Telemedicine in Urban and Suburban Childcare and Elementary Schools Lightens Family Burdens

Increasing Utilization of an In-Home Remote Exam Device in a Complex Care Center

BACKGROUND

The use of telehealth and remote exam devices for children with medical complexity (CMC) allows providers to engage with CMC in their home environment and alleviate caregiver burdens with in-person visits. The authors' objective was to increase the percentage of telehealth visits in which a remote exam device was used in a complex care center from 0% to 50% over a six-month period.

METHODS

This improvement work targeted a pediatric complex care center. The multidisciplinary quality improvement team developed key drivers to design Plan-Do-Study-Act cycles. Key drivers included access to device, timely identification of patients with devices, ease of connection, strong provider coaching, and caregivers and providers who were knowledgeable and motivated in using the device. Interventions focused on increasing distribution of devices, streamlining the scheduling process, establishing a device registry, education for caregivers and providers on using the device successfully, translating materials into common languages, and providing remote Internet connections. The primary outcome measure was the percentage of telehealth visits completed using the remote exam device. The researchers also tracked the number of devices distributed. The active intervention period was June 2021 to December 2021, with continued data collection through April 2022.

RESULTS

The median percentage of telehealth visits using the remote exam device increased from 0% to 43% over the intervention period with non-special cause variation in device utilization in the subsequent four months. The most impactful intervention focused on increasing device distribution.

CONCLUSION

Quality improvement methods were used to increase the utilization of an in-home remote exam device for CMC.

Usability and Feasibility of an in-Home Remote Exam Device in Children with Medical Complexity During the COVID-19 Pandemic

Background: Children with medical complexity (CMC) account for high health care utilization. Telemedicine holds significant potential in CMC, as it allows a provider to engage with CMC in their home environment and can alleviate both financial and transportation burdens. Remote exam devices that enable the performance of a physical exam could expand the ability of providers to clinically assess CMC during a telemedicine visit. In this pilot study, our goal was to develop a process for integrating an in-home remote exam device into a complex care clinic during the COVID-19 pandemic and evaluate the usability and feasibility of this device. Methods: The remote exam device was distributed to caregivers of CMC cared for at a complex care outpatient center. Using deliberate practice framework, our onboarding process provided opportunities for caregivers and providers to learn how to utilize the device. Surveys examining usability and feasibility were administered to both caregivers and providers after each telemedicine encounter. Results: A total of 43 caregivers participated in the onboarding process, which included a total of 83 practice visits. The remote exam device was rated as having excellent usability by caregivers; however, providers rated the device as having lower usability. Feasibility was notable for technology issues contributing to 15% of encounters being cancelled or ending early. Conclusions: The remote exam device was successfully integrated into a complex care clinic. Data from this pilot study supports the usability and feasibility of deploying a remote exam device across a telemedicine platform in a busy and complex outpatient academic practice.

Assessing the potential for virtualizable care in the pediatric emergency department

INTRODUCTION

There is increasing interest for patient-to-provider telemedicine in pediatric acute care. The suitability of telemedicine (virtualizability) for visits in this setting has not been formally assessed. We estimated the proportion of in-person pediatric emergency department (PED) visits that were potentially virtualizable, and identified factors associated with virtualizable care.

METHODS

This was a retrospective analysis of in-person visits at the PED of a Canadian tertiary pediatric hospital (02/2018-12/2019). Three definitions of virtualizable care were developed: (1) a definition based on "resource use" classifying visits as virtualizable if they resulted in a home discharge, no diagnostic testing, and no return visit within 72 h; (2) a "diagnostic definition" based on primary ED diagnosis; and (3) a stringent "combined definition" by which visits were classified as virtualizable if they met both the resource use and diagnostic definitions. Multivariable logistic regression was used to identify factors associated with telemedicine suitability.

RESULTS

There were 130,535 eligible visits from 80,727 individual patients during the study period. Using the most stringent combined definition of telemedicine suitability, 37.9% (95% confidence interval (CI) 37.6%-38.2%) of in-person visits were virtualizable. Overnight visits (adjusted odds ratio (aOR) 1.16-1.37), non-Canadian citizenship (aOR 1.10-1.18), ethnocultural vulnerability (aOR 1.14-1.22), and a consultation for head trauma (aOR 3.50-4.60) were associated with higher telemedicine suitability across definitions.

DISCUSSION

There is a high potential for patient-to-provider telemedicine in the PED setting. Local patient and visit-level characteristics must be considered in the design of safe and inclusive telemedicine models for pediatric acute care.

Analysis of a model for pediatric physical therapy and clinical education via telehealth

A novel entry-level collaborative clinical learning experience (CLE) in pediatric physical therapy (PT) delivered via telehealth was implemented involving 12 families, 54 DPT students, and 12 clinical instructors (CIs). Children of various ages, a wide range of home environments, and diagnoses received individualized PT via telehealth during a four-week CLE. Retrospective quantitative and qualitative analyses of student documentation, video recordings of sessions, and CI, student, and caregiver survey responses were performed. All children demonstrated qualitative improvements and 73% demonstrated quantitative improvements. CIs, students, and caregivers believed the children benefited from the experience and 98% believed the children were able to work toward their goals. Most students (95%) and CIs (100%) felt that it was a valuable and effective learning experience. Most (>71%) CIs and students believed students were able to learn in all relevant domains of the clinical performance instrument. This model provides a unique CLE for students in both pediatric PT and telehealth.

