The Pacific Asynchronous TeleHealth (PATH) system: review of 1,000 pediatric teleconsultations

Comparison of Telemedicine Usage at Two Distinct Medicaid-Focused Pediatric Clinics

Objective: To compare telemedicine versus office visit use at two Medicaid-focused pediatric primary care clinics. Methods: Retrospective cohort study from March 15, 2020 - March 15, 2021 at two Medicaid-focused pediatric primary care clinics. Site A and Site B care for different populations (Site B care for mostly immigrant families with preferred language Spanish). Outcomes included the percent of visits conducted through telemedicine and reason for visit. Descriptive statistics, univariable and multivariable mixed multilevel logistic regression, were used to assess relationship between patient demographics and telemedicine use. Results: Out of 17,142 total visits, 13% of encounters at Site A (n = 987) and 25% of encounters at Site B (n = 2,421) were conducted using telemedicine. Around 13.8% of well-child care (n = 1,515/10,997), 36.2% of mental health care (n = 572/1,581), and 25.0% of acute care/follow-up (n = 1,893/7,562) were telemedicine visits. After adjustment for covariates, there was no difference in odds of a patient having any telemedicine use by preferred language, sex, or payor. Patients 1-4 years of age had the lowest odds of telemedicine use. At Site A, patients who identified as Non-Hispanic Black (odds ratio [OR] = 0.33, 95% confidence interval [CI] = 0.24-0.45), Hispanic/Latinx (OR = 0.40, 95% CI = 0.24-0.66), or other race/ethnicity (OR = 0.35, 95% CI = 0.23-0.55) had lower odds of telemedicine use in comparison to Non-Hispanic White. Conclusions: Telemedicine was successfully accessed by Medicaid enrollees for different types of pediatric primary care. There was no difference in telemedicine use by preferred language and payor. However, differences existed by age at both sites and by race/ethnicity at one site. Future research should explore operational factors that improve telemedicine access for marginalized groups.

Applying a Military Teleophthalmology Mobile App in a Noncombat Emergent Care Setting

INTRODUCTION

Teleophthalmology has a natural role in the military due to the inherent organization of its medical system, which provides care to patients in remote locations around the world. Improving access to ophthalmic care enhances force readiness because ocular trauma and disease can cause vision impairment or blindness and can occur anywhere service members are located. Recently, a secure, Health Insurance Portability and Accountability Act-compliant mobile phone application (app) for teleophthalmology called Forward Operating Base Expert Telemedicine Resource Utilizing Mobile Application for Trauma (FOXTROT) was beta tested in Afghanistan and demonstrated that this solution can improve and extend ophthalmic care in a deployed environment. There are few civilian or military teleophthalmology solutions for ocular trauma and disease in an urgent or emergent ophthalmic care setting. Civilian teleophthalmology solutions have largely been developed for disease-specific models of care. In this work, we address this gap by testing the FOXTROT app in a non-deployed, emergent care setting.

MATERIALS AND METHODS

We evaluated the use of the teleophthalmology mobile phone app (FOXTROT) in a non-deployed military setting at the Malcolm Grow Medical Clinics and Surgery Center at Joint Base Andrews in Maryland. Consults from the emergent care center were placed by providers using the app, and the on-call ophthalmologist responded with treatment and management recommendations. The primary outcomes were response within the requested time, visual acuity tested in both eyes, agreement between the teleophthalmology and the final diagnosis, and the number of communication or technical errors that prevented the completion of consults. The secondary outcomes were average response time and the number of consults uploaded to the medical record.

RESULTS

From October 2020 to January 2022, 109 consults were received. Ten consults had communication or technical errors that prevented the completion of consults within the app and were excluded from the analysis of completed consults. Of the 99 completed consults, responses were given within the requested time in 95 (96.0%), with the average response time in 11 minutes 48 seconds (95% confidence interval, 8 minutes 57 seconds to 14 minutes 41 seconds). Visual acuity was tested in both eyes in 56 (56.6%). There was agreement between the teleophthalmology diagnosis and the final diagnosisin 40 of 50 (80.0%) consults with both a teleophthalmology and final diagnosis. Ninety-eight (99.0%) consults were uploaded to the patient's medical record.

CONCLUSIONS

Beta testing of a teleophthalmology mobile phone app (FOXTROT) in a noncombat emergent care setting demonstrated that this solution can extend ophthalmic care in this environment at a military treatment facility. However, improvements in the reliability of the platform are needed in future developments to reduce communication and technical errors.

Use of telemedicine for initial outpatient subspecialist consultative visit: A national survey of general pediatricians and pediatric subspecialists

BACKGROUND

Evidence-based strategies are needed to support appropriate use of telemedicine for initial outpatient subspecialty consultative visits. To inform such strategies we performed a survey of general pediatricians and pediatric subspecialists about use of telemedicine for patients newly referred for pediatric subspecialty care.

