pandemic. We found that, overall, the patients and providers were satisfied with the TM visits and the majority desired TM to be an option for future visits. We also found that the patients’ digital experiences, perception to not need physical contact, perceived time saved on travel, and access to healthcare providers significantly affected their desire for future telemedicine visits. This study highlights the need for health systems to continue to improve telehealth delivery and invest in innovative solutions to conduct physical examinations and other assessments remotely. Our MFM practice will continue to offer telehealth services moving forward to compliment in-person visits. 

We present the results of a large patient and provider survey study administered to an obstetrical population who completed MFM telemedicine video visits in one of the epicenters of the COVID-19 pandemic. We demonstrated high levels of satisfaction and indicated that more than 70% patients and 80% providers would like obstetrical telehealth visits in the future. Through our analysis comparing patients who desire future TM visits compared with others, we found that the patients’ digital experience, perception of need for physical contact, time saved on travel, and ease of accessibility to their healthcare provider were the drivers for desiring future TM visits. 

Before the COVID-19 pandemic, the use of TM in obstetrics had been described in a rural setting as providing specialized care such as MFM consults to patients geographically distant from specialized clinics with great satisfaction rates. With the restraints of social distancing during the pandemic, TM was implemented widely and rapidly within the metropolitan and surrounding suburban settings. Despite this rapid implementation, our results demonstrate high overall satisfaction rates with TM visits among both patients and providers. This is in line with previous studies evaluating telehealth in obstetrics and gynecology. , No differences in the sign-up or check-in process are likely owing to both groups reporting high levels of satisfaction with the use of a mature technological system as previously reported. A patient's desire for future TM obstetrical visits was also significantly influenced by their perception of the importance of physical contact during the visit, easier accessibility to providers, and time saved from travel. Demographic characteristics did not influence the patient's desire for future telemedicine obstetrical visits. The types of visits, both new consults and follow-up MFM visits, were amenable to TM as well as the diversity of diagnoses that are typically seen in common MFM clinical practice. Interestingly, for patients being seen for fetal indications for MFM care, they were more likely to disagree that TMVs saved them time. This is likely because they still require in-person fetal monitoring services that are not available in current mainstream telehealth modalities. 

COVID-19 poses a significant health risk to both pregnant women and neonates. , The COVID-19 pandemic is a debilitating and frightening time for all patients, including patients and physicians in the field of obstetrics. Given that obstetrics has a uniquely defined system for prenatal care, often incorporating at least 8 to 10 visits with additional ultrasound and fetal monitoring, the field had to quickly modify a majority of this program into telehealth. Aziz et al describes the implementation of telehealth in a New York City (NYC) hospital and clinic system during the pandemic and provides recommendations on how to structure in-person and telehealth prenatal care during times requiring social distancing. NYU Langone Health rapidly implemented the shift to telemedicine quickly and efficiently in many different specialties, and here we see that the patients’ and providers’ digital experiences correlate with high satisfaction with telehealth in obstetrical visits. Although TMVs have been critical in the setting of the pandemic, especially in metropolitan areas such as those where our study was performed, we demonstrate that the majority of obstetrical patients desire future TMVs. Although COVID-19 may be the stimulus for the rapid transformation of telehealth, both the patients’ and providers’ desire for telemedicine services after the pandemic need to be anticipated. In today's obstetrical clinical care model, TM can continue to provide access to obstetrical care and allow for an easier method to see a provider through increased flexibility for both patient and provider. Although a majority of the patients in our study population lived within 10 miles to an ambulatory office, even those <5 miles away had a similar perception of saved time and desire for future TM visits. The trend for patients with poor obstetrical history to desire future TM indicates that easier access to the provider through a telemedicine visit does not only save time but also offers a convenience for patients to access providers without needing to be surrounded by other obstetrical patients; this may serve as a reminder of the hardships these patients have experienced. Another facet to telehealth use is the concern for access and availability for patients of all socioeconomic levels. The study by Chunara et al identifies health disparities as an important aspect of telemedicine that should be addressed as it becomes more integrated into routine medical practice. A recent study from our institution assessing health disparities and telemedicine demonstrated that although there was an increase in the number of Black patients accessing TM, they were still less likely to access TM compared with White patients (0.6 Odds Ratio). This emphasizes the need to focus efforts to increase accessibility to telemedicine services to minimize health disparities and increase telemedicine usage. Our study demonstrates that when a TMV is conducted, there is an equally high degree of satisfaction or agreeability to the telemedicine features between White and Black patients. 

