NARRATIVE/SYSTEMATIC REVIEW/META-ANALYSIS

Telehealth For Equitable Obstetric Care: Addressing Gaps For Patients, Providers, and Payers

Sabrina Movitz, MS¹; Rachel Mayer Ediger, MPH¹; Alison Dingwall, PhD, MPH¹ and Yvonne Butler Tobah, MD, FACOG²

¹The MITRE Corporation, McLean, Virginia, USA; ²The Mayo Clinic, Rochester, Minnesota, USA

Keywords: health equity, obstetrics, prenatal care, telehealth, telemedicine

Abstract

On June 2022, President Biden and Vice President Harris released their blueprint for addressing the maternal health crisis. They stated their “vision for the future is that the United States will be considered the best country in the world to have a baby.” Currently, it is one of the worst among industrialized countries despite the U.S. spending nearly double the average amount on healthcare per capita. The U.S. is amidst a maternal mortality crisis, particularly for Black and American Indian/Alaska Native pregnant people, with more than 80% of the deaths preventable. Telehealth in obstetrics has the potential to reach pregnant people who are not currently being served by the medical system and to improve rates of severe maternal morbidity and mortality; however, more research is needed to understand and monitor its equity, costs, and optimal usage. Extant research shows that telehealth can produce a small positive effect on certain obstetric health outcomes, but pregnant patients’ demographics rarely stratify these research findings. To prevent the perpetuation of existing health inequities, gaps in obstetric telehealth research will need to be addressed. Key knowledge gaps for researchers and policymakers include outcomes, access, satisfaction by patients and providers, potential time savings for patients, and health system cost savings. Implementing equitable obstetric coverage of telehealth services requires clarity from private and public payers for inter-state provisions of care, liability and risk, and service and payment parity.

 

 

COVID-19 Increases Maternal Mortality, Telehealth Usage

On June 2022, President Biden and Vice President Harris released their blueprint for addressing the maternal health crisis. They stated their “vision for the future is that the United States will be considered the best country in the world to have a baby.”¹ Currently, it is one of the worst compared to other industrialized countries, despite the U.S. spending nearly double the average on healthcare per capita.^2,3 The U.S. is amidst a maternal mortality crisis, particularly for Black and American Indian/Alaska Native pregnant people, with more than 80% of the deaths preventable.⁴ COVID-19-related deaths greatly exacerbated this crisis, increasing maternal deaths by 25%.⁵ Telehealth in obstetrics has the potential to increase access for pregnant people who are not currently being served by the medical system and to improve rates of severe maternal morbidity and mortality; however, more research is needed to understand and monitor its equity, costs, and usage.

While the first use of telehealth in a hospital setting was documented as early as the 1960s, the COVID-19 pandemic forced the healthcare system to use the technology in ways that had not been used before.^6,7 It is now clear that telehealth, in general, and, more specifically, telehealth for obstetrics, is here to stay as a permanent fixture in the healthcare system. Despite increased use, many lingering questions exist about its impact on health equity and access.

Extant research shows that telehealth has small positive effects for certain obstetric health outcomes, but these findings are rarely stratified to pregnant patients’ demographics.^8,9 While telehealth has the potential to enhance access to obstetrics, more research is needed to understand who benefits from it, when, why, and at what cost.

This article summarizes key literature, gaps, and future opportunities for researchers in several topic areas (outcomes, access, satisfaction, time savings, and cost savings) regarding equitable obstetric telehealth for patients and providers. As it pertains to this article, health equity is defined as the ability of every pregnant person to attain their highest level of health in the peri- and postpartum period. Patient testimonials from the author support some of the known outcomes regarding cost and time savings for patients in Dr. Yvonne Butler Tobah’s OB Nest randomized-control trial study in conjunction with the Mayo Clinic.^10,11

Additionally, implementing equitable obstetric telehealth requires sufficient prioritization and resources from private and public payers. As such, considerations such as inter-state provisions of care, liability and risk, and service and payment parity are also addressed.

Patients and Providers’ Research Gaps

Research on telehealth’s impact on obstetric care providers and their patients is slim. Table 1 lists a sample of open research questions given the gaps in the literature, documented in further detail below.