METHODS

We developed and fielded an e-mail and postal survey of a national sample of 840 general pediatricians and 840 pediatric subspecialists in May and June 2020.

RESULTS

Of 266 completed surveys (17% response rate), 204 (76%) thought telemedicine should be offered for some and 29 (11%) thought telemedicine should be offered for all initial subspecialist visits. Most respondents who indicated telemedicine should be offered for some initial consultations believed this decision should be made by subspecialty attendings (176/204, 86%). Respondents prioritized several data elements to inform this decision, including clinical information and family-based contextual information (e.g., barriers to in-person care, interest in telemedicine, potential communication barriers). Factors perceived to reduce appropriateness of telemedicine for subspecialty consultation included need for interpreter services and prior history of frequent no-shows. Responses from generalists and subspecialists rarely differed significantly.

CONCLUSIONS

Survey results suggest potential opportunities to support the appropriate use of telemedicine for initial outpatient pediatric subspecialty visits through structured transfer of specific clinical and contextual information at the time of referral and through strategies to mitigate perceived communication or engagement barriers.

IMPLICATION

Pediatric physician beliefs about telemedicine for initial outpatient subspecialty consultative visits may inform future interventions to support appropriate telemedicine use.

LEVEL OF EVIDENCE

Survey of a national sample of clinicians.

Updated Review of the Pacific Asynchronous Telehealth System's Impact on Military Pediatric Teleconsultations

Introduction: The Pacific Asynchronous TeleHealth (PATH) system is an asynchronous provider-to-provider teleconsultation platform utilized by military medical facilities throughout the Western Pacific Region. This study focused on PATH utilization for pediatric cases and its impact on patient transfers and cost avoidance. Methods: This retrospective analysis reviewed PATH cases from March 2017 to February 2020 for patients aged 0-17 years. We reviewed the referring users' responses to survey questions related to the impact of PATH consultation on patient travel for in-person subspecialty care and the need for local referral. Data for cost avoidance were estimated using per diem rates and airline flight costs for Fiscal Year 2020. Results: A total of 2,448 pediatric consultations were submitted from 29 military medical facilities. Pediatric Pulmonology (n = 557, 24.5%), Pediatric Cardiology (n = 446, 19.6%), and Pediatric Neurology (n = 236, 10.37%) had the highest percentage of pediatric teleconsults. Approximately 42% of referring users completed the survey questions. Among survey respondents, 710 (69.4%) indicated that unnecessary patient transfers were prevented, equating to a cost savings of ∼$3.3 million. Conclusions: We observed robust utilization of the PATH system by pediatric providers in the Military Health System that ultimately resulted in substantial cost avoidance. This asynchronous telemedicine platform is a vital asset in locations with limited access or travel restriction to medical specialists, such as during pandemics.

Profiling Pediatric Potentially Avoidable Transfers Using Procedure and Diagnosis Codes

OBJECTIVES

While hospital-hospital transfers of pediatric patients are often necessary, some pediatric transfers are potentially avoidable. Pediatric potentially avoidable transfers (PATs) represent a process with high costs and safety risks but few, if any, benefits. To better understand this issue, we described pediatric interfacility transfers with early discharges.

METHODS

We conducted a descriptive study using electronic medical record data at a single-center over a 12-month period to examine characteristics of pediatric patients with a transfer admission source and early discharge. Among patients with early discharges, we performed descriptive statistics for PATs defined as patient transfers with a discharge home within 24 hours without receiving any specialized procedures or diagnoses.

RESULTS

Of the 2,415 pediatric transfers, 31.4% were discharged home within 24 hours. Among transferred patients with early discharges, 356 patients (14.7% of total patient transfers) received no specialized procedures or diagnoses. Direct admissions were categorized as PATs 1.9-fold more frequently than transfers arriving to the emergency department. Among transferred direct admissions, PAT proportions to the neonatal intensive care unit (ICU), pediatric ICU, and non-ICU were 5.1%, 17.3%, and 27.3%, respectively. Respiratory infections, asthma, and ill-defined conditions (eg, fever, nausea with vomiting) were the most common PAT diagnoses.

CONCLUSIONS

Early discharges and PATs are relatively common among transferred pediatric patients. Further studies are needed to identify the etiologies and clinical impacts of PATs, with a focus on direct admissions given the high frequency of PATs among direct admissions to both the pediatric ICU and non-ICU.

