Telemedicine: Pediatric Applications

Patient Satisfaction With an Early Smartphone-Based Cosmetic Surgery Postoperative Follow-Up

BACKGROUND

While prevalent in everyday life, smartphones are also finding increasing use as a medical care adjunct. The use of smartphone technology as a postoperative cosmetic surgery adjunct for care has received little attention in the literature.

OBJECTIVES

The purpose of this effort was to assess the potential efficacy of a smartphone-based cosmetic surgery early postoperative follow-up program. Specifically, could smartphone photography provided by the patient to the plastic surgeon in the first few days after surgery allay patient's concerns, improve the postoperative experience and, possibly, detect early complications?

METHODS

From August 2015 to March 2016 a smartphone-based postoperative protocol was established for patients undergoing cosmetic procedures. At the time of discharge, the plastic surgeon sent a text to the patient with instructions for the patient to forward a postoperative photograph of the operated area within 48 to 72 hours. The plastic surgeon then made a return call/text that same day to review the patient's progress. A postoperative questionnaire evaluated the patients' postoperative experience and satisfaction with the program.

RESULTS

A total of 57 patients were included in the study. Fifty-two patients responded to the survey. A total of 50 (96.2%) patients reported that the process improved the quality of their postoperative experience. The protocol allowed to detect early complications in 3 cases. The physician was able to address and treat the complications the following day prior to the scheduled clinic follow up.

CONCLUSIONS

The smartphone can be effectively utilized by the surgeon to both enhance the patient's postoperative experience and alert the surgeon to early postoperative problems.

LEVEL OF EVIDENCE

4.

Use of telehealth in the delivery of comprehensive care for patients with haemophilia and other inherited bleeding disorders

Advances in technology such as telemedicine (TM) have made access to cost-effective, quality health care feasible for remote patients. TM is especially well suited for patients with chronic disorders such as haemophilia and related haemostatic disorders that benefit not only from more frequent interaction with care providers at a specialized haemophilia treatment center but also from consultations with other specialists. Telehealth refers to a broader application of TM and includes non-clinical services such as education, provider training, administrative meetings etc. Collaboration with the local primary care provider for management and implementation is key for successful and sustainable TM. This review article provides an overview of types of telemedicine, technical aspects, its benefits and challenges and focuses on the applicability of this technology to persons with bleeding and other blood disorders. Examples of TM strategies, process flow of TM clinic and experiences at the authors haemophilia treatment center (HTC) setting are shared. In addition, mobile health (mHealth) and electronic health (eHealth), both a part of telehealth, and their applications are briefly described. Clearly, widespread adoption of this technology will not only enhance care of patients but will enable more people, especially in underserved areas, to receive specialty care.

Nonemergency Acute Care: When It's Not the Medical Home

The American Academy of Pediatrics (AAP) affirms that the optimal location for children to receive care for acute, nonemergency health concerns is the medical home. The medical home is characterized by the AAP as a care model that "must be accessible, family centered, continuous, comprehensive, coordinated, compassionate, and culturally effective." However, some children and families use acute care services outside the medical home because there is a perceived or real benefit related to accessibility, convenience, or cost of care. Examples of such acute care entities include urgent care facilities, retail-based clinics, and commercial telemedicine services. Children deserve high-quality, appropriate, and safe acute care services wherever they access the health care system, with timely and complete communication with the medical home, to ensure coordinated and continuous care. Treatment of children under established, new, and evolving practice arrangements in acute care entities should adhere to the core principles of continuity of care and communication, best practices within a defined scope of services, pediatric-trained staff, safe transitions of care, and continuous improvement. In support of the medical home, the AAP urges stakeholders, including payers, to avoid any incentives (eg, reduced copays) that encourage visits to external entities for acute issues as a preference over the medical home.

A novel approach in pediatric telegenetic services: geneticist, pediatrician and genetic counselor team

Purpose

Our aim was to improve access to genetic services in an underserved region by developing a collaborative telegenetic service delivery model with a pediatrician, medical geneticist, and genetics counselor (GC).

Methods

Protocols for the evaluation of common genetic indications were developed. Patients referred with indications suggestive of a syndromic etiology were scheduled to see the geneticist directly via telegenetics. Other patients were scheduled to see the pediatrician and GC in person before follow-up with the geneticist if indicated. Patients seen by the geneticist and/or pediatrician/GC were enumerated and the next available appointment was tracked. Patient satisfaction surveys were conducted.

Results

Of the 265 patients evaluated during the study period, 116 (44%) were evaluated by a pediatrician and GC in person first, after which 82 (71% of those evaluated) required further follow-up with the geneticist. The next available appointment with a pediatrician and GC never exceeded 6 weeks, while new appointments with a geneticist ranged from 3 to 9 months. All patients reported high satisfaction with this genetic service model.

Conclusion

The pediatrician/GC clinic provides a model of collaborative care that is a medical home neighbor and exemplifies the integration of genetics into primary care. The telegenetics clinic offers a viable solution to providing competent and convenient access to a geneticist for patients in chronically underserved regions.

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.

What drives attitude towards telemedicine among families of pediatric patients? A survey

BACKGROUND

Telemedicine has been recognized as a way to improve accessibility, quality, and efficiency of care. In view of the introduction of new telemedicine services, we conducted a survey through a self-administered questionnaire among families of children attending the Bambino Gesù Children's Hospital IRCCS, a tertiary care children's hospital located in Rome, Italy.