Table 1. Open research questions: Patients and providers

Stakeholders/Factors in Telehealth	Sample Research Questions
Providers
Time savings	Does telehealth, on average, save obstetric providers time while still enabling them to deliver quality care?
Work-life balance	Does telehealth improve OB providers’ work/life balance and/or reduce burnout?
Satisfaction	How do OB providers from different sociodemographic backgrounds feel about telehealth? How does it impact the patient-provider relationship?
Clinical patient outcomes	Does telehealth for OB care improve rates of severe maternal morbidity and mortality, particularly for Black or African American, and Indigenous pregnant people?
Health equity	Does OB telehealth increase equitable access, even for uninsured or underinsured pregnant people?
Patients
Clinical patient outcomes	Does telehealth for OB care improve rates of severe maternal morbidity and mortality, particularly for Black or African American, and Indigenous pregnant people?
Cost savings	Beyond rurality/distance, are there any other moderating variables for patient cost savings when using OB telehealth?
Patient-reported outcomes	How does patient satisfaction with OB telehealth differ by sociodemographic factors?
Trust in health care	How does patient trust with OB telehealth providers differ by sociodemographic factors? What are the drivers of patient trust when using OB telehealth?
OB: obstetrics.

Telehealth’s Impact on Maternal Mortality Rates is Unclear

Telehealth’s effect on primary maternal health outcomes (rates of severe maternal morbidity and mortality) is a significant unknown in research. Telehealth research indicates comparable health outcomes compared to in-person obstetric care, but there is less evidence that it improves them.^12,13 For pregnant patients considering telehealth, the clearest examples of primary benefits are seen when telehealth options are used for remote monitoring or connecting with patients remotely from appropriate obstetric or neonatal clinically indicated services.¹⁴ Such interventions may include programs focused on postpartum care, contraceptive counseling, or neonatal consultation during pregnancy.⁸ While limited evidence suggests improvement in reaching patients, evidence remains sparse on direct measures of severe maternal morbidity or mortality.

Telehealth options for obstetric care also seem to focus on low-risk pregnancies. Research on primary health outcomes regularly excludes patients deemed high-risk, including non-English speaking people, patients less than 18 years of age, and patients with social determinants of health risks, including inter-partner violence and substance use disorders. It is difficult to assess whether telehealth can become an effective tool for increasing access and improving clinical outcomes if research does not include a broad range of pregnancies, including those who have been historically marginalized. Research that captures whether telehealth improves rates of severe maternal morbidity and mortality is needed, especially for the most medically underserved pregnant people, if telehealth is to become more of a routine part of prenatal care.

Most of Telehealth’s Documented Impacts are on Secondary Outcomes

The most positive outcomes from obstetric telehealth research have been among secondary outcomes. Compared to in-person care, telehealth has been shown to lower rates of pregnancy stress, increase general rates of breastfeeding, increase rates of exclusive breastfeeding, increase rates of perinatal smoking cessation, lower postpartum depression, and more.^8,15–18 These secondary benefits suggest an overall improvement in health and well-being during pregnancy. Still, many more topics could be explored, such as perinatal nutrition, patients’ feelings of empowerment and efficacy, and birth experience/method. Further research into these topics will require consistent disaggregation of patient demographics in their results.

Patient Satisfaction: High With Telehealth, Less Clear for Providers

“I have a young child at home, so it’s easier for me not to always take her to daycare to come to the Clinic.”
OB Nest Patient

Patient and provider satisfaction with maternal telehealth is crucial to ensuring its utilization and access. Agnostic of specialty, there is a large body of research about patient and provider satisfaction with telehealth compared to in-person care.¹⁹ Drilling down into obstetrics, some studies on patient and provider satisfaction report improved rates of reported satisfaction, but many of these studies occurred during the pandemic and are COVID-19 specific.^20–23 Unfortunately, even within this small body of research, a limited number of studies include equity considerations or stratify patient satisfaction by sociodemographic factors. Understanding patient and provider satisfaction (or lack thereof) across a wide array of patients outside of a pandemic setting is crucial for understanding obstetric telehealth’s impact.

Telehealth’s Time Savings: Positive for Patients, Unknown for Providers

While there are several studies about telehealth’s time savings for patients receiving perinatal care, there are little to no data available for providers, regardless of specialty.^24,25 Studies focusing on time savings tend to center on patients, and any anecdotal evidence about providers primarily comes from industry outlets. Only a few surveys attempt to connect providers’ perceived workplace productivity or flexibility when using telehealth to actual time savings. These findings include many assumptions, and more research is needed to understand whether telehealth truly saves time for providers and why.