Advanced Virtual Support for Operational Forces: A 3-Year Summary

INTRODUCTION

The Military Health System mission is to provide medical care throughout the globe to service members and beneficiaries. To achieve this mission in the most austere of locations, telemedical support is an essential force multiplier when robust in-person medical support is not feasible. This led to the development of a telemedical solution initially known as the Virtual Critical Care Consultation service which provided tele-critical care assistance to downrange providers. The VC3 system then expanded to include multiple medical specialties available for consultation. The current version of this telemedical solution is the ADvanced VIrtual Support for OpeRational Forces (ADVISOR) program which is a synchronous and asynchronous telemedicine system that was developed to provide 24/7 remote expert support to military clinicians engaged in casualty care in austere and operational environments.

MATERIALS AND METHODS

This manuscript reviews the ADVISOR program data collected from 2017 to 2020 and provides a rough order of magnitude for return on investment. We reviewed data collected by Operational Virtual Health Reports and Operational Virtual Health Evaluations following synchronous consultations. Part of the data reviewed was available patient demographic data, local caregiver information, the purpose of the consult, recommendations made during the consult, the technology used during the consult, and the patient disposition. They also recorded the evacuation plan for the patient and whether a medical evacuation was escalated (e.g. changed from routine to urgent, or from urgent to critical care air transport), downgraded (e.g. urgent to routine), or avoided altogether based on the telephonic consultation.

RESULTS

There were a total of 156 real-world calls during the evaluation period. The total cost savings for these calls was $1,097,027 (3-year program costs of $909,973 less an average of $87,261+/- $28,633 per call or $2,007,000 total) from downgrading or avoidance of planned evacuations. The unmeasured value associated with ADVISOR consultations should also be commented on. For example, when evacuation plans are escalated based on remote expert consultation, it is probable that the escalation increases patient safety and may avoid medical complications that would result in longer term medical costs to the government.

CONCLUSIONS

Based on the collected information, the financial return on investment has exceeded costs and the system is perceived as being valued added for both local caregivers and remote experts. The system appears to help optimize evacuation planning, specifically by downgrading or eliminating unnecessary evacuations.

Military Telehealth: A Model For Delivering Expertise To The Point Of Need In Austere And Operational Environments

Austere clinical environments are those in which limited resources hamper the achievement of optimal patient outcomes. Operational environments are those in which caregivers and resources are at risk for harm. Military and civilian caregivers experience these environments in the context of war, natural disasters, humanitarian assistance missions, and mass casualty events. The military has a particular interest in enhancing local caregiver capabilities within austere and operational environments to improve casualty outcomes when evacuation is delayed or impossible, reduce the cost and the risk of unnecessary evacuations, enhance the medical response during aid missions, and increase combat effectiveness by keeping service members in the fight as long as possible. This article describes military telehealth as it relates to care in austere and operational environments, and it suggests implications for policy, particularly with respect to the current emphasis on telehealth solutions that might not be feasible in those settings.

Electronic Consultation Systems: Impact on Pediatric Orthopaedic Care

BACKGROUND

The demand for pediatric orthopaedic surgery consultation has grown rapidly, leading to longer wait times for elective consultation in some regions. Some specialties are addressing this increased demand through electronic consultation services. We wanted to examine the impact of pediatric orthopaedic e-consultations in Canada's Eastern Ontario region.

METHODS

We developed a cross-sectional study of all the cases directed to a pediatric orthopaedic surgery specialist using the Champlain Building Access to Specialists through eConsultation (BASE) eConsult service over a 2-year period and examined their impact on in-person referrals, time of e-consultation and primary care satisfaction as well as types of clinical questions that were asked.

RESULTS

Electronic consultations avoided in-person appointments in 68% of the submitted cases. The median response by specialists received by the primary care providers (PCPs) was <20 hours. A total of 69% of consultations involve >1 type of clinical questions, most commonly about basic trauma/fracture care and management recommendations. Ninety-seven percent of the PCPs found the overall value for the care of the patients to be good or excellent.

CONCLUSIONS

This cross-sectional study demonstrates the effective and timely use of eConsult in pediatric orthopaedic surgery. It also shows a significant reduction in the number of in-person consultations required and demonstrates a high satisfaction rate by PCPs using the service.

CLINICAL RELEVANCE

In addition to the efficacy and time-sensitive care provided to the patients, the study shows that, professionally, 89% of PCPs found this service to be excellent or good. The broader implications of electronic consultation on overall quality of care, population health, and patient satisfaction requires further investigation.

Child Health and Telehealth in Global, Underresourced Settings

Telehealth has improved delivery of health care worldwide by improving access to and the quality of health care and by improving the global shortage of health professionals through collaboration and training. Although many telehealth efforts have been reported in adult health care settings, it is important to examine telehealth efforts in the pediatric setting. Children who are most commonly ill and malnourished are often those of underserved populations of the developing world. This article examines current uses of pediatric telehealth in a global setting and discusses key approaches to how telehealth may become successfully integrated and scaled in those settings.

