Telehealth and mail-order abortion possible in some states during pandemic
During the coronavirus pandemic, an increasing number of patients have turned to telehealth. But those who needed abortions still had to travel to clinics for care – even when it comes to medication abortions, which consist of taking a few pills.
This is due in part to U.S. Food and Drug Administration regulations, which require mifepristone, one of the medications used in abortion, to be dispensed at a clinic, hospital or medical office.
On Monday, a Maryland judge issued an injunction blocking these in-person requirements during the COVID-19 crisis:
"The federal government’s general acknowledgment of the difficulty of traveling to medical offices as reflected in its waiver of several in-person requirements, the challenges caused by medical office closures and limited capacity, the heightened health risk that many abortion patients face due to demographic characteristics, the particularized risk and challenges associated with transportation to get to such offices, the greater difficulty of securing childcare under present conditions, and the impact of the economic downturn on the ability of patients to secure transportation and childcare combine to render an in-person visit to pick up medication and sign forms particularly burdensome and dangerous during the pandemic."
So wrote U.S. District Judge for the District of Maryland Theodore Chuang in his opinion, which found the requirements to be a "substantial obstacle."
Advocates noted in the lawsuit that abortion restrictions have worked in tandem with the effects of the coronavirus to disproportionately impact patients of color, low-income people and other already vulnerable populations.
"We’ve seen the undue burden and hardship these restrictions create during COVID-19, especially in communities hit hardest by the pandemic," said Skye Perryman, chief legal officer at the American College of Obstetricians and Gynecologists, which was a coplaintiff in the case.
Studies have shown that although mifepristone's safety record is superior to that of penicillin, it is more heavily restricted than opioids such as fentanyl. Mifepristone, in combination with misoprostol, is FDA-approved for abortions up to ten weeks' gestation.
"The COVID-19 pandemic has shown how telehealth can, if implemented properly, allow clinicians to deliver high-quality care to their patients," Perryman continued, pointing to ACOG's resources for members on telehealth best practices. "Receiving reproductive health care, including early pregnancy termination care, through telehealth is no different."
Abortion providers told Healthcare IT News that they had already shifted much of their practice over to telehealth in the interest of patient safety. But this latest ruling means that many patients won't have to come into the office at all, they said.
"We were already doing much of the education and screening via some sort of telehealth platform," said Dr. Colleen McNicholas, the chief medical officer at Planned Parenthood of the St. Louis Region and Southwest Missouri.
Although Missouri is one of the 18 states with laws that require an abortion provider to be physically present – thereby eliminating telemedicine abortion as an option, even with the latest ruling – neighboring Illinois is not.
There, McNicholas explained, "now we can mail you your medication and help keep you safe" from potentially contracting coronavirus.
As with other healthcare specialties, McNicholas acknowledged that not every case is right for telehealth. Patients are initially evaluated via the clinic's InTouch platform to determine whether they need additional in-person testing, such as an ultrasound or a blood test.
For qualifying patients, McNicholas said, providers at the Illinois clinic are "operationalizing an overnight mailing system so folks can have their pill the next day."
The vast majority of patients choose to have their follow-up virtually, said McNicholas, although they do have the option to visit a health center in person.
Of course, the ruling doesn't remove all barriers to abortion via telemedicine. Some states have laws requiring patients to view ultrasounds, for example, which would mean an in-person visit regardless. And abortion's price tag isn't always covered by insurance, which could put it out of reach financially.
As Dr. Jacquelyn Yeh from Physicians from Reproductive Health pointed out, "there are still obstacles in abortion care for patients."
Yeh, who practices in Seattle, said telemedicine itself has its hurdles. In addition to technological constraints, like smartphone, laptop or broadband access, she pointed out that the at-home environment isn't always ideal for telehealth.
"They might have kids running around," she said, noting that many who seek abortion are already parents. "Patients may not feel the most comfortable."
Yeh's clinic has not yet begun providing abortion medication via telehealth, but provides other reproductive health services virtually. In doing so, it has faced the somewhat typical hiccups that come from implementing a telehealth program, such as a delayed integration of its video platform with its electronic health record system.
"I've had times where I'm like, 'I'm in a Zoom room, you're in a Zoom room and we don't see each other,'" Yeh said.
Given the potentially sensitive nature of reproductive health in particular, Yeh said telemedicine can present unique challenges.
"You don't have that physical communication you can rely on," she explained. "We don't know going in what support [patients] have."
Still, this week's ruling represents a great opportunity during the pandemic, when coronavirus numbers are starting to creep up again, she said, noting that in eastern Washington, patients might have to travel two to three hours to get an abortion in person.
"We also know that COVID is surging in Washington!" she said. "So you're asking people to travel," potentially exposing themselves to coronavirus for medications that could feasibly be available online.
The preliminary injunction is only in effect during the public health emergency, but ACOG's Perryman said the organization has been pushing to end the regulations more broadly.
"ACOG and the broader medical community have been advocating for the end to these burdensome restrictions for several years, and we will continue to do so," said Perryman.
"Even outside of the COVID-19 pandemic, in-person dispensing requirements represent an undue burden to women. They disproportionately negatively impact communities and people who experience structural and inequitable barriers to care," she said.
Kat Jercich is senior editor of Healthcare IT News.
Healthcare IT News is a HIMSS Media publication.