Telemedicine is by no means a new technology, given that audio-video telecommunication links have been utilized for the provision of medical services since the 1950s.1 Nonetheless, telemedicine is currently in a phase of rapid growth and evolution. The combination of increasingly affordable and powerful networking, computing, and communication technology, along with the continued nationwide crisis in health care access and costs, has created a “tipping point,” whereby telemedicine has progressed from a novel means of practicing medicine to practical tool to help address our nation’s health care needs. Telemedicine has also evolved beyond a means of providing care to remote communities to becoming a versatile tool in the delivery of health care in a variety of non-rural settings. Although no one can be everywhere at once, telemedicine allows us to be in more places at once than we’ve ever been before.
The problems of disparities and access to care are even more evident in pediatrics, where subspecialists are fewer in number and more regionalized than adult providers. Numerous successful telemedicine programs across the country have demonstrated the impact that these technologies can have in pediatrics, with many more programs in development. As a versatile means of delivering care, telemedicine can be used at any point during the course of a health care encounter as not only a means of expanding our reach, but also a means of increasing efficiency. Using telemedicine to provide consultations to community hospitals has been shown to improve quality of care,2,3 strengthen the referral base for the consulting facilities,4 facilitate cost savings,5 and improve the financial bottom line for both referring and consulting facilities.4,6
This review highlights some of the ways in which telemedicine is being used to facilitate timely and effective pediatric care in a variety of hospital settings.
The use of telemedicine for evaluation and management of pediatric patients in the hospital setting often begins in the emergency department (ED), where access to pediatric specialty care is particularly challenging in rural areas. Whereas 27% of all ED visits nationwide are by children, only 6% of EDs in the U.S. have all of the necessary pediatric supplies.7 This can lead to difficult situations when seriously ill or injured children present to an ED without the full spectrum of pediatric services and subspecialists. There is substantial evidence that a lack of expertise and equipment in such facilities contributes to a lower quality of care, less-accurate diagnoses, and suboptimal therapies.8–12
Telemedicine has been demonstrated to be effective in the ED management of multiple conditions for both adults and children.2,3,13,14 Numerous programs across the country have been developed for pediatric critical care and emergency medicine telemedicine in rural emergency departments with the goal of providing timely pediatric expertise for seriously ill and injured children. By conducting detailed examinations remotely utilizing high-definition cameras, handheld peripheral devices, and image-sharing technology, telemedicine consultants can get more accurate information, provide faster diagnoses, and recommend more appropriate and timely interventions (Figure 1).
Current telemedicine technology facilitates detailed physical examinations from remote locations, including high-definition images and real-time auscultation with telemedicine-compatible stethoscopes.
Images courtesy of S. David McSwain, MD, MPH
Dharmar et al2 recently demonstrated an improvement in rural ED quality of care when utilizing pediatric critical care telemedicine consultations. The study included 320 patients presenting in the highest triage category to five rural EDs in California and demonstrated significantly higher overall quality-of-care scores when patients received telemedicine consultations from pediatric critical care specialists compared to those receiving no consultation. They also demonstrated a significantly higher rate of additions to diagnostic studies and changes in therapeutic interventions when using telemedicine, and patients’ families rated many aspects of quality of care at the rural ED significantly higher if their child received telemedicine consultations. The use of telemedicine to provide specialty consultations to seriously ill children was also recently shown to improve patient safety by significantly reducing the frequency of physician-related medication errors.15
Another study from Vermont Children’s Hospital evaluated pediatric critical care telemedicine consultation to 10 participating rural hospitals.3 In this study, referring community providers reported that telemedicine consultations improved patient care in 88% of cases and were superior to telephone consultations 55% of the time. Consulting intensivists felt even more strongly, reporting that telemedicine consultations improved patient care in 89% of cases and were superior to telephone consults in 91%.