Time savings for providers is also crucial because it has implications for work-life balance, which has become especially important in a time of increasing clinician burnout and suicide.^26,27 A handful of surveys indicate improvements to clinicians’ well-being, work-life balance, and burnout symptoms due to telehealth.^28–30 However, the effect of these improvements is mediated by specialty. Those reporting positive impacts on well-being are most likely primary care physicians, whereas internal medicine, surgery, and other sub-specialties providers are the least likely. There is no research specifically about obstetric care providers and their work-life balance or time savings related to the use of telehealth.

Telehealth Cost Savings: High for Patients, Unknown for The Healthcare System

While there is more available research about the cost savings of telehealth for patients, there are little to no data available about the cost of telehealth for providers and the larger hospital system compared to in-person care.³¹ While research is starting to focus on this topic, it is limited.³² One survey of physicians from the Mayo Clinic revealed that 80% of those surveyed perceived telehealth as cost- effective. In contrast, a study from Australia revealed that telehealth did not routinely reduce the cost of care delivery compared to the in-person method.^30,33 A third study using time-driven activity-based costing revealed that a virtual sick visit during the pandemic saved the healthcare system $2.92 per visit.³⁴

Cost savings from obstetric telehealth could be inferred from some secondary measures: it has been shown that telehealth reduces the number of no-show appointments and increases patient compliance with the American College of Obstetricians and Gynecologists recommendations.^35,36 To date, however, there is no primary research to quantify these potential cost savings.

Equitable Access to Telehealth: Moderated by The Digital Divide

Who can access and benefit from obstetric telehealth has significant weight given the ongoing maternal mortality crisis in the U.S. and its disproportionate effect on Black and Indigenous pregnant people.³⁷ While telehealth has the potential to reach the pregnant patients who need it most, such as those living in rural areas, there are significant barriers in both research and implementation.³⁸ Equitable access to telehealth is significantly hindered by the fact that one-quarter of Americans do not have access to broadband internet, a social driver of health (SDOH) known as the “digital divide.”^39–41 Even when broadband internet is available, equitable access is moderated by patient comfort with the technology, broadband quality (video call vs. audio-only), and accessible accommodations. More data-driven, patient-centric research about how telehealth affects the most marginalized patient populations are needed to make obstetric care more equitable for all pregnant people.

Striving towards and achieving equity in healthcare and access goes far beyond patients and their providers. The American Medical Association, the American Hospital System, and the American College of Obstetricians and Gynecologists are just a few of the institutions that have put forth equity in telehealth statements, digital health equity resource hubs, and clinical guidance about centering patient equity in obstetrics for providers.^42–44

Insurers/Payers

Equitable telehealth implementation will require significant investment from insurers and other payers. Improvements will only succeed if there is alignment between the patients and providers of telehealth and its financing, risk, and reimbursement. Table 2 outlines a sample of open research questions for insurers and other payers.

Table 2. Open research questions for insurers and other payers

Stakeholder/Topic	Sample Research Questions
Insurers/Payers
Cost savings to health system	How does OB telehealth impact health systems financially? Does it result in cost-savings or is it simply cost-neutral?
Liability/risk	How does the medical liability and malpractice risk landscape change when providing OB care via telehealth? What are the most common sources of malpractice suits when using telehealth today? How have courts been interpreting the law considering COVID-19? What would a model look like to manage this risk more effectively in the future?
Payment parity	What are the current barriers to making national payment parity permanent if COVID-era policies are lifted?
Coverage parity	What are the current barriers to making national coverage parity permanent if COVID-era policies are lifted?
OB: obstetrics.

Fragmented Inter-State Medical Licensure

The current ability of providers to offer telehealth services varies state by state, creating a patchwork quilt of legal guidelines. Almost every state has modified its out-of-state telehealth requirements in response to COVID-19, but it is unclear how long these modifications will remain.⁴⁵ Connecticut’s law, for example, is set to expire in June 2024.⁴⁶ Thirty states and Guam are currently issuing licenses for the Interstate Medical Licensure Compact to simplify the provision of care, and the Department of Veteran’s Affairs (VA) has issued a rule that allows VA providers to teleconference with their patients anywhere in the continental U.S. indefinitely.^47,48 Given that one of the major advantages of telehealth is its ability to be accessed remotely and the fact that out-of-state licensure violations are one of the largest liability exposures for providers, more research must be done on policy frameworks for a national provision of care so that patients in all 50 U.S. states and its territories can benefit.