Comparison of patient responses to telehealth satisfaction surveys in rural and urban populations in Queensland

Objective Telehealth has for many years been identified as a potential contributor to reducing healthcare access inequality. For these benefits to be realised, patients must be accepting and satisfied with the delivery of healthcare in this manner. Measuring patient satisfaction across a large geographical area is important to ensure that investments in telehealth are delivering the benefits that are intended. Methods A brief survey was automatically issued on completion of a patient's telehealth appointment, requesting patient feedback on their experience and information on the location of where they participated in the appointment. These results were compared to an article review which sought examples of other patient satisfaction measures that compared rural and urban populations. Results No significant correlations between survey responses and established demographic indices were found. When stratified by the Modified Monash Model band from which the patient participated in their telehealth appointment from, an ANOVA test determined that rurality was not a predictor of survey response. A review of articles found four articles that compared rural and urban satisfaction responses. Conclusion No evidence of a patient's location influencing their satisfaction with telehealth was observed. This may be attributed to a variety of technical improvements introduced over the past 5-10 years that have made participating in telehealth appointments less technically demanding and more accessible. Telehealth is likely to be contributing to a reduction in healthcare access inequality in Queensland.

The role of telehealth in pediatric emergency care

In 2006, the Institute of Medicine published a report titled "Emergency Care for Children: Growing Pains," in which it described pediatric emergency care as uneven at best. Since then, telehealth has emerged as one of the great equalizers in care of children, particularly for those in rural and underresourced communities. Clinicians in these settings may lack pediatric-specific specialization or experience in caring for critically ill or injured children. Telehealth consultation can provide timely and safe management for many medical problems in children and can prevent many unnecessary and often long transport to a pediatric center while avoiding delays in care, especially for time-sensitive and acute interventions. Telehealth is an important component of pediatric readiness of hospitals and is a valuable tool in facilitating health care access in low resourced and critical access areas. This paper provides an overview of meaningful applications of telehealth programs in pediatric emergency medicine, discusses the impact of the COVID-19 pandemic on these services, and highlights challenges in setting up, adopting, and maintaining telehealth services.

Examining perceptions of a telemedicine network for pediatric emergency medicine: a mixed-methods pilot study

Background

Use of telemedicine for healthcare delivery in the emergency department can increase access to specialized care for pediatric patients without direct access to a children's hospital. Currently, telemedicine is underused in this setting.

Objectives

This pilot research project aimed to evaluate the perceived effectiveness of a telemedicine program in delivering care to critically ill pediatric patients in the emergency department by exploring the experiences of parents/caregivers and physicians.

Methods

Sequential explanatory mixed methods were employed, in which quantitative methods of inquiry were followed by qualitative methods. Data were collected through a post-used survey for physicians, followed by semi-structured interviews with physicians and parents/guardians of children treated through the program. Descriptive statistics were used to analyze the survey data. Reflexive thematic analysis was used to analyze interview data.

Results

The findings describe positive perceptions of telemedicine for emergency department pediatric care, as well as barriers and facilitators to its use. The research also discusses implications for practice and recommendations for overcoming barriers and supporting facilitators when implementing telemedicine programming.

Conclusion

The findings suggest that a telemedicine program has utility and acceptance among parents/caregivers and physicians for the treatment of critically ill pediatric patients in the emergency department. Benefits recognized and valued by both parents/caregivers and physicians include rapid connection to sub-specialized care and enhanced communication between remote and local physicians. Sample size and response rate are key limitations of the study.

Use of Telemedicine in Pediatric Ophthalmology in the Underserved Population

Access to pediatric eye care is critical in diagnosing and treating eye disease promptly to prevent visual impairment. The demand for pediatric ophthalmology is high, even in developed countries, and significant socioeconomic disparities exist in access to care. The purpose of this article is to summarize the current literature on the use of telemedicine in pediatric ophthalmology in the underserved population and to identify areas of opportunity. A detailed literature review was performed in PubMed and Google Scholar on October 1, 2021. All articles in English that described the use of telemedicine in pediatric ophthalmology, with particular attention to the underserved pediatric population, were included. There is a paucity of literature on the visual outcomes from pediatric teleophthalmology alone, and even less in underserved populations specifically. Literature supports its use in subacute to chronic eye disease, return and postoperative visits, and screening for retinopathy in prematurity in particular. Collaboration between pediatric optometrists and pediatric ophthalmologists for both asynchronous and synchronous care delivery models has shown promise in several studies. It is essential to operate within the limits of pediatric teleophthalmology and utilize this valuable service for its strengths. Telemedicine may expand access to pediatric ophthalmologists in underserved populations and may reduce the burden of eye disease.

Understanding Drivers of Telemedicine in Pediatric Medical Care

Purpose: As the demand for telemedicine services continues, greater knowledge about health care delivery preferences can inform high quality, efficient care. The present study sought to evaluate patient and family characteristics that may influence telemedicine utilization, particularly the choice between telephone and video telemedicine visits. Methods: This is a single-site cross-sectional, mixed methods study aimed at identifying factors associated with use of telephone and video telemedicine visits with pediatric patients and their families. Results: Seven hundred seventy-five (n = 775) caregivers completed a survey and 22 caregivers participated in follow-up focus groups and interviews. Findings indicate that female caregivers, those with higher education levels, and those with experience with technology were more likely to choose video telemedicine visits. Qualitative feedback provided several valuable recommendations based on patient/family experiences, which fell into four categories, including scheduling, accessibility, treatment resources, and care coordination. Conclusion: Findings demonstrate that previous experience, familiarity, and technology access may be important drivers in health care modality preference. Key elements that emerged relevant to user satisfaction and overall quality of the telemedicine experience: caregiver choice on visit type (telemedicine vs. in-person), child health care needs, and telemedicine education/training. As society moves toward pay-per-performance and value-based reimbursement, it is imperative that we focus on experience, health care needs, and training to improve patient experience and lower health care costs.