The Children’s Hospital Los Angeles has also employed telemedicine in their disaster response plan, utilizing mobile telemedicine carts at remote sites to assist in triage, transfer decisions, and medical logistics coordination. A 2012 pilot study demonstrated that pediatric specialists were able to successfully provide remote triage and treatment consults during two separate disaster drills at three Los Angeles County hospitals.16 With telemedicine programs already being implemented in many EDs across the country, the use of these systems in disaster preparedness and education would appear to be a logical next step to enable the most efficient use of limited pediatric resources and specialty personnel.
The decision to transport a patient to a referral facility is often a difficult one. All transports come with inherent risks, particularly when transporting by air, and hospitalizing a child at a referral center can create numerous hardships for the child’s family. At the same time, the lack of access to needed expertise, diagnostic tools, and therapies for children in many rural areas necessitates that those children be transferred.
In most situations, a physician consulting with a rural provider about a pediatric patient will err on the side of caution. Further, because the ability to get an accurate clinical picture over the phone is significantly limited, unnecessary transports are not uncommon.17 Telemedicine allows for a more accurate determination of who truly does need to be transferred. As an added benefit, the patient and family may get to virtually meet their doctor or care team prior to the transfer, which can decrease some of the anxiety associated with the transfer. The feasibility and accuracy of utilizing telemedicine to determine the need for transfer to a referring facility was demonstrated in 1998.18 Since then, multiple programs across the country have been successfully implemented.
In addition, the use of telemedicine allows for a more appropriate determination of the mode of transportation through better assessment of stability for transport, as well as more accurate diagnosis and therapeutic decision-making prior to transport. This reduces the rate of air transportation, with subsequent decreases in costs and risks, and allows family to travel with their child.2
The use of telemedicine during a transport is a trickier proposal due to the requirement for a stable telecommunications connection. This has been evaluated in telestroke care19 and among simulated trauma patients.20 Researchers found that the connection was not reliable enough to ensure a stable connection, but that when the connection allowed for an evaluation, the quality of the evaluations was good. In addition, the studies found significantly improved monitoring, recognition rates for key clinical signs, and critical interventions. Despite these promising findings, further technological advances are required before telemedicine-equipped ambulances are reliable enough for clinical use. However, given the current rate of technological advancement for mobile networked communication, the use of telemedicine during transports may not be too far away.
Telemedicine is also increasingly being utilized at one of the other major pediatric “entry points” to the hospital: the newborn nursery. With the heavy focus on regionalization of neonatology, telemedicine provides a useful means of both strengthening regionalization and keeping providers more connected.
In September 2010, the U.S. Health and Human Services Secretary’s Advisory Committee on Heritable Disorders in Newborns and Children recommended that critical cyanotic congenital heart disease be added to the recommended uniform screening panel for newborns. That recommendation, and the subsequent implementation strategies published in Pediatrics in 2011,21 has put pediatric cardiology services in high demand across the country, as many rural facilities are faced with finding a means of performing pediatric echocardiograms on some of their newborns without an obligatory transfer to a referral center. Telemedicine has been recommended as a means of addressing this need.21 Pediatric telecardiology enables pediatric cardiologists to evaluate newborns with concern for congenital heart disease remotely, including use of echocardiography and electrocardiogram interpretation, to determine which children require transfer, which can be followed up as outpatients, and which can remain at their local facility.5,22,23 These programs have demonstrated lower costs of care, a reduction in unnecessary transfers, accurate diagnoses, and more timely evaluations and decision-making.22,23 In this edition of Pediatric Annals, Minton et al. discuss the additional ways in which telehealth is being implemented in neonatal care.
Inpatient wards also provide numerous opportunities to utilize telemedicine, both for children in community facilities and referral centers. Telemedicine can enable remote consultation with a variety of pediatric subspecialists for patients hospitalized in their community facility (Figure 2). Such consultations provide many benefits for all involved, allowing children and their families to stay in their own community, avoiding costly transfers, providing a more timely service, allowing community facilities to keep more of their patients, and allowing pediatric subspecialists — many of whom are in very short supply — to reach more patients more efficiently.
A variety of telemedicine endpoints are available to allow pediatric specialists to consult on children hospitalized at their community hospital.