Telehealth Liability and Risk: Significance Unknown

Medical malpractice liability and risk is a significant gray area for providers and their insurers. Not all medical liability insurance covers telehealth by default, so providers may need to buy supplemental coverage in the case of a misdiagnosis, licensure, or other issue.⁴⁹ Analysis from 2014 to 2018 shows that 66% of malpractice claims in telehealth were related to misdiagnosis, compared to 47% for in-person claims.⁵⁰ Research that continually monitors the volume, subject, and outcomes of malpractice claims relating to telehealth can highlight areas in which policy and processes require ongoing revisions.⁵¹

Separately, cybersecurity and data privacy threats in healthcare are rising, introducing a new layer of liability.⁵² Cyber insurance, which is especially important for patient data transmitted over video, is often not included in medical liability insurance and must be purchased separately.⁵³ These varying supplemental forms of insurance create a complicated legal landscape as risk is shifted away from the individual and towards insurance companies, many of which are already operating at a loss due to increased ransomware attacks on healthcare systems.⁵² A comprehensive policy framework that harmonizes these various forms of coverage would allow providers and insurers to more clearly manage the risks associated with practicing medicine virtually while keeping their patients safe.

Service and Payment Parity: Stable for Now, Later Unclear

The onset of COVID-19 caused a rapid shift in the policy landscape of telehealth, wherein video or audio appointments were reimbursed by national payers at the same rate as in-person appointments.⁵⁴ While telehealth is emerging as a permanent fixture of the healthcare system, it is uncertain whether insurance coverage will continue to reimburse for telehealth visits and at what rate. Many states are creating coverage requirements for private payers and Medicaid, including payment parity.⁵⁵ On May 11, 2023, the Centers for Medicare and Medicaid Services (CMS) ended the COVID-19 public health emergency (PHE) status.⁵⁶ Will telehealth become widely available to all as a result of this pandemic, or will insurers decide to cover a telehealth appointment only when there is ample evidence of a condition-specific outcome for telehealthcare? Those affected by this shifting landscape will need ample research, data, and proposed policy frameworks to identify the best way forward.

Changes to Covid-19 Medicaid Policies: 2023

Most states expanded Medicaid coverage for telehealth during the COVID-19 PHE. This is important as four out of 10 births in the U.S. are financed through Medicaid, which covers people up to 60 days postpartum, leaving many birthing people without insurance coverage after the 60-day postpartum lapse.⁵⁷ Given that many severe maternal morbidity and mortality conditions occur during the postpartum period, approximately 27 states and Washington, DC, have approved extending the covered postpartum period up to 12 months.⁵⁸ During the declared COVID-19 PHE, states were eligible for enhanced federal matching of funds only if Medicaid coverage remained continuous, so many postpartum people who gave birth post-January 2020 had continuous coverage.⁵⁹ Since the end of the COVID-19 PHE, most states have opted to make permanent the once-temporary expanded telehealth coverage for Medicaid.⁶⁰ In addition, several have indicated plans for assessing telehealth quality and patient outcomes, and nearly half of all states have initiatives for addressing broadband access to mitigate telehealth challenges. HHS continues to update its telehealth guidelines regularly.⁶⁰

Does Obstetric Telehealth Miss The Mark When it Comes to Equity?

If we measure what matters, existing research is missing the mark by not consistently collecting and disaggregating patient demographics and mapping those demographics onto research results. Additionally, obstetric telehealth research often includes exclusion criteria, leading to majority-white, college-educated, low-risk participants with private insurance. This does not represent those most impacted by severe maternal morbidity and mortality.

While ongoing data suggest that telehealth services may result in several important positive impacts, including reaching patients from a distance, these benefits and research findings must be extended to include all patients, lest it widen the health equity gap. The current body of obstetric telehealth research that details—or even acknowledges—the various backgrounds of its participants is an order of magnitude smaller than obstetric telehealth research as a whole. It is past time to change this narrative. “A rising tide lifts all boats,” so designing research with a central focus on equity will allow pregnant patients, providers, and payers to improve obstetric care for all—and perhaps the larger healthcare system.⁶¹

Contributors

The author is responsible for conception through publication.

