Feasibility of offering medical abortions by video telemedicine: two years experience. Ellen R Wiebe MD 1,2, Cheryl Couldwell 2 University of British Columbia1, Willow Women’s Clinic2, Vancouver, BC Willow Women’s Clinic BACKGROUND PROBLEMS WE SOLVED There are four possible models when providing telemedicine abortions: Clinic-to-clinic. In the model developed by Planned Parenthood in Iowa a woman presents to an outlying Planned Parenthood clinic that does not have a physician on site [1]. A trained member of staff at the outlying clinic takes a medical history and performs an ultrasound, which is then uploaded to a secure server. The staff member also provides information and obtains informed consent. The physician located at another clinic then reviews the history and ultrasound and then has a video conference with the woman using an encrypted internet connection. A tele-pharmacy system allows a physician to enter a code to open a locked drawer in the remote clinic that has been preloaded with individual doses of mifepristone and misoprostol. Clinic-to-woman at home: This model is used by our free-standing urban abortion clinic in Vancouver, Canada [2] and described in this poster. Internet and email. The online non-profit project Women on Web was set up in 2006 with the aim of increasing access to safe abortions [3]. The website (www.womenonweb.org) refers women to a doctor online who can provide them with a medical abortion using the combined regimen of mifepristone and misoprostol, provided they fill in the online consultation form and meet the specified eligibility criteria. Women who reside in countries without access to safe abortion, are up to nine weeks pregnant, wish to terminate their pregnancy and have no contraindications receive the medication and a pregnancy test by mail or courier. Women are advised to have an ultrasound examination before treatment to determine gestational length. Three weeks following treatment, women are advised to do a urine pregnancy test, have an ultrasound examination performed or visit a doctor to confirm that the abortion is complete. In over 4,000 cases, the follow-up rate was 50-60%; 0.9% reported a continuing pregnancy (failure) and 12.3% reported a surgical aspiration. Internet website only. In 2002, Ibis Reproductive Health and the Office of Population Research at Princeton University jointly developed a multilingual web site dedicated to information about medication abortion: www.medicationabortion.com [4]. In 12 months during 2004-5, the site received more than 78,000 visits and nearly 240,000 page requests in four languages. About one third of the Spanish language site visits included the misoprostol only regimen, indicating that women in Latin American countries, where abortion is restricted and self-induced abortions using misoprostol are common, may be using this site to get the information they require. Other websites with accurate information on medical abortion are also available online, including www.womenonweb.com and www.medicalabortionconsortium.org. Billing/licensing/insurance: We had discussions with our third party payer about billing codes, etc. We met with our licensing authority to discuss the program. We talked to our malpractice insurer. Everyone was satisfied with the results of the discussions. Technical: Although we have wireless internet throughout the clinic, we found it could not be upgraded adequately, so we need to use wired connections and sign in and out of Skype. We had hoped to have an iPad move through the clinic just like a patient, but that didn’t work well enough. We had to upgrade our audio on several computers. Booking/clinic flow: We book them on the daily schedule (in a different color) and our office staff call them by telephone and check their Skype connections before the appointment time. The doctor or counselor just comes into the room and the patient is on the screen ready to talk. Colleagues: We needed to have some chats with our rural colleagues who were upset with our urgent ultrasound requisitions or just curious. Rh negative women: These are dealt with individually. We have arranged for anti-D to be given by a local family doctor or hospital and have had women sign consents to not receive anti-D if they plan no further pregnancies. RESULTS Age (years) Distance (hours) gest age (days) Dating US Rh status F/U Outcome 1 35 5 42 yes pos TM Completed 1 week 2 24 6 no Neg phone Spont abortion 3 28 46 More miso, complete week 2 4 51 Pos 31 49 40 No f/u 7 8 25 10 9 26 44 27 36 11 34 37 Surgical completion 12 13 14 15 38 16 23 47 17 neg 18 19 20 21 43 Completed 2 weeks (no extra meds) 22 DISCUSSION The main innovation in this program is that we are seeing patients in their own homes using their own technology (a computer or smart phone) and yet providing the same physician and counseling services as we do in our clinic. This method of providing telemedicine abortions is feasible in our setting. The feedback we have had from the women who used our service is very positive. Each one was so grateful to be able to get a medical abortion and not need to travel. On the other hand, very few eligible women use this service; most prefer to travel. Many women may not be aware of the service or prefer surgery. OUR PROGRAM Our clinic provides medical abortions in person and also uses video-conferencing for women who cannot easily travel to the clinic. Since mifepristone is not registered in Canada, medical abortions are provided with methotrexate and misoprostol [5]. To be eligible, the women must live in British Columbia (where the physicians are licensed), have access to a laboratory for timely serum quantitative β-hCG estimations and be able to travel to the clinic or to another community for surgical completion, if necessary. They see a physician and counsellor by Skype video-conferencing for eligibility screening, information and consent. They go to a local laboratory for a baseline hCG test, then have repeat hCG tests on the day of the medication and one week later. If the initial hCG is greater than 5000 IU/L, an ultrasound is booked at a local facility. The medicines are couriered or a prescription is faxed to a local pharmacy. In a follow-up visit by Skype, a physician discusses the woman’s reaction to the medication and her blood test results. If the hCG level has fallen by 80% in one week, she is told that the abortion is complete, and she needs no further follow-up. If she needs more medication, surgery or further blood tests, these are arranged. CONCLUSION Telemedicine can improve access to abortion. This clinic-to-woman model, using video-conferencing, is feasible but used infrequently. REFERENCES RESULTS Grossman D, Grindlay K, Buchacker T, Lane K, Blanchard K. Effectiveness and acceptability of medical abortion provided through telemedicine. Obstet Gynecol. 2011;118:296-303. Wiebe ER., Use of telemedicine for providing medical abortion, International Journal of Gynecology and Obstetrics (2013), doi: 10.1016/j.ijgo.2013.07.0389. Gomperts R, Petow SA, Jelinska K, Steen L, Gemzell-Danielsson K, Kleiverda G. Regional differences in surgical intervention following medical termination of pregnancy provided by telemedicine. Acta Obstet Gynecol Scand. 2012;91:226-31. Foster AM, Wynn LL, Trussell J. Evidence of global demand for medication abortion information: An analysis of www.medicationabortion.com. Contraception 2013 (in press). doi:10.1016/j.contraception.2013.05.005. Wiebe E, Dunn S, Guilbert E, Jacot F, Lugtig L. Comparison of abortions induced by methotrexate or mifepristone followed by misoprostol. Obstet Gynecol. 2002 May;99(5 Pt 1):813-9 From May 2012 to May 2014, we saw 22 medication abortion women by Skype (Table 1). One woman miscarried (5%); one required surgical completion (5%) and the others aborted uneventfully. One was lost to follow-up (5%). During the same 2 years, 66 women were seen in clinic for the first visit and booked for telemedicine follow-up. One was lost to follow-up (1.5%), three had surgery (5.0%) and 12 (18.2%) needed another follow-up visit (more misoprostol or another HCG). During the same time, we saw about 3200 women for the usual in-clinic medical abortion visits.