Closing Disparities in Pediatric Diabetes Telehealth Care: Lessons From Telehealth Necessity During the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic necessitated using telehealth to bridge the clinical gap, but could increase health disparities. This article reports on a chart review of diabetes telehealth visits occurring before COVID-19, during shelter-in-place orders, and during the reopening period. Visits for children with public insurance and for those who were non-English speaking were identified. Telehealth visits for children with public insurance increased from 26.2% before COVID-19 to 37.3% during shelter-in-place orders and 34.3% during reopening. Telehealth visits for children who were non-English speaking increased from 3.5% before COVID-19 to 17.5% during shelter-in-place orders and remained at 15.0% during reopening. Pandemic-related telehealth expansion included optimization of workflows to include patients with public insurance and those who did not speak English. Increased participation by those groups persisted during the reopening phase, indicating that prioritizing inclusive telehealth workflows can reduce disparities in access to care.

Implementation of Telehealth Services in Rural Schools: A Qualitative Assessment

BACKGROUND

In rural areas with health professional workforce shortages, telehealth offers an opportunity to address service gaps and meet the health needs of students. Few studies have examined telehealth implementation in rural schools. This study explores facilitators and barriers to the implementation of telehealth programs in rural schools and identifies strategies for successful implementation to inform future school-based telehealth initiatives.

METHODS

We conducted semi-structured qualitative interviews with 50 key informants involved in the implementation of telehealth programs funded through the School-Based Telehealth Network Grant Program. Researchers completed a thematic analysis of interview transcripts.

RESULTS

The most commonly cited barriers were technology, reimbursement for services, and facilitating acceptance of the telehealth among school staff, clinicians, parents, and students. Key informants identified strategies for facilitating program implementation, including technology training and support, marketing efforts, and integration into existing school processes.

CONCLUSIONS

School-based telehealth can augment clinical capacity in areas with clinician shortages. Entities interested in such an approach to care must engage with their school community to ensure successful implementation. For rural, school-based telehealth to gain greater adoption and be sustained, these services must be reimbursable by Medicaid and private insurers.

Pediatric subspecialty telemedicine use from the patient and provider perspective

BACKGROUND

To characterize telemedicine use among pediatric subspecialties with respect to clinical uses of telemedicine, provider experience, and patient perceptions during the COVID-19 pandemic.

METHODS

We performed a mixed-methods study of telemedicine visits across pediatric endocrinology, nephrology, orthopedic surgery, and rheumatology at a large children's hospital. We used deductive analysis to review observational data from 40 video visits. Providers and patients/caregivers were surveyed around areas of satisfaction and communication.

RESULTS

We found adaptations of telemedicine including shared-screen use and provider-guided parent procedures among others. All providers felt that it was safest for their patients to conduct visits by video, and 72.7% reported completing some component of a clinical exam. Patients rated the areas of being respected by the clinical staff/provider and showing care and concern highly, and the mean overall satisfaction was 86.7 ± 19.3%.

CONCLUSIONS

Telemedicine has been used to deliver care to pediatric patients during the pandemic, and we found that patients were satisfied with the telemedicine visits during this stressful time and that providers were able to innovate during visits. Telemedicine is a tool that can be successfully adapted to patient and provider needs, but further studies are needed to fully explore its integration in pediatric subspecialty care.

IMPACT

This study describes telemedicine use at the height of the COVID-19 pandemic from both a provider and patient perspective, in four different pediatric subspecialties. Prior to COVID-19, pediatric telehealth landscape analysis suggested that many pediatric specialty practices had pilot telehealth programs, but there are few published studies evaluating telemedicine performance through the simultaneous patient and provider experience as part of standard care. We describe novel uses and adaptations of telemedicine during a time of rapid deployment in pediatric specialty care.

Evaluating Telehealth Implementation in the Context of Pediatric Chronic Pain Treatment during COVID-19

Telehealth has emerged as a promising healthcare delivery modality due to its ability to ameliorate traditional access-level barriers to treatment. In response to the onset of the novel coronavirus (COVID-19) pandemic, multidisciplinary pain clinics either rapidly built telehealth infrastructure from the ground up or ramped up existing services. As the use of telehealth increases, it is critical to develop data collection frameworks that guide implementation. This applied review provides a theoretically-based approach to capitalize on existing data sources and collect novel data to inform virtually delivered care in the context of pediatric pain care. Reviewed multisource data are (1) healthcare administrative data; (2) electronic chart review; (3) clinical health registries; and (4) stakeholder feedback. Preliminary telehealth data from an interdisciplinary pediatric chronic pain management clinic (PPMC) serving youth ages 8–17 years are presented to illustrate how relevant implementation outcomes can be extracted from multisource data. Multiple implementation outcomes were assessed, including telehealth adoption rates, patient clinical symptoms, and mixed-method patient-report telehealth satisfaction. This manuscript provides an applied roadmap to leverage existing data sources and incorporate stakeholder feedback to guide the implementation of telehealth in pediatric chronic pain settings through and beyond COVID-19. Strengths and limitations of the modeled data collection approach are discussed within the broader context of implementation science.