Reduction in Medical Evacuations from Iraq and Syria Following Introduction of an Asynchronous Telehealth System

Introduction

While deployed, military medical personnel manage routine medical issues that fall under the category of Disease Non-Battle Injury (DNBI). The 86th Combat Support Hospital (CSH) partnered with Combined Joint Task Force-Operation Inherent Resolve (CJTF-OIR) Surgeon Cell, and Special Operations Joint Task Force-Operation Inherent Resolve (SOJTF-OIR) Surgeon Cell, to introduce the Health Experts onLine Portal (HELP) telemedicine system to medical personnel in Iraq and Syria. HELP is an asynchronous (store and forward) online system that provides secure provider-to-provider teleconsultation services for routine patient care and medical evacuation (MEDEVAC) coordination. The goal was to reduce the need for MEDEVAC by providing expert consultation to medical providers in farther-forward deployed units.

Material and Methods

In June 2017, the 86th CSH launched HELP telemedicine services for Kuwait. Following the successful implementation of the telemedicine system in Kuwait, the 86th CSH leadership partnered with CJTF-OIR and SOJTF-OIR medical leadership in launching the system within Iraq and Syria as well as making the system available to all deployed locations in Central Command (CENTCOM). This was a prospective cohort study designed to determine if having convenient and secure access to remote subspecialty consultation would be associated with a reduction in routine MEDEVACs from far forward in the battle space. In August 2017, new-user training was completed and the program launched in Iraq and Syria. This study analyzes the baseline MEDEVAC rate in 3 months before the implementation of HELP telemedicine compared to 3 months following the implementation.

Results

Iraq and Syria cases in the HELP telemedicine system accounted for 17.2% (76) of total CENTCOM telemedicine case volume over the 7-month study period. Comparing the 3-month period before and after implementation of HELP, use of asynchronous telemedicine in Iraq and Syria was associated with a reduction in total MEDEVACs from 157 to 68 (56.7% reduction, p &lt; 0.001). DNBI represented the majority of the change, (65.0% reduction, p &lt; 0.001). MEDEVAC for battle-related injuries decreased slightly from 13 to 6 per 3-month period (p = 0.03).

Conclusions

This is the first prospective study to demonstrate an association between the initiation of asynchronous telemedicine capabilities in a combat zone and decreased MEDEVACs. Annualized numbers would predict a reduction of 328 MEDEVACs/year for each 10,000 personnel by utilizing asynchronous telemedicine. This represents a significant potential cost savings of $1.2 million/year through avoidance of routine medical movement of personnel and supports unit readiness by retaining service members in areas of combat operations.

A Systematic Review of the Use of Telemedicine in the Military Forces Worldwide

Context: Considering the pivotal role of telemedicine in providing healthcare services for remote areas, some of the military medical centers, especially in developed countries, use different types of telemedicine programs. Objectives: The present study aimed at identifying the implemented telemedicine projects in military medicine worldwide and introducing their features. Evidence Acquisition: The current systematic review was performed in 2018. PubMed, Scopus, Embase, and Web of Science databases were searched for articles published from 2014 to 2018 by a combination of related keywords, and the related original articles were then selected based on the inclusion and exclusion criteria. Data were collected by a data extraction form, and then the data were summarized and reported based on the study objectives. Results: Of the 173 articles retrieved from the first round of search, 12 were included in the study; five (41.66%) studies had used the synchronous (real-time telemedicine) method. The United States, with nine studies, had the highest number of projects in military telemedicine. Most studies (n = 7) were performed on tele-psychology and the application of telemedicine in psychology. All selected studies reported the positive effects of telemedicine on providing healthcare for military forces. Conclusions: The proper utilization of telemedicine equipment is effective in saving time for both patients and healthcare providers, reducing costs, supporting in natural disasters, and satisfying patients with military medicine. To achieve telemedicine program objectives, they should be set precisely. Considering the importance of timely healthcare services, it is suggested to utilize synchronous methods and tools such as video conferencing.

Socioeconomic patient benefits of a pediatric neurosurgery telemedicine clinic

OBJECTIVE

The objective of this study was to examine the socioeconomic benefits to the patients and families attending a regional pediatric neurosurgery telemedicine clinic (PNTMC).

METHODS

A PNTMC was organized by the Division of Pediatric Neurosurgery of the University of Florida College of Medicine-Jacksonville based at Wolfson Children's Hospital and by the Children's Medical Services (CMS) to service the Southeast Georgia Health District. Monthly clinics are held with the CMS nursing personnel at the remote location. A retrospective review of the clinic population was performed, socioeconomic data were extracted, and cost savings were calculated.

