By Carol M. Ostrom
The Seattle Times.
“Isn’t there an app for that?”
Turns out there is, if what you’re after is birth control or a test for a sexually transmitted infection.
In the latest example of fast-growing “telemedicine,” video conferencing that virtually extends medical expertise, Planned Parenthood is rolling out a pilot project for real-time “office visits” that bring patient and medical provider face to face on a smartphone, tablet or personal computer.
Fueling the Planned Parenthood Care project, under way in Washington and Minnesota, is a “horrible statistic,” says Chris Charbonneau, president and CEO of Planned Parenthood of the Great Northwest: “People are sexually active for six to nine months before they get a really reliable birth-control method.”
One result: an estimated 52,500 unintended pregnancies in Washington in 2010, according to the state Department of Health.
Combine that with the prevalence of chlamydia, the most commonly reported sexually transmitted infection (STI) in the U.S., and gonorrhea — both primarily affecting people ages 15 to 24 — and Planned Parenthood hatched a plan to meet young people where they live: on their phones and mobile devices.
For now, the virtual visits create a streamlined process for getting mail-order birth control — and soon, test kits for two common sexually transmitted infections.
Along with convenience, the virtual visits provide a technological answer to this question, Charbonneau says: “How do we see people who either can’t or have difficulty walking into bricks-and-mortar sites, to at least get them started on birth control” or begin investigating a potential sexually transmitted infection?
The national Planned Parenthood organization chose Washington as one of the first states for the project because of its long history of support for women’s reproductive rights and its strong local chapter, according to the local organization.
Planned Parenthood hopes the project will expand next to Alaska and eventually go nationwide. Obstacles include state laws — and possibly some controversy in the wake of a telemedicine controversy in Iowa.
Here’s how the virtual visit works: Download a “Planned Parenthood Care” app for an Apple or Android device, or go to plannedparenthood.org and fill in state of residence.
A Washington resident will get another screen, fill out some forms and be invited to an “office visit” with a medical provider — in this case, a nurse practitioner.
“You find yourself in a face-to-face visit,” Charbonneau says. “You can see her and she can see you. It’s like going to your doctor, except you’re not breathing the same air.”
The visit costs $45, and for now, the patient also will pay for the pills, patches or ring, and for test kits when those become available. Insurance coverage is in the works, Charbonneau says.
Patients who test positive for chlamydia will be sent pills; those who test positive for gonorrhea will be urged to come in for injections. Patients who report symptoms that could be something else will be told they need an in-person exam.
For now, shipping logistics have stalled Planned Parenthood’s desire to offer emergency contraception such as Plan B (“morning-after” pill), because the pills must be taken soon after intercourse to be effective.
The virtual-office-visit idea was more than two years in the making. Hurdles included privacy, technology, legal issues, payments, making sure STI test kits could survive temperature extremes, crafting foolproof instructions — and questions.
For example: Don’t doctors need patients’ medical histories, and don’t patients need pelvic exams?
“You remember back in the day, we thought we needed a pelvic exam and 37 other things in order to get birth-control pills,” Charbonneau says. “It turns out that the perfect was the enemy of the good there.”
All it really did was convince a lot of women that birth control had something to do with having a pelvic exam, she says. In fact, the only relevant test is blood pressure to make sure it’s not high, she says, a number the medical provider will ask for.
In most communities, blood-pressure readings are available at drugstores and community centers.
“When we actually took ourselves through the discipline of figuring out exactly what’s safe and what’s not safe, in the bricks-and-mortar world we decided long ago we didn’t have to do a pelvic exam,” Charbonneau says, and it didn’t make sense to add requirements for the online world.
In terms of medical history, she says, think about what happens in most offices: Patients self-report their medical history.
What about making sure the patient isn’t pregnant?
Same drill: Patients self-report the date of their last menstrual period, as they would in an office. In any case, none of the birth-control methods dispensed would affect an existing pregnancy, Charbonneau notes.
Washington nursing laws and rules don’t have any language about “telehealth” visits, said Deborah Carlson, nurse-practice adviser to the state’s Nursing Care Quality Assurance Commission.
Under state law, Carlson noted, anyone of any age can obtain birth control without a parent’s consent; those under 14 must have parental consent for STI testing or treatment.
Most issues surrounding telemedicine center on payments or rules for preventing out-of-state practitioners from “seeing” Washington patients.
But in the last legislative session, a broadly supported measure to allow insurance billing and reimbursements for telemedicine consultations was derailed after Dr. Patricia O’Halloran, a Tacoma internist, raised the specter of “webcam abortions” for patients who had “never seen any physician.”
O’Halloran was referring to an ongoing legal case in Iowa, where the medical board last year banned Planned Parenthood from using a webcam visit to dispense the abortion drug RU-486 to patients.
Charbonneau notes that for a patient to receive either a surgical or chemical abortion, the national standard of care dictates she must receive a pelvic exam and an ultrasound.
But Iowa’s law, unlike Washington’s, requires a doctor to physically hand the drug to the patient. So Planned Parenthood in Iowa devised a system in which its doctors in major cities could remotely dispense the drug to patients in outlying clinics through a webcam and mechanical setup that opens a drawer and releases the pills.
Charbonneau says the two situations are very different. In Washington, medical providers other than doctors are allowed to dispense the drug, so there would be no need for a webcam system.
“We will never be sending people we have never touched RU-486,” she says. “There aren’t any phone apps for ultrasounds.”
On Tuesday, the Iowa Supreme Court stopped the medical board from enforcing the ban, but the case will continue.
RU-486, which ends an early-term pregnancy, differs from the emergency contraception “morning-after pill” that Planned Parenthood in Washington hopes to be able to dispense through virtual office visits.
According to scientific investigation, the morning-after pill interrupts ovulation and slows sperm so there is never a fertilized egg.
But some anti-abortion activists still believe emergency contraception can prevent a fertilized egg from implanting, and consider that to be an abortion.
Some activists also worry that webcam visits, though solely for birth control, may ultimately lead to more abortions.
“We know how these things start,” says Dan Kennedy, CEO of Human Life of Washington. “Who is honestly going to believe that’s as far as it goes?”
O’Halloran says that for a teen, having an STI test kit available by mail might tempt some with infections to delay necessary examinations.
And although she says telemedicine can be useful after a doctor-patient relationship is established — for example, for follow-up visits with mental-health patients — in this case, she thinks they shortcut a crucial step.
“It strikes me as a real disservice to young girls and women to deny them the benefits of an in-person history and physical exam by a doctor before they’re potentially prescribed hormonal pills, patches or rings.”
Kennedy agrees. “There should be a primary physician who knows the background, the family background and health, and can have a more intimate relationship with the patient. You can’t have much of a relationship over telemedicine.”
For Charbonneau, it’s back to that ‘perfect-is-the-enemy-of-the-good’ equation, and that statistic about the months of sexual activity without effective contraception.
“We have to ask ourselves: Do we really need to make getting birth control and disease screening harder than it already is?” she says.
And as far as the doctor-patient relationship goes, for 85 percent of Washington’s Planned Parenthood patients, she says, “Planned Parenthood is their primary-care doctor.”
Telemedicine, she predicts, will help bridge physical distance in many ways — measuring heart rates, testing blood sugar, monitoring from afar. “Some people are calling it the ‘nurse in your purse,'” she says, and contraception is a natural fit.
“We set about trying to figure out what would be legal, what would be possible, what is good care. We feel like we wrapped that all up in a bow in Planned Parenthood Care.”
