Barriers and facilitators to pediatric emergency telemedicine in the United States

Perceived Benefits, Barriers, and Drivers of Telemedicine From the Perspective of Skilled Nursing Facility Administrative Staff Stakeholders

Potentially avoidable hospitalizations (PAHs) of skilled nursing facility (SNF) patients are common and costly. Telemedicine represents a unique approach to manage and potentially reduce PAHs in SNFs, having been used in a variety of settings to improve coordination of care and enhance access to providers. Nonetheless, broad implementation and use of telemedicine lags in SNFs relative to other health care settings. To understand why, we surveyed SNF administrative staff attending a 1-day telemedicine summit. Participants saw the highest value of telemedicine in improving the quality of care and reducing readmissions. They identified hospital and managed care telemedicine requirements as primary drivers of adoption. The most significant barrier to adoption was the initial investment required. A joint research-policy effort to improve the evidence base around telemedicine in SNFs and introduce incentives may improve adoption and continued use of telemedicine in this setting.

Impact of Telemedicine on Severity of Illness and Outcomes Among Children Transferred From Referring Emergency Departments to a Children's Hospital PICU

OBJECTIVES

To compare the severity of illness and outcomes among children admitted to a children's hospital PICU from referring emergency departments with and without access to a pediatric critical care telemedicine program.

DESIGN

Retrospective cohort study.

SETTING

Tertiary academic children's hospital PICU.

PATIENTS

Pediatric patients admitted directly to the PICU from referring emergency departments between 2010 and 2014.

INTERVENTIONS

None.

MEASUREMENTS

Demographic factors, severity of illness, and clinical outcomes among children receiving care in emergency departments with and without access to pediatric telemedicine, as well as a subcohort of children admitted from emergency departments before and after the implementation of telemedicine.

MAIN RESULTS

Five hundred eighty-two patients from 15 emergency departments with telemedicine and 524 patients from 60 emergency departments without telemedicine were transferred and admitted to the PICU. Children admitted from emergency departments using telemedicine were younger (5.6 vs 6.9 yr; p< 0.001) and less sick (Pediatric Risk of Mortality III score, 3.2 vs 4.0; p < 0.05) at admission to the PICU compared with children admitted from emergency departments without telemedicine. Among transfers from emergency departments that established telemedicine programs during the study period, children arrived significantly less sick (mean Pediatric Risk of Mortality III scores, 1.2 units lower; p = 0.03) after the implementation of telemedicine (n = 43) than before the implementation of telemedicine (n = 95). The observed-to-expected mortality ratios of posttelemedicine, pretelemedicine, and no-telemedicine cohorts were 0.81 (95% CI, 0.53-1.09), 1.07 (95% CI, 0.53-1.60), and 1.02 (95% CI, 0.71-1.33), respectively.

CONCLUSIONS

The implementation of a telemedicine program designed to assist in the care of seriously ill children receiving care in referring emergency departments was associated with lower illness severity at admission to the PICU. This study contributes to the body of evidence that pediatric critical care telemedicine programs assist referring emergency departments in the care of critically ill children and could result in improved clinical outcomes.

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.

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.

The role of telemedicine in pediatric critical care

Telemedicine technologies involve real-time, live, interactive video and audio communication and allow pediatric critical care physicians to have a virtual presence at the bedsides of critically ill children. Telemedicine use is increasing and will be a common in remote emergency departments, inpatient wards, and intensive care units for pediatric care. Hospitals and physicians that use telemedicine technologies provide higher quality of care, are more efficient in resource use with improved cost-effectiveness, and have higher satisfaction among patients, parents, and remote providers. More research will result in improved access to pediatric critical care expertise.

Pediatric Critical Care Telemedicine Program: A Single Institution Review

BACKGROUND

Rural and community emergency departments (EDs) often receive and treat critically ill children despite limited access to pediatric expertise. Increasingly, pediatric critical care programs at children's hospitals are using telemedicine to provide consultations to these EDs with the goal of increasing the quality of care.

MATERIALS AND METHODS

We conducted a retrospective review of a pediatric critical care telemedicine program at a single university children's hospital. Between the years 2000 and 2014, we reviewed all telemedicine consultations provided to children in rural and community EDs, classified the visits using a comprehensive evidence-based set of chief complaints, and reported the consultations' impact on patient disposition. We also reviewed the total number of pediatric ED visits to calculate the relative frequency with which telemedicine consultations were provided.

RESULTS

During the study period, there were 308 consultations provided to acutely ill and/or injured children for a variety of chief complaints, most commonly for respiratory illnesses, acute injury, and neurological conditions. Since inception, the number of consultations has been increasing, as has the number of participating EDs (n = 18). Telemedicine consultations were conducted on 8.6% of seriously ill children, the majority of which resulted in admission to the receiving hospital (n = 150, 49%), with a minority of patients requiring transport to the university children's hospital (n = 103, 33%).

CONCLUSIONS

This single institutional, university children's hospital-based review demonstrates that a pediatric critical care telemedicine program used to provide consultations to seriously ill children in rural and community EDs is feasible, sustainable, and used relatively infrequently, most typically for the sickest pediatric patients.