RESULTS

Clinic visits from August 2011 through January 2017 were reviewed. Fifty-five patients were seen in a total of 268 initial and follow-up PNTMC appointments. The average round-trip distance for a family from home to the University of Florida Pediatric Neurosurgery (Jacksonville) clinic location versus the PNTMC remote location was 190 versus 56 miles, respectively. The families saved an average of 2.5 hours of travel time and 134 miles of travel distance per visit. The average transportation cost savings for all visits per family and for all families was $180 and $9711, respectively. The average lost work cost savings for all visits per family and for all families was $43 and $2337, respectively. The combined transportation and work cost savings for all visits totaled $223 per family and $12,048 for all families. Average savings of $0.68/mile and $48.50/visit in utilizing the PNTMC were calculated.

CONCLUSIONS

Managing pediatric neurosurgery patients and their families via telemedicine is feasible and saves families substantial travel time, travel cost, and time away from work.

Acceptability, Usability, and Effectiveness: A Qualitative Study Evaluating a Pediatric Telemedicine Program

BACKGROUND

Pediatric emergency telemedicine consultations have been shown to provide support to community emergency departments treating critically ill pediatric patients. However, despite the recognized value of telemedicine, adoption has been slow. To determine why clinicians frequently do not use telemedicine when it is available for pediatric patients, as well as to learn how to improve telemedicine programs, we conducted a qualitative study using stakeholder interviews.

METHODS

We conducted a qualitative study using grounded theory methodology, with in-depth interviews of referring and accepting physicians and referring, transport, and transfer center nurses. We analyzed data iteratively and adapted the interview guide based on early interviews. We solicited feedback from the participants on the conceptual model.

RESULTS

Sixteen interviews were conducted; all respondents had been involved in a telemedicine consultation at least five times, with some having used telemedicine more than 30 times. Analysis resulted in three themes: 1) recognizing and addressing telemedicine biases are central to gaining buy-in; 2) as technology advances, telemedicine processes need to adapt accordingly; and 3) telemedicine increases collaboration among health care providers and patients/families in the patient care process.

CONCLUSIONS

To improve patient care through increased use of telemedicine for pediatric emergency consultations, processes need to be modified to address provider biases and end-user concerns. Processes should be adapted to allow users to utilize a variety of technologies (including smartphones) and to enable more users, such as nurses, to participate. Finally, telemedicine can be used to improve the patient and family experience by including them in consultations.

[Intervention programs for psychological stress in children of military personnel in the USA - Results of a systematic literature review with regard to transferability to Germany]

Intervention programs for psychological stress in children of military personnel in the USA - Results of a systematic literature review with regard to transferability to Germany Abstract. Military personnel who have been deployed in war zones or other unstable regions are at an increased risk to develop mental health disorders, including posttraumatic stress disorder. Likewise, their children are at high risk to develop mental health problems as well as emotional and behavioral difficulties. Most research on prevalence of mental health problems as well as on interventions within this group was conducted in the USA. In Germany, no systematic intervention for children of military members focusing on their experiences of deployment exist. The systematic literature review aimed to analyze existing intervention programs in the USA, in particular for children of military members regarding evidence, type and addressed target group (parents, children, both). Compared to the social welfare and health care systems in the USA, the German systems are different. Hence, a second aim was to examine the transferability of these programs to the specific needs of children of German military members (Bundeswehr). 27 intervention programs could be included in the review. Programs, directly or indirectly, are addressing the needs of children of a deployed parent. They are usually focusing on the "emotional cycle of deployment" (phase of preparation of deployment, separation phase of deployment and the return of the deployed parent). The programs mainly focused on parenting skills, family reactions to stress, coping strategies of families, and the feeling of coherence within the family. Only 20 % of the interventions could be assigned to the type of indicated prevention. Nine interventions have shown positive effects (either in RCT or non-experimental designs). Several elements of the programs are transferable to the German situation of children of military members. In particular, contents which address the specific situation of families with a military member are desperately needed in Germany. Transferability is limited by the non-comparability of health care and social welfare systems in the USA and in Germany.

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.

The impact of electronic consultation on a Canadian tertiary care pediatric specialty referral system: A prospective single-center observational study

Background

Champlain BASE^™ (Building Access to Specialists through eConsultation) is a web-based asynchronous electronic communication service that allows primary-care- practitioners (PCPs) to submit “elective” clinical questions to a specialist. For adults, PCPs have reported improved access and timeliness to specialist advice, averted face-to-face specialist referrals in up to 40% of cases and high provider satisfaction.

Objective

To determine whether the expansion of eConsult to a pediatric setting would result in similar measures of improved healthcare system process and high provider acceptance reported in adults.

Design

Prospective observational cohort study.

Setting

Single Canadian tertiary-care academic pediatric hospital (June 2014–16) servicing 1.2 million people.

Participants

1. PCPs already using eConsult. 2.Volunteer pediatric specialists provided services in addition to their regular workload. 3.Pediatric patients (< 18 years-old) referred for none-acute care conditions.