A Telehealth Initiative to Decrease No-Show Rates in a Pediatric Asthma Mobile Clinic

BACKGROUND/PROBLEM

Failed patient care appointments (no-shows) can lead to negative patient health outcomes and increased healthcare costs. There is evidence that telehealth is a safe, effective, and a cost-efficient option for those unable to attend in-person visits. No-show rates in pediatrics are unique due to reliance on caregivers to attend appointments. A pediatric asthma mobile van, which provides specialty care to children at schools in low-income communities in Chicago, was experiencing a high no-show rate.

METHODS/INTERVENTIONS

Building on evidence that the use of telehealth technology improves access to care, the purpose of this quality improvement initiative was to implement a new telehealth option for off-site parents to attend their child's on-site appointment. The designed initiative followed the Plan-Do-Study-Act model with three small phases of change. The first phase assessed telehealth interest using a Likert-scale questionnaire. The second phase designed and implemented a telehealth option and collected no-show rates pre- and post- implementation. The final phase assessed parental satisfaction using a Telehealth Usability Questionnaire.

RESULTS

Over 50% of participants stated interest in the parent off-site telehealth option for their child's appointment. No-show rates decreased from 36% to 7.9%-18% per month over a 10-month implementation period. Post-telehealth surveys completed by parents revealed this version of telehealth improved access to care for their child, saved them time, and was simple to use.

CONCLUSION

No-show rates decreased after successful implementation of an innovative approach to telehealth. This parent off-site telehealth model can be another approach toward increasing pediatric healthcare access.

Telehealth for Pediatric Cardiology Practitioners in the Time of COVID-19

Due to the COVID-19 pandemic, there has been an increased interest in telehealth as a means of providing care for children by a pediatric cardiologist. In this article, we provide an overview of telehealth utilization as an extension of current pediatric cardiology practices and provide some insight into the rapid shift made to quickly implement these telehealth services into our everyday practices due to COVID-19 personal distancing requirements. Our panel will review helpful tips into the selection of appropriate patient populations and specific cardiac diagnoses for telehealth that put patient and family safety concerns first. Numerous practical considerations in conducting a telehealth visit must be taken into account to ensure optimal use of this technology. The use of adapted staffing and billing models and expanded means of remote monitoring will aid in the incorporation of telehealth into more widespread pediatric cardiology practice. Future directions to sustain this platform include the refinement of telehealth care strategies, defining best practices, including telehealth in the fellowship curriculum and continuing advocacy for technology.

Taking Up the Challenge

Proven capacity to enable both valid diagnostic decisions and effective management decisions should be required before health care innovations are adopted in routine practice. Various care models, although distinct in capacity for information acquisition and status of effectiveness and efficiency assessment, are marketed as telemedicine. Ability to meet criteria of effective and efficient decision making depends heavily on both the type of clinical problem at hand and the diagnostic and communication tools included in the telemedicine model. As an example of a problem-type-specific, connected care model supported by a well-developed evidence base, we review research findings that support widespread implementation of a model for primary care pediatrics. But, as an understanding of disruptive innovations would predict and as our experience has shown, such evidence is not sufficient by itself to ensure adoption and dissemination. Disruptive innovations are "cheaper, simpler, more convenient products and services that start by meeting the needs of less demanding customers." Such innovations threaten the value of existing services and organizations offering them. Consequently, dominant provider organizations positioned to develop telemedicine, but with important revenue streams threatened by telemedicine, anticipate negative financial impact. Accordingly, these organizations typically obstruct the adoption of disruptive innovations, or are at least slow to adopt them. Organizations funding health services research, investigators, provider organizations, individual providers, and payers, all share responsibility for developing the evidence base supporting connected care. For models supported by a solid evidence base, the challenge extends to ensuring widespread availability of this useful service.

School-Based Telepsychiatry in an Urban Setting: Efficiency and Satisfaction with Care

Background and Introduction: Given the shortage of child psychiatrists in most areas, telepsychiatry may increase accessibility of psychiatric care in schools, in part by improving psychiatrists' efficiency and reach. The current study assessed consumer and provider satisfaction with school-based telepsychiatry versus in-person sessions in 25 urban public schools and compared the efficiency of these service delivery models. Materials and Methods: In total, 714 satisfaction surveys were completed by parents, students, school clinicians, and child psychiatrists following initial (26.3%) and follow-up (67.2%) visits (6.4% did not indicate type of visit). Most of these surveyed visits were for medication management (69.9%) or initiation of medication (22%). Efficiency analyses compared time saved via telepsychiatry versus in-person care. Researchers also conducted focus groups with providers to clarify preferences and concerns about telepsychiatry versus in-person visits. Results: Consumers were highly satisfied with both in-person and telepsychiatry-provided school psychiatry services and showed no significant differences in preference. Providers reported both in-person and telepsychiatry were equally effective and showed a slight preference for in-person sessions, citing concerns about ease of video equipment use. Telepsychiatry services were more efficient than in-person services, as commute/setup occupied about 28 psychiatrist hours total per month. Discussion and Conclusions: Findings suggest that students, parents, and school clinicians perceive school-based telepsychiatry positively and equal to on-site care. Child psychiatrists have apprehension about using equipment, so equipment training/preparation and provision of technical support are needed. Implications of study findings for telepsychiatry training and implementation in schools are discussed.

Antibiotic Prescribing During Pediatric Direct-to-Consumer Telemedicine Visits

BACKGROUND AND OBJECTIVES

Use of commercial direct-to-consumer (DTC) telemedicine outside of the pediatric medical home is increasing among children, and acute respiratory infections (ARIs) are the most commonly diagnosed condition at DTC telemedicine visits. Our objective was to compare the quality of antibiotic prescribing for ARIs among children across 3 settings: DTC telemedicine, urgent care, and the primary care provider (PCP) office.