Acknowledgments

The authors recognize The MITRE Independent Research and Development Program’s collaboration with the Mayo Clinic in support of this research. In addition, the authors thank Becky Crawford, Lauren Athota, Brendan Smith, Francis Campion, and Sybil Russell from The MITRE Corporation for their review of the article.

Approved for Public Release; Distribution Unlimited. Public Release Case Number 23-1074.

References

1. White House Blueprint for addressing the maternal health crisis [Internet]. The White House: The Office of the President of the United States; 2022 [cited 2023 Sep 27]. Available from: https://www.whitehouse.gov/wp-content/uploads/2022/06/Maternal-Health-Blueprint.pdf
2. How does health spending in the U.S. compare to other countries? [Internet]. Peterson-KFF Health System Tracker; 2023 [cited 2023 Sep 28]. Available from: https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries/
3. The U.S. Maternal mortality crisis continues to worsen: an international comparison [Internet]. The Commonwealth Fund; 2022 [cited 2023 Sep 28]. Available from: https://www.commonwealthfund.org/blog/2022/us-maternal-mortality-crisis-continues-worsen-international-comparison
4. Four in 5 pregnancy-related deaths in the U.S. are preventable [Internet]. CDC Newsroom; 2022 [cited 2023 Sep 28]. Available from: https://www.cdc.gov/media/releases/2022/p0919-pregnancy-related-deaths.html
5. U. S. Government Accountability Office. Maternal health: outcomes worsened and disparities persisted during the pandemic | U.S. GAO [Internet]. Gao.gov; 2022 [cited 2023 Sep 28]. Available from: https://www.gao.gov/products/gao-23-105871
6. Nesbitt TS. The evolution of telehealth: where have we been and where are we going? [Internet]. The role of telehealth in an evolving health care environment: workshop summary. National Academies Press (U.S.); 2012 [cited 2023 Sep 28]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK207141/
7. Gao C, Malin BA, Chen Y. Telehealth uptake into primary care during the COVID-19 pandemic. Stud Health Technol Inform. 2022 Jun 6;290:1032–3. https://doi.org/10.3233/SHTI220253
8. DeNicola N, Grossman D, Marko K, Sonalkar S, Butler Tobah YS, Ganju N, et al. Telehealth interventions to improve obstetric and gynecologic health outcomes: a systematic review. Obstet Gynecol. 2020 Feb;135(2):371. https://doi.org/10.1097/AOG.0000000000003646
9. Movitz S, Mayer R, Dingwall A. Incorporating equity into maternal telehealth. Georgetown Med Rev [Internet]. 2022 Aug 31 [cited 2023 Sep 28]. Available from: https://gmr.scholasticahq.com/article/37490-incorporating-equity-into-maternal-telehealth?auth_token=BXM-DlNYGZJfJ2ffEvOA
10. Woo VG, Lundeen T, Matula S, Milstein A. Achieving higher-value obstetrical care. Am J Obstet Gynecol. 2017 Mar;216(3):250.e1–14. https://doi.org/10.1016/j.ajog.2016.12.033
11. Butler Tobah YS. OB Nest: a new vision for prenatal care—Mayo Clinic [Internet]. 2021 [cited 2023 Sep 28]. Available from: https://www.mayoclinic.org/medical-professionals/obstetrics-gynecology/news/ob-nest-a-new-vision-for-prenatal-care/mac-20509442
12. Weigel G, Frederiksen B. Telemedicine and pregnancy care [Internet]. KFF; 2020 [cited 2023 Sep 28]. Available from: https://www.kff.org/womens-health-policy/issue-brief/telemedicine-and-pregnancy-care/
13. Cantor A, Jungbauer R, Totten A, Tilden E, Holmes R, Ahmed A, et al. Telehealth strategies for the delivery of maternal health care [Internet]. Washington, DC: Patient-Centered Outcomes Research Institute (PCORI); 2022 Jul. (PCORI Evidence Synthesis). Report No.: Rapid Review No. 02 [cited 2023 Sep 27]. Available from: https://www.pcori.org/sites/default/files/PCORI-Rapid-Review-Telehealth-Strategies-for-the-Delivery-of-Maternal-Healthcare.pdf