Main outcomes and measures

Specialty service utilization and access, impact on PCP course-of-action and referral-patterns and survey-based provider satisfaction data were collected.

Results

1064 eConsult requests from 367 PCPs were answered by 23 pediatric specialists representing 14 specialty-services. The top three specialties represented were: General Pediatrics 393 cases (36.9%), Orthopedics 162 (15.2%) and Psychiatry 123 (11.6%). Median specialist response time was 0.9 days (range <1 hour-27 days), most consults (63.2%) required <10minutes to complete and 21/21(100%) specialist survey-respondents reported minimal workload burden. For 515/1064(48.4%) referrals, PCPs received advice for a new or additional course of action; 391/1064(36.7%) referrals resulted in an averted face-to-face specialist visit. In 9 specialties with complete data, the median wait-time was significantly less (p<0.001) for an eConsult (1 day, 95%CI:0.9–1.2) compared with a face-to-face referral (132 days; 95%CI:127–136). The majority (>93.3%) of PCPs rated eConsult as very good/excellent value for both patients and themselves. All specialist survey-respondents indicated eConsult should be a continued service.

Conclusions and relevance

Similar to adults, eConsult improves PCP access and timeliness to elective pediatric specialist advice and influences their care decisions, while reporting high end-user satisfaction. Further study is warranted to assess impact on resource utilization and clinical outcomes.

Pediatric neurosurgery telemedicine clinics: a model to provide care to geographically underserved areas of the United States and its territories

OBJECTIVE The author describes the creation, structuring, and development of a pediatric neurosurgery telemedicine clinic (TMC) to provide telehealth across geographical, time, social, and cultural barriers. METHODS In July 2009 the University of Florida (UF) Division of Pediatric Neurosurgery received a request from the Southeast Georgia Health District (Area 9-2) to provide a TMC to meet regional needs. The Children's Medical Services (CMS) of the State of Georgia installed telemedicine equipment and site-to-site connectivity. Audiovisual connectivity was performed in the UF Pediatric Neurosurgery office, maintaining privacy and HIPAA (Health Insurance Portability and Accountability Act) requirements. Administrative steps were taken with documentation of onsite training of the secretarial and nursing personnel of the CMS clinic. Patient preregistration and documentation were performed as required by the UF College of Medicine-Jacksonville. Monthly clinics are held with the CMS nursing personnel presenting the pertinent clinical history and findings to the pediatric neurosurgeon in the presence of the patient/parents. Physical findings and diagnostic studies are discussed, and management decisions are made. RESULTS The first TMC was held in August 2011. A total of 40 TMC sessions have been held through January 2016, with a total of 43 patients seen: 13 patients once; 13 patients twice; 8 patients for 3 visits; 2 for 4 visits; 2 for 6 visits; 2 for 5 visits; 2 for 7 visits; and 1 patient has been seen 8 times. CONCLUSIONS Pediatric patients in areas of the continental US and its territories with limited access to pediatric neurosurgery services could benefit from this model, if other pediatric neurosurgery centers provide telehealth services.

Synchronous telehealth for outpatient allergy consultations: A 2-year regional experience

BACKGROUND

Telehealth continues to advance as a health care modality; however, reported experience for synchronous TeleAllergy is limited.

OBJECTIVE

To determine the percentage of new and follow-up visits conducted via TeleAllergy in a hospital-based clinic.

METHODS

A retrospective study evaluating the first 2 years of a synchronous patient-to-allergist TeleAllergy platform.

RESULTS

A total of 112 synchronous TeleAllergy encounters were conducted from January 2014 through December 2015; 66 (59%) of these were new consultations. The mean (SD) age was 26.9 (15.3) years, and 54% of the participants were female. Food allergy (30%), allergic rhinitis (20%), and urticaria (16%) represented the top 3 consultation reasons. Sixteen of 66 patients (24.2%) and 3 of 46 patients (6.5%) attending new and follow-up TeleAllergy visits, respectively, were recommended for an in-person appointment (P = .02). No difference was found between new and follow-up TeleAllergy visits regarding subsequent telephone communication (41% vs 26%, P = .11) or prescriptions ordered (50% vs 33%, P = .08). New TeleAllergy visits were more likely to have more than 1 laboratory test ordered (45% vs 17%, P = .002). On the basis of patient location, the 112 TeleAllergy visits resulted in an estimated savings of 200 workdays or schooldays, US$58,000 in travel-related costs, and 80,000 kilometers not driven.

CONCLUSION

Both new and follow-up visits to the allergist/immunologist were well received by patients and demonstrated significant indirect cost savings, with less than one fourth of the patients recommended for an in-person visit. This appears to be the first systematic assessment of TeleAllergy for new and follow-up patient encounters in a clinic-based allergy/immunology practice.

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.