METHODS

In a retrospective cohort study using 2015-2016 claims data from a large national commercial health plan, we identified ARI visits by children (0-17 years old), excluding visits with comorbidities that could affect antibiotic decisions. Visits were matched on age, sex, chronic medical complexity, state, rurality, health plan type, and ARI diagnosis category. Within the matched sample, we compared the percentage of ARI visits with any antibiotic prescribing and the percentage of ARI visits with guideline-concordant antibiotic management.

RESULTS

There were 4604 DTC telemedicine, 38 408 urgent care, and 485 201 PCP visits for ARIs in the matched sample. Antibiotic prescribing was higher for DTC telemedicine visits than for other settings (52% of DTC telemedicine visits versus 42% urgent care and 31% PCP visits; P < .001 for both comparisons). Guideline-concordant antibiotic management was lower at DTC telemedicine visits than at other settings (59% of DTC telemedicine visits versus 67% urgent care and 78% PCP visits; P < .001 for both comparisons).

CONCLUSIONS

At DTC telemedicine visits, children with ARIs were more likely to receive antibiotics and less likely to receive guideline-concordant antibiotic management compared to children at PCP visits and urgent care visits.

Webside Manner: A Key to High-Quality Primary Care Telemedicine for All

Evaluation of telemedicine, including videoconferencing, specifically focused on primary care, has demonstrated quality as good as in-person care, reduced cost, elimination of socioeconomic disparities in access, and high levels of patient satisfaction. Distinctly different care models are currently marketed by provider organizations as telemedicine. Inclusion (or not) of videoconferencing capacity constitutes a distinguishing feature that is likely to impact effectiveness, but provider organizations, regulatory agencies, and payers have largely overlooked this distinction. Reassurance reducing patient and family anxiety has long been recognized as essential to both patient satisfaction and value of the medical profession. Interaction that reduces anxiety requires empathic communication. Interpersonal communication involves more than words; also key are intonation of voice, facial expression, body language, and capacity to accurately "read" emotions in others and to respond effectively. Telemedicine with videoconferencing has been shown to redress disparities in access while providing high-quality care that is well accepted by both patients and providers. Technical and practical barriers to inclusion of videoconferencing in telemedicine are minimal. Real-time video interaction, enabling "webside manner," should be the default communication mode as telemedicine is increasingly accepted by patients, clinicians, and provider organizations as a tool to ensure high-quality primary care for all.

Systematic Review of School Telehealth Evaluations

School telehealth is an alternative delivery model to increase student health-care access with minimal evaluation to aid decision makers in the adoption or expansion of programs. This systematic review assesses school-based telehealth programs using a dissemination and implementation (D&I) framework to inform practitioners and decision makers of the value of school telehealth. We assessed findings from 20 studies on telehealth published between January 2006 and June 2018 and summarized program evaluation on a range of D&I constructs. The sample population included children in school- or center-based early childhood education under age 22 and included parents, providers, and school personnel across urban and suburban locations. There is some evidence that school telehealth can reduce emergency department visits and improve health status for children with chronic and acute illnesses. Future research should report on barriers and facilitators of implementation of programs, including costs related to application of telehealth services and utilization rates.

The Current Pediatric Telehealth Landscape

The growth and evolution of telehealth are opening new avenues for efficient, effective, and affordable pediatric health care services in the United States and around the world. However, there remain several barriers to the integration of telehealth into current practice. Establishing the necessary technical, administrative, and operational infrastructure can be challenging, and there is a relative lack of rigorous research data to demonstrate that telehealth is indeed delivering on its promise. That being said, a knowledge of the current state of pediatric telehealth can overcome many of these barriers, and programs are beginning to collaborate through a new pediatric telehealth research network called Supporting Pediatric Research on Outcomes and Utilization of Telehealth (SPROUT). In this report, we provide an update on the landscape of pediatric telehealth and summarize the findings of a recent SPROUT study in which researchers assessed pediatric telehealth programs across the United States. There were >50 programs representing 30 states that provided data on their implementation barriers, staffing resources, operational processes, technology, and funding sources to establish a base understanding of pediatric telehealth infrastructure on a national level. Moving forward, the database created from the SPROUT study will also serve as a foundation on which multicenter studies will be developed and facilitated in an ongoing effort to firmly establish the value of telehealth in pediatric health care.

Rural Family Physicians Are Twice as Likely to Use Telehealth as Urban Family Physicians

BACKGROUND

Telehealth has the potential to reduce health inequities and improve health outcomes among rural populations through increased access to physicians, specialists, and reduced travel time for patients.

INTRODUCTION

Although rural telehealth services have expanded in several specialized areas, little is known about the attitudes, beliefs, and uptake of telehealth use in rural American primary care. This study characterizes the differences between rural and urban family physicians (FPs), their perceptions of telehealth use, and barriers to further adoption.

MATERIALS AND METHODS

Nationally representative randomly sampled survey of 5,000 FPs.

RESULTS

Among the 31.3% of survey recipients who completed the survey, 83% practiced in urban areas and 17% in rural locations. Rural FPs were twice as likely to use telehealth as urban FPs (22% vs. 10%). Logistic regressions showed rural FPs had greater odds of reporting telehealth use to connect their patients to specialists and to care for their patients. Rural FPs were less likely to identify liability concerns as a barrier to using telehealth.

