Advancing the reach of care through telemedicine

New technologies in medicine have allowed the care of pediatric patients through remote monitoring and even use of video and audio so a physician can see a patient in real time. Telemedicine is especially helpful in rural areas where subspecialists may not be readily available and in schools to provide care for children who may not have access to health care.

“I’ve been pushing telemedicine in my world because it’s the best use of patient-centered care I can think of,” Neil E. Herendeen, MD, MS, who is associate professor of pediatrics at Golisano Children’s Hospital and the University of Rochester Medical School, told Infectious Diseases in Children. “There’s nothing more patient-centered than going in and doing a virtual house call. It saves time on my end because I see each patient in my waiting room by clicking on my computer. It still delivers that personal care.”

Infectious Diseases in Children spoke with several experts about the different models of telemedicine available, as well as barriers, compliance issues and reimbursement.

Classic model of telemedicine

Michael R. Slaper, MHSA, who is the telemedicine program coordinator at Nationwide Children’s Hospital Center for Telehealth in Columbus, Ohio, told Infectious Diseases in Children that “store and forward telemedicine” is the most primitive form of telemedicine.

According to Jeffrey R. Kile, MD, MHA, FAAP, of Pediatric Associates of Kingston in Kingston, Pa., this type of telemedicine involves information from tests being stored on a computer and then forwarded to another hospital that practices telemedicine for a physician’s review.

“The physician gives it a read and then sends it back,” he said. “That is more static because it’s not in real time.”

Technology-enhanced telemedicine

Today’s telemedicine includes real-time video and audio so a physician can directly monitor a patient with the help of someone trained in the technologies. These include attachments for cellphones, stethoscopes, otoscopes, cameras and other devices that send pictures to the reviewing physician.

Herendeen said with technology-enhanced telemedicine, the attachments allow technicians to further examine a patient.

“That’s where we’ve come up with this telemedicine assistant role,” he said. “A lot of programs are using nurses in that role. We’ve taken it a step lower and trained someone to use the cameras.”

In a study published in Critical Care Medicine in October, researchers examined parent satisfaction with telemedicine consultation, telephone consultations and no pediatric specialist consultations. The study included 320 children aged 0 to 17 years who presented in the highest triage category to five rural EDs with access to consultations from an academic children’s hospital; 58 had telemedicine consultation, 63 had telephone consultations and 199 had no pediatric specialist consultations.

Higher quality-of-care scores were recorded among patients who received telemedicine consultation compared with those who received no consultation, and 97% of patients rated overall telemedicine experience as “extremely helpful.”

James P. Marcin, MD, MPH, professor of pediatric critical care at UC Davis School of Medicine and UC Davis Children’s Hospital in Sacramento, Calif., who was involved in the study, said the available technology should be used to improve the quality of care delivered to these patients when no pediatric specialists are available in their community.

“People say a picture is worth a thousand words,” he said. “With medicine, video conferencing brings us right to the bedside, allowing us to see what’s happening and collaborate with on-site doctors and nurses to provide the best possible care to our patients.”

Slaper said this technology truly enables patients and physicians to connect in real-time without having to worry about geographic distances: “If you implement virtual clinics, it could alleviate a lot of constraints on families or patients if they have to drive several hours to an outpatient visit. Instead, they can theoretically stay in their home community and miss less time at school or work, and because they are close to home, get back to their daily life sooner.”

Another study published in Pediatrics in November conducted by Dharmar and colleagues evaluated 234 seriously ill and injured children aged 1 to 16 years who presented to eight rural EDs to determine the frequency of physician-related medication errors for children who received telemedicine consultations. This study also evaluated children who received telephone consultations vs. no-consultations.

More than 400 medications were administered and researchers found that only 3.4% of patients who received telemedicine consultation had medication errors compared with 10.8% of the telephone consultation group and 12.5% of the no-consultation group.

School-based telemedicine

School-based telemedicine allows children in rural areas to receive care remotely from a physician while sitting in the school nurse’s office.

“The school nurses do a lot more care and have a better idea of who needs to be sent home because they’re sick and who can stay in school until the end of the day,” Herendeen said.

Stephen W. North, MD, MPH, who is founder of the Center for Rural Health Innovation in Bakersville, N.C., said the center operates a telemedicine program called “MY Health-e-Schools” to help care for more than 4,000 students and faculty members at 14 schools.

North also works with other providers in the area to ensure that everyone in informed about the child’s care.