The Health Experts onLine at Portsmouth (HELP) system: One-year review of adult and Pediatric Asynchronous Telehealth Consultations

Introduction:

The Health Experts onLine at Portsmouth teleconsultation system is designed to connect health providers in the Navy Medicine East Region to specialists at Naval Medical Center Portsmouth.

Methods:

A review of the first year of the Health Experts onLine at Portsmouth system was performed. Data on each teleconsultation were extracted from the Health Experts onLine at Portsmouth system database and analyzed.

Results:

From June 2014 to May 2015 there have been 585 teleconsultations. Providers stationed on 36 ships/submarines and at 28 remote military treatment facilities have utilized the Health Experts onLine at Portsmouth system. Over 280 specialists in 34 different specialties were consulted. The median time to first response from a specialist was 6 h and 8 min, with 75% of all consults being addressed within 24 h. Eighteen medevacs were recommended. Thirty-nine potential medevacs were prevented, and 100 potential civilian network deferrals were prevented, resulting in an estimated savings of over US$580,000.

Discussion:

Based on the 1-year metrics, Health Experts onLine at Portsmouth has provided improved access and quality of care to service members and their families throughout the Navy Medicine East Region. It has helped avoid over US$580,000 in unnecessary cost burden. Further review at the 2-year time interval will demonstrate the continued growth and effectiveness of the Health Experts onLine at Portsmouth system.

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.

Establishing an integrated gastroenterology service between a medical center and the community

AIM

To combine community and hospital services in order to enable improvements in patient management, an integrated gastroenterology service (IGS) was established.

METHODS

Referral patterns to specialist clinics were optimized; open access route for endoscopic procedures (including esophago-gastro-duodenoscopy, sigmoidoscopy and colonoscopy) was established; family physicians' knowledge and confidence were enhanced; direct communication lines between experts and primary care physicians were opened. Continuing education, guidelines and agreed instructions for referral were promoted by the IGS. Six quality indicators were developed by the Delphi method, rigorously designed and regularly monitored. Improvement was assessed by comparing 2010, 2011 and 2012 indicators.

RESULTS

An integrated delivery system in a specific medical field may provide a solution to a fragmented healthcare system impaired by a lack of coordination. In this paper we describe a new integrated gastroenterology service established in April 2010. Waiting time for procedures decreased: 3 mo in April 30th 2010 to 3 wk in April 30th 2011 and stayed between 1-3 wk till December 30th 2012. Average cost for patient's visit decreased from 691 to 638 NIS (a decrease of 7.6%). Six health indicators were improved significantly comparing 2010 to 2012, 2.5% to 67.5%: Bone densitometry for patients with inflammatory bowel disease, preventive medications for high risk patients on aspirin/NSAIDs, colonoscopy following positive fecal occult blood test, gastroscopy in Barrett's esophagus, documentation of family history of colorectal cancer, and colonoscopy in patients with a family history of colorectal cancer.

CONCLUSION

Establishment of an IGS was found to effectively improve quality of care, while being cost-effective.

Increasing hospitalizations in inflammatory bowel disease among children in the United States, 1988-2011

BACKGROUND

Our objective was to characterize national trends in inflammatory bowel disease (IBD)-related hospitalizations for children. We hypothesized that over time, improvements in care would be associated with a decrease in hospitalization rates, similar to what has been observed in Canadian children with IBD.

METHODS

Retrospective, serial, cross-sectional analysis of annual, nationally representative samples of children with IBD.

RESULTS

Overall, discharges for all children irrespective of diagnosis decreased from 1988 to 2011 (P for trend <0.001). In contrast, discharges for children with IBD rose over the same time period from 6.1 (95% confidence interval [CI], 4.0-8.2) to 8.2 (95% CI, 5.5-10.9) per 100,000 individuals per year (P for trend <0.001). More of this rise occurred in hospitalizations that did not have IBD-related endoscopy or surgery performed (P for trend <0.001). Although mean length of stay decreased over the study period (P for trend <0.001), total hospital days increased over the latter half of the study with a significant increase over the entire study period (P for trend <0.001).

CONCLUSIONS

Contrary to clinically informed hypotheses, nationally representative rates of hospitalization for pediatric patients with IBD have increased since the mid-1990s. This directly contrasts with stable rates over the preceding years. Most of the expansion in hospital care seems to be related to hospitalizations that do not include procedures. Several lines of future research may greatly facilitate a better understanding of the epidemiologic, therapeutic, and health care resource issues at play.