DISCUSSION

Telemedicine allows rural patients to see specialists without leaving their communities and permits rural FPs to take advantage of specialist expertise, expand their scope of practice, and reduce the feeling of isolation experienced by rural physicians.

CONCLUSION

Efforts to raise awareness of current payment policies for telehealth services, addressing the limitations of current reimbursement policies and state regulations, and creating new avenues for telehealth reimbursement and technological investments are critical to increasing primary care physician use of telehealth services.

Pursuit of Value in Connected Healthcare

INTRODUCTION

Potential for direct patient care through remote exchange of health-related information has expanded enormously with the proliferation of technologies leveraging ubiquitous connectivity, but implementation of connected care has been slow and controversial.

MATERIALS AND METHODS

This review demonstrates that controversy regarding connected care arises largely from the fact that proponents and critics are generally considering distinctly different care models. Differences are highlighted to mitigate controversy and to distinguish capacities of these different models.

RESULTS

Distinguishing capacities is essential for establishing the evidence base supporting safety, effectiveness, and efficiency. In care of a particular patient's problem, value is achieved when resources allocated meet requirements for diagnosis and intervention but do not exceed them. Robust evidence supports the value of some well-defined connected care models, exemplified by the Health-e-Access Telemedicine Model.

CONCLUSIONS

The pursuit of value in connected care is fundamentally the same as with in-person care. Provider organizations, legislators, regulators, and payers face not only a complex task in defining standards and enabling appropriate use, but also a heavy burden of responsibility for unleashing connected care that will benefit the entire community.

Patient evaluation of an acute care pediatric telemedicine service in urban neighborhoods

BACKGROUND

Telemedicine has enhanced care for children with illness in Rochester, NY, since May 2001, enabling 13,568 acute illness visits through December 2013. Prior findings included high parent satisfaction with childcare- and school-based telemedicine ("school telemedicine") and potential to replace 85% of office visits for illness. Urban neighborhood telemedicine ("neighborhood telemedicine") was designed to offer convenient care for illness episodes that school telemedicine often cannot serve because illness arises when children are at home or symptoms preclude attendance. This study was designed to characterize health problems prompting neighborhood telemedicine use and to assess parent perceptions of its value.

MATERIALS AND METHODS

A parent satisfaction instrument was developed with input from parents and providers. Neighborhood telemedicine was initiated in January 2009 and totaled 1,362 visits through November 2013. During a 29-month survey period through January 2012, 3,871 acute illness telemedicine visits were completed, 908 (23.5%) of them via neighborhood telemedicine. Instruments were completed for 392 (43.2%) of the 908 visits.

RESULTS

Neighborhood telemedicine comprised 27% of all telemedicine visits during the year of peak neighborhood activity. Almost all survey respondents were satisfied or highly satisfied with neighborhood visits (97.6%) and endorsed greater convenience than alternatives (94.5%).

CONCLUSIONS

Family preferences and the high value placed on neighborhood telemedicine suggest such service is important, especially in health systems driven by patient values. Service provided by neighborhood telemedicine holds potential to meet a large demand for care of acute childhood illness. Financing reform to support patient-centered care (e.g., bundled payments) should encompass sustainable business models for this service.

Implementing school based telehealth for children with medical complexity

PURPOSE

This quality improvement project aimed to improve parental experiences with healthcare delivery and collaborative health care offered at a school serving children with medical complexity (CMC) by implementing telehealth services.

METHODS

Parents of students at an urban public charter school for CMC were surveyed before and after telehealth was implemented at the school for two months, and again one year later, using the Measure of Processes of Care (MPOC-20).

RESULTS

Parental scores on the MPOC-20 were generally high both before and after the implementation of telehealth. There were no significant differences in the scores. Anecdotally, parent satisfaction with telehealth services was high. A review of the utilization of school-based telehealth during the 2015-2016 school year among 13 schools, including this unique school for CMC, revealed that the odds of having a telehealth visit at the school for CMC vs the other 12 schools was 23.8 (p value < 0.001; CL:11.2 to 50.6).

CONCLUSION

Parental experiences with healthcare delivery were high both before and after the implementation of telehealth at an urban public charter school for CMC. Utilization of telehealth at the school for CMC was significantly higher than that of children enrolled in the program at 12 other schools. Further research is needed to evaluate parental experiences with school-based telehealth services.

Pediatric Telehealth: Opportunities and Challenges

This article examines the current role of telehealth as a tool in the delivery of pediatric health care. It defines telemedicine and telehealth and provides an overview of different types of telehealth services. The article then explores the potential of telehealth to improve pediatric health care quality and safety through increased access to care, enhanced communication, expanded educational opportunities, and better resource utilization. It also discusses current challenges to the implementation of telehealth, including technological, financial, and licensing barriers, as well as provider, patient, and legal concerns.

Telemedicine Applications for the Pediatric Emergency Medicine: A Review of the Current Literature

OBJECTIVE

The aim of this study was to review current literature relating to telemedicine in pediatric emergency medicine including its clinical applications and challenges associated with its implementation.

METHODS

We reviewed the literature using standard search methods in accordance with preferred reporting items for systematic reviews and meta-analysis. We included the studies done in emergency settings for all age groups and narrowed our search to the articles that are relevant to "impact on quality of care" and "patient outcome." We also described current telemedicine uses, software, hardware, and other requirements needed for pediatric emergency applications.

RESULTS

Telemedicine has a potential role in pediatric emergency medicine for real-time decision making to improve quality of care for children. Logistic and legal challenges exist for pediatric emergency medicine applications similar to its uses in other settings.