“We send a note to all of the providers, ideally within 24 hours of seeing a child, so if they were to get a call at their office, they’d know that I had prescribed a drug or that I didn’t,” he said. “The other part of that communication is that we haven’t gotten a lot of pushback from providers about not providing adequate care or not communicating with them. That sometimes is one of the criticisms of school-based health care.”

According to North, another advantage is the ability to take a picture and look at changes over time.

“If I’m seeing a student with a rash or an ear infection, I can take a picture of that and put it in their medial record so that when they come back 3 days later and see someone else, we can look at the same picture and see if it’s changed,” he said. “That’s not a convenience that I have in my office.”

However, North said there are some issues between the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Family Educational Rights and Privacy Act, which is essentially the educational equivalent of HIPAA.

“Because we’re providing care in a school and using the school nurse, we’ve had to have the nurses sign waivers understanding that when tests are done under direction of myself or the pediatric nurse practitioner, it’s a medical issue, not part of the school health record,” he said.

North said he has not experienced many issues with parents refusing this type of care for their children. When MY Health-e-Schools was started, a comprehensive needs assessment was conducted and North and colleagues found that only 10% of parents said they “probably wouldn’t” or “definitely wouldn’t” use telemedicine.

Using telemedicine to diagnose and treat infectious diseases

According to Kile, infectious diseases that would be difficult to diagnose using telemedicine are ones without any outward signs.

“When you see signs during a physical exam, that sort of tips you in the direction of what the diagnosis will be,” he said.

However, Herendeen said when the telemedicine program first started at Golisano Children’s Hospital, he and colleagues conducted a head-to-head comparison of children who walked into the clinic to see what could be diagnosed by telemedicine and what could be diagnosed in person.

“We found there was very little we couldn’t do [with telemedicine],” he said. “We could do anything except abdominal pain and gastroenteritis. I can’t get a great listen with the stethoscope to bowel sounds. I can watch a video clip of someone pushing on the patient’s stomach for me, but it’s different than me putting my own hand on their stomach and feeling.”

At worst, Herendeen said telemedicine can provide a second-level triage of these types of problems. However, he added, that is not what he does most of the time, and 96% of telemedicine visits are able to be completed.

“It doesn’t seem to impair us to say that there are certain conditions we’re unable to do by telemedicine,” he said.

Benefits of telemedicine

Slaper said telemedicine has the ability to increase the relationship between the provider and patient.

“Patients have a very finite amount of time with their provider when they come in for an office visit or a sick visit,” he said. “Technology can be used as an extension of that relationship in a way that providers can educate their patients and have them self-manage themselves when they’re out of the four walls of either their physicians’ office or the hospital.”

Herendeen said the biggest benefit of telemedicine is to the patient because of ease of access, especially with school-based telemedicine.

“The child isn’t going to save a lot of time relating to the medical component of being examined, taking photos, etc, but the difference is that parents don’t necessarily have to leave work to make the encounter happen and the children can return to class,” he said. “The real saving is to the child’s time and the parent’s time. That’s what family-centered and patient-centered care is all about.”

Barriers and compliance issues

Marcin said, historically, barriers to telemedicine have involved overall cost of the programs, cost of equipment, telecommunications, connections of equipment and training people to use the equipment.

“There are risks that private health information could be compromised through electronic storage and transmission,” Kile said.

Herendeen said most electronic medical record models are not geared toward images and sound waves, although they are easily downloaded, but meant for typing and documenting words.

“But right now, the big companies that have done electronic records have not gone out of their way to make the interface easy,” he said. “Even when they do open that portal so we can transfer them, you get back to your local information specialty group who says there may be viruses and won’t download the images.”

From a security standpoint, Herendeen said some system manufacturers are reluctant to add more images onto their system.

“The reluctance there is how do you manage all of the data and that size of information,” he said.

Obstacle to reimbursement

“There’s non-uniform reimbursement right now, and each state has its Medicaid program set up a different way, if at all, to reimburse for services for telemedicine,” Slaper said. “Private payers are just starting to wade in the waters to say they will reimburse for limited services, but even with them it’s not uniform across the board.”

According to the National Conference of State Legislatures’ State Coverage for Telehealth Services website, 43 states and the District of Columbia provide some form of Medicaid reimbursement for these services. Nineteen states and the District of Columbia also require private insurance plans in the state to cover the services. Arizona plans to join the list in January. — by Amber Cox

References:

Dharmar M. Crit Care Med. 2013;41:2388-2395.
Dharmar M. Pediatrics. 2013;132:1090-1097.
State Coverage for Telehealth Services. Available at: www.ncsl.org/research/health/state-coverage-for-telehealth-services.aspx. Accessed March 14, 2014.
Dharmar M. 2013;41:2388-2395.Dharmar M. 2013;132:1090-1097.State Coverage for Telehealth Services. Available at: www.ncsl.org/research/health/state-coverage-for-telehealth-services.aspx. Accessed March 14, 2014.