There are limited studies of substantial quality on the implementation of telehealth in obstetrics and gynecology. A review by Lassens et al  assessed 9 randomized controlled trial studies for quality and bias indicators, revealing intermediate-to-high bias in a majority of the studies. The evaluation of only low bias studies demonstrated a significant decrease in low birthweight births and a reduction in neonatal intensive care unit admissions in pregnancies managed with telemedicine. Thus, evaluating the pregnancy outcomes of patients who participated in TM during their obstetrical care through the COVID-19 epidemic would be an informative future research. In our study, we found that patients are less likely to desire TM for future obstetrical visits when they feel that lack of physical examination is an issue. In addition, our data suggests that patients with a fetal indication were less likely to agree that telehealth saved them time traveling to medical offices. Although conclusions cannot be made from this small sample of patients, it does highlight aspects of telemedicine that require optimization, such as increased surveillance and fetal monitoring required for fetal indications. Currently, a physical visit for ultrasound and fetal testing is required to safely assess both maternal and fetal well-being. However, there are evolving enhancements to telehealth that may address these issues. Mhajna et al has shown comparable performance of remote fetal and maternal monitoring systems within 8 beats per minute compared with standard of care cardiotocography. In addition, the utilization of technological tools to allow providers to conduct a physical examination virtually and more comprehensively is becoming increasingly more available. The implementation of telehealth applications such as integrated physical examination devices equipped with video and auditory aids, remote patient monitoring of vital signs and blood glucose, or fetal monitoring such as electronic fetal monitoring or even ultrasound may help augment and improve patient outcomes and satisfaction. For instance, a prospective cohort study using telehealth for postpartum blood pressure monitoring in a rural setting demonstrated 95% retention rate, 0% hospital readmission rate, and 86% patient satisfaction rate. Similar applications are being suggested for antepartum blood pressure monitoring and glucose management in pregnancy. 

This is a large patient and provider survey for obstetrical telemedicine visits conducted in the New York metropolitan and surrounding areas, which is an epicenter of the COVID-19 pandemic. The surveys were performed no more than 7 weeks from the initial telehealth visit, thereby decreasing recall bias. The greatest strength of this study is our detailed analysis distinguishing patients who desired future telemedicine vs those who were neutral or disagreed with the option. This led to the identification of both modifiable and perceived factors that drive a patient's desire for future telemedicine visits. There are also limited provider satisfaction assessments of telemedicine applications in obstetrics and gynecology. Similar to previously described studies, we also find that our provider-administered survey demonstrates a similarly high degree of satisfaction in all areas reviewed, which correlates with a desire for future telemedicine visits. Furthermore, this study is not without limitations. Survey studies have inherent levels of bias at varying levels, including response decline, question design, and extremes in patient opinions, which can skew survey answering. With a response rate of 65%, it is unclear whether the patient responses represented in this study could be skewed more negatively or positively. However, we found only minor differences in the gestational age and marital status in our responders compared with nonresponders, indicating a good overall representation of the target population. Our survey did not include open-ended questions for suggestions from patients on what would improve the telemedicine experience, which is one suggested approach to reduce bias. This was not done because of the extensive time and resources needed to further analyze this type of information. Most of the patient surveys were completed over telephone calls. Therefore, the patients may have felt the need to answer more favorably, which may be another potential bias. To minimize this bias, telephone surveys were not conducted by the provider who conducted the telemedicine visits, and some patients chose to complete the survey through the provided survey link on their own. Indeed, we assessed a large obstetrical cohort. However, we did not have adequate numbers in some of the subgroups to provide robust statistical analyses. Therefore, future studies may attempt increased numbers in some of the groups such as patients with fetal indications for MFM care to further improve this modality for their care. Finally, although this study assesses the satisfaction and implementation of TM in obstetrical care, it does not assess quality and safety. Future studies on maternal and fetal outcomes based on those included in this study may help to elucidate the safety and future of TM in obstetrical care. 

The COVID-19 pandemic initiated a rapid increase in the use of telehealth in all areas of medicine. We assessed the patient and provider satisfaction with telehealth use within a large suburban region surrounding the NYC metropolitan area from a MFM practice during the height of the COVID-19 pandemic. We found that, overall, the patients and providers were satisfied with the TM visits and the majority desired TM to be an option for future visits. We also found that the patients’ digital experiences, perception to not need physical contact, perceived time saved on travel, and access to healthcare providers significantly affected their desire for future telemedicine visits. This study highlights the need for health systems to continue to improve telehealth delivery and invest in innovative solutions to conduct physical examinations and other assessments remotely. Our MFM practice will continue to offer telehealth services moving forward to compliment in-person visits. 