14. Hirshberg A, Sammel MD, Srinivas SK. Text message remote monitoring reduced racial disparities in postpartum blood pressure ascertainment. Am J Obstet Gynecol. 2019 Sep 1;221(3):283–5. https://doi.org/10.1016/j.ajog.2019.05.011
15. Tobah YSB, LeBlanc A, Branda ME, Inselman JW, Morris MA, Ridgeway JL, et al. Randomized comparison of a reduced-visit prenatal care model enhanced with remote monitoring. Am J Obstet Gynecol. 2019 Dec 1;221(6):638.e1–8. https://doi.org/10.1016/j.ajog.2019.06.034
16. Hubschman-Shahar LE. Lactation telehealth in primary care: a systematic review. Breastfeed Med [Internet]. 2022 Jan 5 [cited 2023 Sep 28]. Available from: https://www.liebertpub.com/doi/10.1089/bfm.2021.0105
17. Marcucci B. Use of telehealth to increase breastfeeding exclusivity and duration. Clin Lact. 2018 May 1;9(2):66–71. https://doi.org/10.1891/2158-0782.9.2.66
18. Posmontier B, Neugebauer R, Stuart S, Chittams J, Shaughnessy R. Telephone-administered interpersonal psychotherapy by nurse-midwives for postpartum depression. J Midwifery Womens Health. 2016 Jul;61(4):456–66. https://doi.org/10.1111/jmwh.12411
19. Becevic M, Boren S, Mutrux R, Shah Z, Banerjee S. User satisfaction with telehealth: study of patients, providers, and coordinators. Health Care Manag. 2015 Dec;34(4):337. https://doi.org/10.1097/HCM.0000000000000081
20. Pflugeisen BM, Mou J. Patient satisfaction with virtual obstetric care. Matern Child Health J. 2017 Jul;21(7):1544–51. https://doi.org/10.1007/s10995-017-2284-1
21. Nelson GA, Holschuh C. Evaluation of telehealth use in prenatal care for patient and provider satisfaction: a step toward reducing barriers to care. J Nurse Pract. 2021 Apr 1;17(4):481–4. https://doi.org/10.1016/j.nurpra.2020.12.026
22. Liu CH, Goyal D, Mittal L, Erdei C. Patient satisfaction with virtual-based prenatal care: implications after the COVID-19 pandemic. Matern Child Health J. 2021;25(11):1735–43. https://doi.org/10.1007/s10995-021-03211-6
23. Wali R, Alhakami A, Alsafari N. Evaluating the level of patient satisfaction with telehealth antenatal care during the COVID-19 pandemic at King Abdul-Aziz Medical City, Primary Health Care Center, Specialized Polyclinic. Womens Health (Lond). 2022 Jun 21;18:17455057221104660. https://doi.org/10.1177/17455057221104659
24. Barbour KD, Nelson R, Esplin MS, Varner M, Clark EA. 873: a randomized trial of prenatal care using telemedicine for low-risk pregnancies: patient-related cost and time savings. Am J Obstet Gynecolo. 2017 Jan 1;216(1):S499. https://doi.org/10.1016/j.ajog.2016.11.782
25. Smith VJ, Marshall A, Lie MLS, Bidmead E, Beckwith B, Van Oudgaarden E, et al. Implementation of a fetal ultrasound telemedicine service: women’s views and family costs. BMC Pregnancy Childbirth. 2021 Jan 8;21(1):38. https://doi.org/10.1186/s12884-020-03532-4
26. Shanafelt TD, West CP, Dyrbye LN, Trockel M, Tutty M, Wang H, et al. Changes in burnout and satisfaction with work-life integration in physicians during the first 2 years of the COVID-19 pandemic. Mayo Clin Proc. 2022 Dec 1;97(12):2248–58. https://doi.org/10.1016/j.mayocp.2022.09.002
27. Kingston AM. Break the silence: physician suicide in the time of COVID-19. Mo Med. 2020;117(5):426–9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7723130/
28. deMayo R, Huang Y, Lin E-JD, Lee JA, Heggland A, Im J, et al. Associations of telehealth care delivery with pediatric health care provider well-being. Appl Clin Inform. 2022 Jan;13(1):230–41. https://doi.org/10.1055/s-0042-1742627
29. Bunnell BE, Barrera JF, Paige SR, Turner D, Welch BM. Acceptability of telemedicine features to promote its uptake in practice: a community telemental health providers survey. Int J Environ Res Public Health. 2020 Jan;17(22):8525. https://doi.org/10.3390/ijerph17228525