CONCLUSIONS

Current frameworks exist in the use of telemedicine for pediatric emergency medicine. Research is still needed to see whether clinical outcomes are improved with pediatric emergency telemedicine solutions. Practical issues regarding training, accessibility, and resource allocation should be explored as pediatric emergency telemedicine evolves.

Addressing health disparities in rural communities using telehealth

The regionalization of pediatric services has resulted in differential access to care, sometimes creating barriers to those living in underserved, rural communities. These disparities in access contribute to inferior healthcare outcomes among infants and children. We review the medical literature on telemedicine and its use to improve access and the quality of care provided to pediatric patients with otherwise limited access to pediatric subspecialty care. We review the use of telemedicine for the provision of pediatric subspecialty consultations in the settings of ambulatory care, acute and inpatient care, and perinatal and newborn care. Studies demonstrate the feasibility and efficiencies gained with models of care that use telemedicine. By providing pediatric subspecialty care in more convenient settings such as local primary care offices and community hospitals, pediatric patients are more likely to receive care that adheres to evidence-based guidelines. In many cases, telemedicine can significantly improve provider, patient, and family satisfaction, increase measures of quality of care and patient safety, and reduce overall costs of care. Models of care that use telemedicine have the potential to address pediatric specialists' geographic misdistribution and address disparities in the quality of care delivered to children in underserved communities.

Care Offered by an Information-Rich Pediatric Acute Illness Connected Care Model

BACKGROUND AND OBJECTIVES

Prevailing regulatory and financing issues constrain dissemination of connected care despite evidence supporting acceptability, effectiveness, and efficiency. In this analysis we describe care provided over a 12-year period by Health-e-Access, an evidence-based, information-rich, connected care model designed to serve children with acute illness. We demonstrate the broad clinical capacity of this care model and key components imparting this capacity.

MATERIALS AND METHODS

Since 2001, Health-e-Access has been used in childcare, elementary schools, neighborhood after-hours sites, and a school for children with severe disabilities in Rochester, NY. With Health-e-Access, videoconference (preferably) or telephone enables parent, patient, and provider engagement. Technology includes the capacity for acquisition and exchange of a broad range of clinical observations, qualifying Health-e-Access as an information-rich model and differentiating it from multiple other connected care models commonly labeled telemedicine. Primary diagnoses recorded for completed visits were classified according to resources (technology, personnel, examination type) required to complete encounters appropriately.

RESULTS

Among 13,812 Health-e-Access visits initiated through June 2013, 98.2% were completed. Capacity for ear-nose-throat examination and close inspection of eye and skin were sufficient to identify positive findings supporting 95.2% of primary diagnoses. Videoconference and stethoscope were considered essential for observations required to rule out serious conditions often presenting in similar fashion to these 95%.

CONCLUSIONS

Health-e-Access included technology essential for establishing diagnoses, ruling out more serious conditions, and identifying problems beyond its scope. Regulations enabling and financing incentivizing replication of similar connected care models would benefit families and communities substantially. Observations challenge regulatory bodies and payers to support connected health services of comparable value.

High-Intensity Telemedicine Decreases Emergency Department Use for Ambulatory Care Sensitive Conditions by Older Adult Senior Living Community Residents

BACKGROUND

Emergency department (ED) visits for ambulatory care sensitive conditions (ACSCs) are common among older adults. The high-intensity telemedicine model of care has been proposed as an innovative approach to expand access to acute illness care, thereby preventing ED visits. The aim of this study was to assess the effect of a high-intensity telemedicine program for senior living community (SLC) residents on the rate of ED use for ACSCs.

METHODS

We performed a prospective cohort study at a primary care geriatrics practice that provides care to 22 SLCs. Six SLCs selected as intervention facilities, with the remaining SLCs serving as controls. Consenting practice patients at intervention facilities could have patient-to-provider, real-time, or store-and-forward high-intensity telemedicine services to diagnose and treat illnesses. The primary outcome was the rate of ED visits for which the primary diagnosis was an "ambulatory-care-sensitive" condition by the Institute of Medicine, which we compared between control and intervention participants.

RESULTS

During the study period, control participants had 310 ED visits for ACSCs, for a rate of 0.195 visits/person-year. Intervention participants visited the ED for ACSCs 85 times, for a rate of 0.138 visits/person-year [unadjusted rate ratio (RR): 0.71, 95% confidence interval (CI): 0.53-0.94]. Among intervention participants, ED use for ACSCs decreased at an annual rate of 34% (RR: 0.661, 95% CI: 0.444-0.982), whereas, in the control group there was no statistically significant change in ED use over time (RR: 1.01, 95% CI: 0.90-1.14).

CONCLUSIONS

Providing acute illness care by high-intensity telemedicine to older adults residing in SLCs significantly decreases the rate of ED use for ACSCs over 1 year, compared with no change in the rate of ED use for ACSCs among the control group.

High-Intensity Telemedicine Decreases Emergency Department Use by Senior Living Community Residents

BACKGROUND

The failure to provide timely acute illness care can lead to adverse consequences or emergency department (ED) use. We evaluated the effect on ED use of a high-intensity telemedicine program that provides acute illness care for senior living community (SLC) residents.

MATERIALS AND METHODS

We performed a prospective cohort study over 3.5 years. Six SLCs cared for by a primary care geriatrics practice were intervention facilities, with the remaining 16 being controls. Consenting patients at intervention facilities could access telemedicine for acute illness care. Patients were provided patient-to-provider, real-time, or store-and-forward high-intensity telemedicine (i.e., technician-assisted with resources beyond simple videoconferencing) to diagnose and treat acute illnesses. The primary outcome was the rate of ED use.