For more information:

Neil E. Herendeen, MD, can be reached at 601 Elmwood Ave., Box 632, Rochester, NY 14642; email: neil_herendeen@urmc.rochester.edu.
Jeffrey R. Kile, MD, MHA, FAAP, can be reached at Pediatric Associates of Kingston, 425 Tioga Ave., Kingston, PA 18704; email: jeffkilemd@hotmail.com.
James P. Marcin, MD, MPH, can be reached at UC Davis Department of Pediatrics, 2516 Stockton Blvd., Sacramento, CA 95817; email: jpmarcin@ucdavis.edu.
Steve North, MD, MPH, can be reached at 120 Oak Ave., Spruce Pine, NC 28777; email: steve.north@crhi.org.
Michael Slaper, MHSA, can be reached at: 700 Children’s Dr., Columbus, OH 43205; email: michael.slaper@nationwidechildrens.org.

Disclosure: Herendeen, Kile, Marcin, North and Slaper report no relevant financial disclosures.

Does telemedicine have a place in routine care in pediatrics?

I use these devices and find them helpful.

As Medical Director of the Arizona Telemedicine Program, I have used and worked with clinicians who have used multiple electronic diagnostic devices, including stethoscopes, otoscopes and hand-held cameras.

The electronic stethoscope is useful for the diagnosis of murmurs, wheezes and other abnormal sounds. It is also a great teaching tool that can record heart sounds that may be unknown to a learner and be used for later review. The quality of the electronic stethoscope has made it both my daily stethoscope as well as my telemed stethoscope. It’s just what I carry in my pocket now!

The electronic otoscope is the mainstay for many nurse-based school clinics. The tele-otoscope is not a direct translation from the otoscope we learned to use in medical school. The examiner must look at the video screen and not toward the patient’s ear. All while advancing the instrument into the patient’s ear. Like in medical school, we all practice on ourselves first. 

The hand-held camera has multiple purposes, including for dermatology and, with appropriate disposable covers, oral care.

All of these tools serve to extend the clinicians reach and provide care to patients who are in areas otherwise not served.

Ana Maria Lopez, MD, MPH, FACP, is Medical Director for the Arizona Telemedicine Program and Professor of Medicine and Pathology at the University of Arizona Cancer Center in Tucson. Lopez can be reached at alopez@uacc.arizona.edu. Disclosure: Lopez reports no relevant financial disclosures.

 

I don’t use these devices and I see no benefit to them.

We have minimal experience with this telemedicine format in our office. I know that our hospital uses a robot for night coverage of adult patients, which can show the distant on-call doctors the patient and discuss care with them. The pediatric exam of the infant and young child, and the teenager, could never be supplanted by a videoconference machine. I could only see its role in psychiatric and counseling issues. But even half of these visits involve the parent who mentions casually "oh, by the way, he is ... coughing, has a sore throat, a belly ache, etc."

I personally believe that I see too many critical findings and subtleties on my examinations, including demeanor and affect and rashes that would never show up on any telemedicine. I also spend all day playing "divert and distract" in my anxious or crying infants and children.

Furthermore, I can see minimal — if any — role in the high percentage of my complicated ill patients. For example, I have had children come in for a mild sore throat for 2 hours, and the next day may be on death’s door. The teen in for headache, who by the way has innumerable self-inflicted cuts on her abdomen or arm. A few petichiae on the back which are due to early meningococcemia and the incidental discolored mole which is pre-melanoma. There are many examples of this disparity in severity every day.

I have used a superb ($10,000) tele-otoscope in a clinical trial. It is very impractical and time-consuming to routinely use in any child less than 3 years old (peak age for most acute otitis media) because the child must be held totally still, all ear cerumen must still be removed from these small ear canals, and then the data must be transmitted from an extra computer. Who will do this? I do not trust this technology for every day pediatric practice in community offices yet.

Stan L. Block, MD, FAAP, is in private practice in Bardstown, Ky., and is also professor of clinical pediatrics at the University of Kentucky College of Medicine in Lexington, and at the University of Louisville Medical School in Louisville. Block is a member of the Infectious Diseases in Children Editorial Board. Block can be reached at slblockmd@hotmail.com. Disclosure: Block reports no relevant financial disclosures.