30. Malouff TD, TerKonda SP, Knight D, Abu Dabrh AM, Perlman AI, Munipalli B, et al. Physician satisfaction with telemedicine during the COVID-19 pandemic: the Mayo Clinic Florida experience. Mayo Clin Proc Innov Qual Outcomes. 2021 Aug 1;5(4):771–82. https://doi.org/10.1016/j.mayocpiqo.2021.06.006
31. Demaerschalk BM, Cassivi SD, Blegen RN, Borah B, Moriarty J, Gullerud R, et al. Health economic analysis of postoperative video telemedicine visits to patients’ homes. Telemed J E Health [Internet]. 2021 Jun 7 [cited 2023 Sep 28]. Available from: https://www.liebertpub.com/doi/10.1089/tmj.2020.0257
32. Thao V, Dholakia R, Kreofsky BL, Moriarty JP, Colby CE, Demaerschalk BM, et al. Modeling the cost of teleneonatology from the health system perspective. Telemed J E Health [Internet]. 2022 Oct 7 [cited 2023 Sep 28]. Available from: https://www.liebertpub.com/doi/10.1089/tmj.2021.0527
33. Snoswell CL, Taylor ML, Comans TA, Smith AC, Gray LC, Caffery LJ. Determining if telehealth can reduce health system costs: scoping review. J Med Internet Res. 2020 Oct 19;22(10):e17298. https://doi.org/10.2196/17298
34. Dooley MJ, Simpson KN, Simpson AN, Nietert PJ, Williams JD, King K, et al. A modification of time-driven activity-based costing for comparing cost of telehealth and in-person visits. Telemed J E Health [Internet]. 2022 Oct 7 [cited 2023 Sep 28]. Available from: https://www.liebertpub.com/doi/10.1089/tmj.2021.0338
35. Muppavarapu K, Saeed SA, Jones K, Hurd O, Haley V. Study of impact of telehealth use on clinic “no show” rates at an academic practice. Psychiatr Q. 2022 Jun 1;93(2):689–99. https://doi.org/10.1007/s11126-022-09983-6
36. Hirshberg A, Sammel MD, Srinivas SK. Text message remote monitoring reduced racial disparities in postpartum blood pressure ascertainment. Am J Obstet Gynecol. 2019 Sep 1;221(3):283–5. https://doi.org/10.1016/j.ajog.2019.05.011
37. Hoyert DL. Maternal mortality rates in the United States, 2020 [Internet]. 2022 [cited 2023 Sep 28]. Available from: https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2020/maternal-mortality-rates-2020.htm
38. Kozhimannil KB, Interrante JD, Henning-Smith C, Admon LK. Rural-urban differences in severe maternal morbidity and mortality in the U.S., 2007–15. Health Aff [Internet]. 2019 Dec 3 [cited 2023 Sep 28]. Available from: https://www.healthaffairs.org/doi/10.1377/hlthaff.2019.00805
39. Internet/broadband fact sheet [Internet]. Pew Research Center: Internet, Science & Tech. [cited 2023 Sep 28]. Available from: https://www.pewresearch.org/internet/fact-sheet/internet-broadband/
40. Federal Communications Commission. Advancing broadband connectivity as a social determinant of health [Internet]. [cited 2023 Sep 28]. Available from: https://www.fcc.gov/health/SDOH
41. Eyrich NW, Andino JJ, Fessell DP. Bridging the digital divide to avoid leaving the most vulnerable behind. JAMA Surg. 2021 Aug 1;156(8):703–4. https://doi.org/10.1001/jamasurg.2021.1143
42. Equity in telehealth: taking key steps forward [Internet]. American Medical Association; 2022 [cited 2023 Sep 27]. Available from: https://www.ama-assn.org/system/files/issue-brief-equity-in-telehealth.pdf
43. Digital Health Equity | AHA [Internet]. American Hospital Association. [cited 2023 Sep 28]. Available from: https://www.aha.org/digitalequity
44. Equity-Focused Clinical Guidance and Policies [Internet]. American College of Gynecologists and Obstetricians. [cited 2023 Sep 28]. Available from: https://www.acog.org/about/diversity-equity-and-inclusive-excellence/clinical-guidance-and-policies
45. Licensure [Internet]. Telehealth.HHS.gov. [cited 2023 Sep 28]. Available from: https://telehealth.hhs.gov/licensure
46. State Telehealth Policies for Cross-State Licensing [Internet]. The Center for Connected Health Policy. [cited 2023 Sep 28]. Available from: https://www.cchpca.org/topic/cross-state-licensing-professional-requirements/