RESULTS

We enrolled 494 of 705 (70.1%) subjects/proxies in the intervention group; 1,058 subjects served as controls. Control and intervention subjects visited the ED 2,238 and 725 times, respectively, with 47.3% of control and 43.4% of intervention group visits resulting in discharge home. Among intervention subjects, ED use decreased at an annualized rate of 18% (rate ratio [RR]=0.82; 95% confidence interval [CI], 0.70-0.95), whereas in the control group there was no statistically significant change in ED use (RR=1.01; 95% CI, 0.95-1.07; p=0.009 for group-by-time interaction). Primary care use and mortality were not significantly different.

CONCLUSIONS

High-intensity telemedicine significantly reduced ED use among SLC residents without increasing other utilization or mortality. This alternative to traditional acute illness care can enhance access to acute illness care and should be integrated into population health programs.

The Use of Telemedicine to Address Access and Physician Workforce Shortages

The use of telemedicine technologies by primary care pediatricians, pediatric medical subspecialists, and pediatric surgical specialists (henceforth referred to as "pediatric physicians") has the potential to transform the practice of pediatrics. The purpose of this policy statement is to describe the expected and potential impact that telemedicine will have on pediatric physicians' efforts to improve access and physician workforce shortages. The policy statement also describes how the American Academy of Pediatrics can advocate for its members and their patients to best use telemedicine technologies to improve access to care, provide more patient- and family-centered care, increase efficiencies in practice, enhance the quality of care, and address projected shortages in the clinical workforce. As the use of telemedicine increases, it is likely to impact health care access, quality, and education and costs of care. Telemedicine technologies, applied to the medical home and its collaborating providers, have the potential to improve current models of care by increasing communication among clinicians, resulting in more efficient, higher quality, and less expensive care. Such a model can serve as a platform for providing more continuous care, linking primary and specialty care to support management of the needs of complex patients. In addition, telemedicine technologies can be used to efficiently provide pediatric physicians working in remote locations with ongoing medical education, increasing their ability to care for more complex patients in their community, reducing the burdens of travel on patients and families, and supporting the medical home. On the other hand, telemedicine technologies used for episodic care by nonmedical home providers have the potential to disrupt continuity of care and to create redundancy and imprudent use of health care resources. Fragmentation should be avoided, and telemedicine, like all primary and specialty services, should be coordinated through the medical home.

Telemedicine: Pediatric Applications

Telemedicine is a technological tool that is improving the health of children around the world. This report chronicles the use of telemedicine by pediatricians and pediatric medical and surgical specialists to deliver inpatient and outpatient care, educate physicians and patients, and conduct medical research. It also describes the importance of telemedicine in responding to emergencies and disasters and providing access to pediatric care to remote and underserved populations. Barriers to telemedicine expansion are explained, such as legal issues, inadequate payment for services, technology costs and sustainability, and the lack of technology infrastructure on a national scale. Although certain challenges have constrained more widespread implementation, telemedicine's current use bears testimony to its effectiveness and potential. Telemedicine's widespread adoption will be influenced by the implementation of key provisions of the Patient Protection and Affordable Care Act, technological advances, and growing patient demand for virtual visits.

Telehealth in the school setting: an integrative review

Telehealth, the provision of health care through long-distance telecommunications technology, is a tool that can be used by school nurses to address and improve the health status of schoolchildren. The purpose of this literature review is to examine research related to implementation of telehealth in the school setting. A review of the literature was conducted using CINAHL, ERIC, Medline, and PubMed databases and the search terms such as telehealth, telecare, telemedicine, school, and schools. Fifteen research studies related to telehealth in the school setting were identified. Themes identified included benefits, barriers, feasibility, and limitations of telehealth. Implications for practice are presented, along with the potential of telehealth to integrate with the Affordable Care Act. School nurses who use telehealth can further meet the health needs of children in their care. The future of health care and school nursing is changing, and telehealth is a tool that can improve care in an innovative and efficient way.

Improving access to care through the patient-centered medical home

School-based health centers (SBHCs) serve an essential role in providing access to high-quality, comprehensive care to underserved children and adolescents in more than 2,000 schools across the United States. SBHCs are an essential component of the health care safety net, and their role in the patient-centered medical home (PCMH) continues to evolve as both collaborating partners and, when fully functioning, independent PCMHs. The American Academy of Pediatrics (AAP) supports the use of SBHCs, citing the proven benefits and exciting potential as justification, but also offers caution and recommends a focus on communication within the community. Traditional "brick and mortar" SBHCs are more likely to be located in urban communities (54.2% urban versus 18.0% rural) and be in schools with more students, allowing for a greater return on investment. Current SBHCs are located in schools with an average population of 997 students. The need for a large school population to help an SBHC approach financial viability excludes children in rural communities who are more likely to attend a school with fewer than 500 students, be poor, and have difficulty accessing health care.2 The expansion of telehealth technologies allows the creation of solutions to decrease geographic barriers that have limited the growth of SBHCs in rural communities. Telehealth school-based health centers (tSBHCs) that exclusively provide services through telemedicine are operating and developing in communities where geographic barriers and financial challenges have prevented the establishment of brick and mortar SBHCs. TSBHCs are beginning to increase the number and variety of services they provide through the use of telehealth to include behavioral health, nutrition services, and pediatric specialists. Understanding the role of tSBHCs in the growth of the PCMH model is critical for using these tools to continue to improve child and adolescent health.