For children already admitted to a referral center, telemedicine can be used to facilitate nighttime coverage by physicians taking home call, allowing general and subspecialty pediatricians and pediatric surgical specialists the ability to assess patients from home, including new admissions who they may not otherwise see until the next day, as well as patients being evaluated for discharge home.24 Increased availability of attending physician staff via telemedicine could improve quality, facilitate shorter lengths of stay, and improve patient safety. Telemedicine also allows for improved supervision and teaching of residents and advanced-practice providers during off hours, allowing supervising physicians to observe examinations and physical findings, review radiographic images, better demonstrate their teaching points, and interactively display reference materials while instructing trainees. Physicians are able to evaluate their patients who have an acute change in status or periodically check in on worrisome patients from home, which can save valuable time compared to driving in to the hospital.
Telemedicine can also be utilized to integrate primary care physicians into the care of their hospitalized patients. Numerous software programs are available that allow pediatricians to connect to hospital-based telemedicine units from their home or office. Videoconferencing with patients and their families through telemedicine may allow them to better understand their patient’s course and strengthen their relationship with the patient and family. Primary pediatricians could also participate in multidisciplinary care conferences and discharge planning, facilitating a more seamless transition from the inpatient to the outpatient setting for complex patients. Telehome care programs have been designed to improve the transition from hospital care to home care for children with complex and challenging medical conditions such as congenital heart disease, chronic lung disease, and airway problems.25,26
Intensive Care Units
Only 3% of pediatric critical care specialists practice in rural areas.3 As a result, children in need of critical care services are often subjected to potentially long and risky transports to a pediatric ICU. Even children who are not in immediate need of critical care services may be transported due to concern regarding eventual need for such services or need for other subspecialty services not available at the referring facility.17 This often results in the transfer of patients that could have safely remained at their community facility, which can strain the capacity of pediatric ICUs and result in inefficient use of resources for the care of these patients.
The tele-ICU concept is becoming increasingly popular in adult medicine, whereby multiple community ICUs are continuously monitored by a centralized remote monitoring station, and telemedicine is utilized to provide critical care expertise at facilities where critical care specialists are not always available.27,28 Due to lower overall numbers of critically ill pediatric patients, the limited evidence base for the tele-ICU model, and the high costs of these systems, a pediatric continuous-oversight tele-ICU model is unlikely to become widespread in the immediate future. However, ad hoc pediatric critical care telemedicine consultations to hospitalized children in community multidisciplinary ICUs have proven successful. Several programs are now in existence where pediatric critical care specialists consult to pediatric patients hospitalized in larger community hospitals without a full-spectrum pediatric ICU. In general, these patients are “less ill” than those typically admitted to a regional pediatric ICU, with less complex disease processes and shorter lengths of stay.29 The University of California – Davis critical care telemedicine program has been providing pediatric critical care consultation to a rural medical-surgical ICU since 2000, which has not only proven to be feasible,29 but has generated significant cost savings from avoided transfers and significant additional revenue to the participating rural hospital.6,30
One unique aspect of practicing hospital-based telemedicine involves the issue of credentialing of providers. In May 2011, the Centers for Medicare and Medicaid Services (CMS) released new guidelines on the provision of telemedicine services that included a mechanism for Medicare-participating hospitals to confer privileges to telemedicine providers by relying on the credentialing decisions of the facility providing telemedicine services, also known as “credentialing by proxy.” These guidelines closely follow the Joint Commission guidelines on credentialing of telemedicine providers, released in 2004, and dramatically streamline the credentialing and privileging process for provision of telemedicine services. Many telemedicine programs and health care facilities across the country have implemented this new credentialing mechanism, which saves telemedicine service providers from the complex and redundant process of credentialing multiple telemedicine providers at multiple remote facilities, and saves referring facilities much of the workload associated with credentialing a telemedicine consultant staff that may number in the hundreds.