Assessing the quality of teleconsultations in a store-and-forward telemedicine network

Store-and-forward telemedicine in resource-limited settings is becoming a relatively mature activity. However, there are few published reports about quality measurement in telemedicine, except in image-based specialties, and they mainly relate to high- and middle-income countries. In 2010, Médecins Sans Frontières (MSF) began to use a store-and-forward telemedicine network to assist its field staff in obtaining specialist advice. To date, more than 1000 cases have been managed with the support of telemedicine, from a total of 40 different countries. We propose a method for assessing the overall quality of the teleconsultations provided in a store-and-forward telemedicine network. The assessment is performed at regular intervals by a panel of observers, who – independently – respond to a questionnaire relating to a randomly chosen past case. The answers to the questionnaire allow two different dimensions of quality to be assessed: the quality of the process itself and the outcome, defined as the value of the response to three of the four parties concerned, i.e., the patient, the referring doctor, and the organization. It is not practicable to estimate the value to society by this technique. The feasibility of the method was demonstrated by using it in the MSF telemedicine network, where process quality scores, and user-value scores, appeared to be stable over a 9-month trial period. This was confirmed by plotting the cusum of a portmanteau statistic (the sum of the four scores) over the study period. The proposed quality-assessment method appears feasible in practice, and will form one element of a quality assurance program for MSF’s telemedicine network in future. The method is a generally applicable one, which can be used in many forms of medical interaction.

The impact of telemedicine intensivist support and a pediatric hospitalist program on a community hospital

BACKGROUND

Because of centralization of care, pediatric patients often require transfer for subspecialty care. We evaluated the impact of telemedicine critical care consultation and a pediatric hospitalist program on enabling patients to remain at a community hospital.

PATIENTS AND METHODS

This is a retrospective chart review of pediatric patients at a community hospital receiving critical care consultation from a tertiary children's hospital from January 2006 to October 2009. Patient cohorts differed by modality of intensivist consultation (telephone versus telemedicine) and modality of inpatient ward care at the community hospital (primary care physician versus hospitalist). Patients were compared for differences in transfer rate and rate of diversion from the pediatric intensive care unit to the tertiary ward.

RESULTS

One hundred fifty-three charts were analyzed: 41 from prior to hospitalist and telemedicine implementation (Cohort 1), 56 from post-implementation of telemedicine but pre-hospitalist program (Cohort 2), and 56 after implementation of both the telemedicine and hospitalist programs (Cohort 3). Baseline data did not differ among cohorts. Transfer rates after intensivist consultation were lower after implementation of telemedicine consultation (100%, 85.7%, and 87.5% in Cohorts 1-3, respectively; p=0.04). The proportion of transferred patients who were diverted to the tertiary ward decreased over time (19.5%, 14.5%, and 6.1% in Cohorts 1-3, respectively; p=0.003).

CONCLUSIONS

Telemedicine consultation between pediatric intensivists and community hospital physicians combined with a pediatric hospitalist program at the community hospital has the potential to improve triage of pediatric patients and reduce the need to transfer patients.

The U.S. Army Telemedicine and m-Health Program: making a difference at home and abroad

This article highlights the deployment of telemedicine by the U.S. Army through the various echelons of care and in overseas locations, including range and scope of health services provided by telemedicine in a challenging environment. This is followed by a discussion of technological developments advances in mobile communications likely to change the practice of telemedicine in the military from limited fixed-point access to a highly mobile individual with handheld communication devices.

Adoption of telemedicine: from pilot stage to routine delivery

BACKGROUND

Today there is much debate about why telemedicine has stalled. Teleradiology is the only widespread telemedicine application. Other telemedicine applications appear to be promising candidates for widespread use, but they remain in the early adoption stage. The objective of this debate paper is to achieve a better understanding of the adoption of telemedicine, to assist those trying to move applications from pilot stage to routine delivery.

DISCUSSION

We have investigated the reasons why telemedicine has stalled by focusing on two, high-level topics: 1) the process of adoption of telemedicine in comparison with other technologies; and 2) the factors involved in the widespread adoption of telemedicine. For each topic, we have formulated hypotheses. First, the advantages for users are the crucial determinant of the speed of adoption of technology in healthcare. Second, the adoption of telemedicine is similar to that of other health technologies and follows an S-shaped logistic growth curve. Third, evidence of cost-effectiveness is a necessary but not sufficient condition for the widespread adoption of telemedicine. Fourth, personal incentives for the health professionals involved in service provision are needed before the widespread adoption of telemedicine will occur.

SUMMARY

The widespread adoption of telemedicine is a major -- and still underdeveloped -- challenge that needs to be strengthened through new research directions. We have formulated four hypotheses, which are all susceptible to experimental verification. In particular, we believe that data about the adoption of telemedicine should be collected from applications implemented on a large-scale, to test the assumption that the adoption of telemedicine follows an S-shaped growth curve. This will lead to a better understanding of the process, which will in turn accelerate the adoption of new telemedicine applications in future. Research is also required to identify suitable financial and professional incentives for potential telemedicine users and understand their importance for widespread adoption.