47. Compact State Map [Internet]. Interstate Medical Licensure Compact. [cited 2023 Sep 28]. Available from: https://www.imlcc.org/participating-states/
48. VA Expands Telehealth by allowing health care providers to treat patients across state lines—VA News [Internet]. 2019 [cited 2023 Sep 28]. Available from: https://news.va.gov/press-room/va-expands-telehealth-by-allowing-health-care-providers-to-treat-patients-across-state-lines/
49. Legal considerations [Internet]. Telehealth.HHS.gov. [cited 2023 Sep 28]. Available from: https://telehealth.hhs.gov/providers/legal-considerations
50. Uptick in telehealth reveals medical malpractice concerns [Internet]. Bloomberg Law. [cited 2023 Sep 28]. Available from: https://news.bloomberglaw.com/health-law-and-business/uptick-in-telehealth-reveals-medical-malpractice-concerns
51. Rowland SP, Fitzgerald JE, Lungren M, Lee E (Hsieh), Harned Z, McGregor AH. Digital health technology-specific risks for medical malpractice liability. NPJ Digit Med. 2022 Oct 20;5:157. https://doi.org/10.1038/s41746-022-00698-3
52. Lamb T, Parker M. Cyber insurance—from risk transference to organizational insurance [Internet]. Health and Human Services; 2021. (The 405(d) Post). Report No.: XVI [cited 2023 Sep 27]. Available from: https://405d.hhs.gov/Documents/405d-post-volxvi-2022-may.pdf
53. Physician cybersecurity [Internet]. American Medical Association; 2023 [cited 2023 Sep 28]. Available from: https://www.ama-assn.org/practice-management/sustainability/physician-cybersecurity
54. Billing for telehealth [Internet]. Telehealth.HHS.gov. [cited 2023 Sep 28]. Available from: https://telehealth.hhs.gov/providers/billing-and-reimbursement
55. Policy Research [Internet]. National Conference of State Legislatures. [cited 2023 Sep 28]. Available from: https://www.ncsl.org/research/health/state-coverage-for-telehealth-services
56. Moving forward after the COVID-19 public health emergency | CMS [Internet]. Centers for Medicare and Medicaid Services. [cited 2023 Sep 29]. Available from: https://www.cms.gov/priorities/health-equity/minority-health/resource-center/moving-forward-after-covid-19-public-health-emergency
57. Martin J, Hamilton B, Osterman M, Driscoll A. Births: final data for 2019 [Internet]. Centers for Disease Control and Prevention; 2021 Mar. (National Vital Statistics Reports). Report No.: Volume 70, Number 2 [cited 2023 Sep 27]. Available from: https://www.cdc.gov/nchs/data/nvsr/nvsr70/nvsr70-02-508.pdf
58. Medicaid Postpartum Coverage Extension Tracker | KFF [Internet]. KFF; 2023 [cited 2023 Sep 28]. Available from: https://www.kff.org/medicaid/issue-brief/medicaid-postpartum-coverage-extension-tracker/
59. Musumeci M. Key questions about the new increase in federal medicaid matching funds for COVID-19 [Internet]. KFF; 2020 [cited 2023 Sep 28]. Available from: https://www.kff.org/coronavirus-covid-19/issue-brief/key-questions-about-the-new-increase-in-federal-medicaid-matching-funds-for-covid-19/
60. Hinton E, Raphael J, Haldar S, Gifford K, Lashbrook A, Nardone M, et al. How the pandemic continues to shape medicaid priorities: results from an annual medicaid budget survey for state fiscal years 2022 and 2023—Telehealth—10030 [Internet]. KFF; 2022 [cited 2023 Sep 28]. Available from: https://www.kff.org/report-section/medicaid-budget-survey-for-state-fiscal-years-2022-and-2023-telehealth/
61. Telehealth policy changes after the COVID-19 public health emergency [Internet]. Telehealth.HHS.gov. [cited 2023 Sep 28]. Available from: https://telehealth.hhs.gov/providers/telehealth-policy/policy-changes-after-the-covid-19-public-health-emergency

Copyright Ownership: This is an open-access article distributed in accordance with the Creative Commons Attribution Non-Commercial (CC BY-NC 4.0) license, which permits others to distribute, adapt, enhance this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0.