The updated credentialing process not only reduces the time required for the initial deployment of telemedicine services, but also allows rural hospitals in need of additional telemedicine services to initiate them at their facility within weeks instead of months. New telemedicine providers can be quickly added to a roster of telemedicine consultants for an existing program, provided that the referring facility approves the new addition. Multiple safeguards are in place to ensure appropriate medical practice and empower the referring sites to have specific providers removed from the list of consultants if they deem it necessary. The requirements include a short addition to the referring facility bylaws stating that credentialing by proxy will be utilized for telemedicine services. As providers across the country become more familiar with the process, credentialing by proxy for telemedicine is expected to become increasingly widespread.
Future of Telemedicine
The increasing portability of networked devices will further enhance the ability of physicians to integrate telemedicine with their usual clinical workflow. With tablet computers becoming commonplace in the hospital setting, as well as the rise of emerging technologies such as smart watches and smart glasses with heads-up displays, the possibilities for expanding our reach and increasing our efficiency far beyond the traditional boundaries are expanding rapidly. As telehealth is increasingly integrated into standard practice, this technology will soon be an essential component for the delivery of services in any comprehensive health care system.
- Zundel KM. Telemedicine: history, applications, and impact on librarianship. Bull Med Libr Assoc. 1996;84(1):71–79.
- Dharmar M, Romano PS, Kuppermann N, et al. Impact of critical care telemedicine consultations on children in rural emergency departments. Crit Care Med. 2013;41(10):2388–2395. doi:10.1097/CCM.0b013e31828e9824 [CrossRef]
- Heath B, Salerno R, Hopkins A, Hertzig J, Caputo M. Pediatric critical care telemedicine in rural underserved emergency departments. Pediatr Crit Care Med. 2009;10(5):588–591. doi:10.1097/PCC.0b013e3181a63eac [CrossRef]
- Dharmar M, Sadorra CK, Leigh P, et al. The financial impact of a pediatric telemedicine program: a children’s hospital’s perspective. Telemed J E Health. 2013;19(7):502–508. doi:10.1089/tmj.2012.0266 [CrossRef]
- Sable C, Roca T, Gold J, et al. Live transmission of neonatal echocardiograms from underserved areas: accuracy, patient care, and cost. Telemed J. 1999;5(4):339–347. doi:10.1089/107830299311907 [CrossRef]
- Marcin JP, Nesbitt TS, Kallas HJ, et al. Use of telemedicine to provide pediatric critical care inpatient consultations to underserved rural Northern California. J Pediatr. 2004;144(3):375–380. doi:10.1016/j.jpeds.2003.12.017 [CrossRef]
- Institute of Medicine. IOM report: the future of emergency care in the United States health system. Acad Emerg Med. 2006;13(10):1081–1085. doi:10.1197/j.aem.2006.07.011 [CrossRef]
- Athey J, Dean JM, Ball J, Wiebe R, Melese-d’Hospital I. Ability of hospitals to care for pediatric emergency patients. Pediatr Emerg Care. 2001;17(3):170–174. doi:10.1097/00006565-200106000-00005 [CrossRef]
- McGillivray D, Nijssen-Jordan C, Kramer MS, Yang H, Platt R. Critical pediatric equipment availability in Canadian hospital emergency departments. Ann Emerg Med. 2001;37(4):371–376. doi:10.1067/mem.2001.112253 [CrossRef]
- Esposito TJ, Sanddal ND, Dean JM, et al. Analysis of preventable pediatric trauma deaths and inappropriate trauma care in Montana. J Trauma. 1999;47(2):243–251; discussion 251–253. doi:10.1097/00005373-199908000-00004 [CrossRef]
- Pollack MM, Alexander SR, Clarke N, et al. Improved outcomes from tertiary center pediatric intensive care: a statewide comparison of tertiary and nontertiary care facilities. Crit Care Med. 1991;19(2):150–159. doi:10.1097/00003246-199102000-00007 [CrossRef]
- Gregory CJ, Nasrollahzadeh F, Dharmar M, Parsapour K, Marcin JP. Comparison of critically ill and injured children transferred from referring hospitals versus in-house admissions. Pediatrics. 2008;121(4):e906–e911. doi:10.1542/peds.2007-2089 [CrossRef]
- Benger JR, Noble SM, Coast J, Kendall JM. The safety and effectiveness of minor injuries telemedicine. Emerg Med J. 2004;21(4):438–445.