METHODS

We investigated sociodemographic data, clinical information, technological profile, attitude towards telemedicine, perceived advantages of telemedicine, fears regarding telemedicine, willingness to use a smartphone app providing telemedicine services and willingness to use a televisit service. Through logistic regression, we explored the effect of sociodemographic and clinical variables and technological profile on willingness of using a telemedicine app and a televisit service.

RESULTS

We enrolled a total of 751 families. Most patients had a high technological profile, 81% had at least one account on a social network. Whatsapp was the most popular messaging service (76%). Seventy-two percent of patients would use an app for telemedicine services and 65% would perform a televisit. Owning a tablet was associated with both outcome variables - respectively: OR 2.216, 95% CI 1.358-3.616 (app) and OR 2.117, 95% CI 1.415-3.168 (televisit). Kind of hospitalization, diagnosis of a chronic disease, disease severity and distance from the health care center were not associated with the outcome variables.

CONCLUSION

Families of pediatric patients with different clinical problems are keen to embark in telemedicine programs, independently from severity of disease or chronicity, and of distance from the hospital.

Overview on the Challenges and Benefits of Using Telehealth Tools in a Pediatric Population

Telehealth in Pediatric Medicine presents many of the same benefits and challenges noted in adult-based medicine. In terms of health care delivery, the promise of improving access and reducing costs using telehealth in Pediatrics, particularly chronic care, is high. The ability to address clinician shortages and provide remote guidance for chronic care pathways from pediatric subspecialists to rural-based referring physicians is a developing model that represents a sustainable and cost-effective strategy to improve pediatric care. The adoption and implementation of consistent telehealth programs require a readjustment of current regulatory rules and a national discussion on reimbursement and compliance standards. Presently, state laws generally define the rules, whereby health systems or practices can use telehealth for patient care and education. Long-term telehealth program development depends on the ongoing value and use case provided by pediatric advocates for this emerging health care delivery model.

Design and Implementation of a Telepediatric Primary-Level and Low-Cost System to Reduce Unnecessary Patient Transfers

BACKGROUND

Most inhabitants in Latin America are concentrated in large urban foci with different access to facilities. Although the main hospitals offer specialized services, economically vulnerable populations cannot easily afford these services, the pediatric population being most affected. This article presents the design and implementation of a low cost telepediatric system, applied to primary care hospitals through a study in Bogotá, Colombia, mainly aimed to reduce the number of unnecessary transfers commonly sent to specialized medical services.

MATERIALS AND METHODS

The system was carried out over 6 months with a higher incidence of acute respiratory illness in children between 0 and 5 years in nine primary care hospitals in Bogotá. Nineteen (n = 19) pediatricians were trained by a group of engineers that supports the system permanently. The reduction of patient transfers was compared with previous reports of the National Statistical Department in Colombia.

RESULTS

The system reduced both the number of patient transfers to higher level hospitals by 83% and the waiting times for patient transfer, improving healthcare in pediatric patients at a reasonable cost, affecting more than 700 patients. At the same time, a decrease of about 17% in the use of antibiotics was observed, which is an important current public health issue.

CONCLUSIONS

The use of telemedicine improves the efficiency of public health resources, even in big cities such as Bogotá, reducing the number of unnecessary patient transfers and the optimization and appropriate use of medicines.

Interhospital transfer of pediatric neurosurgical patients

OBJECTIVE The purpose of this study was to describe patterns of transfer, resource utilization, and clinical outcomes associated with the interhospital transfer of pediatric neurosurgical patients. METHODS All consecutive, prospectively collected requests for interhospital patient transfer to the pediatric neurosurgical service at Texas Children's Hospital were retrospectively analyzed from October 2013 to September 2014. Demographic patient information, resource utilization, and outcomes were recorded and compared across predefined strata (low [< 5%], moderate [5%-30%], and high [> 30%]) of predicted probability of mortality using the Pediatric Risk of Mortality score. RESULTS Requests for pediatric neurosurgical care comprised 400 (3.7%) of a total of 10,833 calls. Of 400 transfer admissions, 96.5%, 2.8%, and 0.8% were in the low, moderate, and high mortality risk groups, respectively. The median age was 54 months, and 45% were female. The median transit time was 125 minutes. The majority of transfers were after-hours (69.8%); nearly a third occurred during the weekend (32.3%). The median intensive care unit stay for 103 patients was 3 days (range 1-269 days). Median length of hospital stay was 2 days (range 1-269 days). Ninety patients (22.5%) were discharged from the emergency room after transfer. Seventy-seven patients (19.3%) required neurosurgical intervention after transfer, with the majority requiring a cranial procedure (66.2%); 87.3% of patients were discharged home. CONCLUSIONS This study highlights patient characteristics, resource utilization, and outcomes among pediatric neurosurgical patients. Opportunities for quality improvement were identified in diagnosing and managing isolated skull fractures and neck pain after trauma.

A Review of Pediatric Telemental Health

Because of the widening gap between need for child mental health services and availability of child specialists, secure videoconferencing options are more needed than ever to address access challenges across underserved settings. This article reviews real-time videoconferencing evidence across telemental health with children and adolescents. It summarizes emerging guidelines that inform best practices for child telemental health using videoconferencing. It presents a case example of best practices across behavioral health specialties. Videoconferencing is an effective approach to improving access to behavioral health interventions for children and adolescents. Telemental health shows promise for disseminating evidence-based treatments to underserved communities.

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.

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.