- Galli R, Keith JC, McKenzie K, Hall GS, Henderson K. TelEmergency: a novel system for delivering emergency care to rural hospitals. Ann Emerg Med. 2008;51(3):275–284. doi:10.1016/j.annemergmed.2007.04.025 [CrossRef]
- Dharmar M, Kuppermann N, Romano PS, et al. Telemedicine consultations and medication errors in rural emergency departments. Pediatrics. 2013;132(6):1090–1097. doi:10.1542/peds.2013-1374 [CrossRef]
- Burke RV, Berg BM, Vee P, et al. Using robotic telecommunications to triage pediatric disaster victims. J Ped Surg. 2012;47(1):221–224. doi:10.1016/j.jpedsurg.2011.10.046 [CrossRef]
- Wakefield DS, Ward M, Miller T, et al. Intensive care unit utilization and interhospital transfers as potential indicators of rural hospital quality. J Rural Health. 2004;20(4):394–400. doi:10.1111/j.1748-0361.2004.tb00054.x [CrossRef]
- Kofos D, Pitetti R, Orr R, Thompson A. Telemedicine in pediatric transport: a feasibility study. Pediatrics. 1998;102(5):E58. doi:10.1542/peds.102.5.e58 [CrossRef]
- Liman TG, Winter B, Waldschmidt C, et al. Telestroke ambulances in prehospital stroke management: concept and pilot feasibility study. Stroke. 2012;43(8):2086–2090. doi:10.1161/STROKEAHA.112.657270 [CrossRef]
- Charash WE, Caputo MP, Clark H, et al. Telemedicine to a moving ambulance improves outcome after trauma in simulated patients. J Trauma. 2011;71(1):49–54; discussion 55. doi:10.1097/TA.0b013e31821e4690 [CrossRef]
- Kemper AR, Mahle WT, Martin GR, et al. Strategies for implementing screening for critical congenital heart disease. Pediatrics. 2011;128(5):e1259–e1267. doi:10.1542/peds.2011-1317 [CrossRef]
- Awadallah S, Halaweish I, Kutayli F. Tele-echocardiography in neonates: utility and benefits in South Dakota primary care hospitals. S D Med. 2006;59(3):97–100.
- Castela E, Ramalheiro G, Pires A, et al. Five years of teleconsultation: experience of the Cardiology Department of Coimbra Pediatric Hospital. Rev Port Cardiol. 2005;24(6):835–840.
- Yager PH, Cummings BM, Whalen MJ, Noviski N. Nighttime telecommunication between remote staff intensivists and bedside personnel in a pediatric intensive care unit: a retrospective study. Crit Care Med. 2012;40(9):2700–2703. doi:10.1097/CCM.0b013e3182591dab [CrossRef]
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- McCrossan B, Morgan G, Grant B, et al. Assisting the transition from hospital to home for children with major congenital heart disease by telemedicine: a feasibility study and initial results. Med Inform Internet Med. 2007;32(4):297–304. doi:10.1080/14639230701791611 [CrossRef]
- Rosenfeld BA, Dorman T, Breslow MJ, et al. Intensive care unit telemedicine: alternate paradigm for providing continuous intensivist care. Crit Care Med. 2000;28(12):3925–3931. doi:10.1097/00003246-200012000-00034 [CrossRef]
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- Marcin JP, Schepps DE, Page KA, et al. Pediatr Crit Care Med. 2004;5(3):251–256. doi:10.1097/01.PCC.0000123551.83144.9E [CrossRef]
- Marcin JP, Nesbitt TS, Struve S, Traugott C, Dimand RJ. Financial benefits of a pediatric intensive care unit-based telemedicine program to a rural adult intensive care unit: impact of keeping acutely ill and injured children in their local community. Telemed J E Health. 2004;10(Suppl 2):S1–5. doi:10.1089/1530562042631994 [CrossRef]