An Economic Framework to Measure Value of Pediatric Telehealth

Advances in Pediatric Telehealth Education and Training: A National Survey

Background: The COVID-19 pandemic accelerated the formal integration of telehealth into education curricula and training programs, prompting the need to reevaluate the current landscape and inform a research agenda. We developed a survey to assess telehealth education and training curriculum, competencies, certification, and research across pediatric medical centers. Methods: Questions were derived from a previously published national survey and de novo. The survey was distributed across national pediatric professional associations. Results: In total, 32 respondents representing medical centers (86.5%) were providing telehealth education and/or training. Most were internally developed didactic (78.6%) and experiential (64.3%) curricula. Respondents who included education and/or training in telehealth research protocols and conducted telehealth research (74%) reported mandatory or optional training in tele-research. A form of certification was preferred by most organizations (>60%). Conclusion: Telehealth education and training are key factors within current and future service development, provision, and research to demonstrate competencies and positively impact patient care.

Translating Value Across Telehealth Stakeholders: A Rapid Review of Telehealth Measurement Evidence and a New Policy Framework to Guide Telehealth Researchers

Introduction: The surge in virtual care during the pandemic was accompanied by an increase in telehealth data of interest to policy stakeholders and other health care decision makers. However, these data often require substantial preprocessing and targeted analyses to be usable. By deliberately evaluating telehealth services with stakeholder perspectives in mind, telehealth researchers can more effectively inform clinical and policy decision making. Objective: To examine existing literature on telehealth measurement and evaluation and develop a new policy-oriented framework to guide telehealth researchers. Materials and Methods: A systematic rapid review of literature on telehealth measurement and evaluation was conducted by two independent reviewers in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The findings were analyzed and applied to the Supporting Pediatric Research on Outcomes and Utilization of Telehealth Evaluation and Measurement (STEM) Framework through the lens of key health care delivery decision makers to create a STEM Policy Framework Results: An initial search yielded 2,324 peer-reviewed articles and gray literatyre from 2012 to 2022, of which 56 met inclusion criteria. These measured and evaluated telehealth access (41.5%), quality (32.1%), cost (15.1%), experience (5.7%), and utilization (5.7%), consistent with the STEM Framework domains, but there was no universal approach. The STEM Policy Framework focuses this literature by describing data measures for each domain from the perspectives of five stakeholders. Conclusions: Literature describing measurement and evaluation approaches for telehealth is limited and not standardized, with few considering policy stakeholder perspectives. With this proposed STEM Policy Framework, we aim to improve this body of literature and support researchers seeking to inform telehealth policy through their work.

Telehealth Evaluation in the United States: Protocol for a Scoping Review

BACKGROUND

The rapid expansion of telehealth services, driven by the COVID-19 pandemic, necessitates systematic evaluation to guarantee the quality, effectiveness, and cost-effectiveness of telehealth services and programs in the United States. While numerous evaluation frameworks have emerged, crafted by various stakeholders, their comprehensiveness is limited, and the overall state of telehealth evaluation remains unclear.

OBJECTIVE

The overarching goal of this scoping review is to create a comprehensive overview of telehealth evaluation, incorporating perspectives from multiple stakeholder categories. Specifically, we aim to (1) map the existing landscape of telehealth evaluation, (2) identify key concepts for evaluation, (3) synthesize existing evaluation frameworks, and (4) identify measurements and assessments considered in the United States.

METHODS

We will conduct this scoping review in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews and in line with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). This scoping review will consider documents, including reviews, reports, and white papers, published since January 1, 2019. It will focus on evaluation frameworks and associated measurements of telehealth services and programs in the US health care system, developed by telehealth stakeholders, professional organizations, and authoritative sources, excluding those developed by individual researchers, to collect data that reflect the collective expertise and consensus of experts within the respective professional group.

RESULTS

The data extracted from selected documents will be synthesized using tools such as tables and figures. Visual aids like Venn diagrams will be used to illustrate the relationships between the evaluation frameworks from various sources. A narrative summary will be crafted to further describe how the results align with the review objectives, facilitating a comprehensive overview of the findings. This scoping review is expected to conclude by August 2024.

CONCLUSIONS

By addressing critical gaps in telehealth evaluation, this scoping review protocol lays the foundation for a comprehensive and multistakeholder assessment of telehealth services and programs. Its findings will inform policy makers, health care providers, researchers, and other stakeholders in advancing the quality, effectiveness, and cost-effectiveness of telehealth in the US health care system.

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Telehealth and Children with Medical Complexity

Although use of telehealth may have begun centuries ago and has grown considerably through the 20th century, the coronavirus disease 2019 pandemic skyrocketed telemedicine's reach, including its use in pediatrics. The American Academy of Pediatrics endorses telehealth as a "critical infrastructure to efficiently implement the medical home model of care." Particularly for children with medical complexity (CMC), telehealth offers great promise to improve access to continuous, coordinated primary care, reduce time to pediatric subspecialty care, and support distance education for both pediatric providers and patients and their families. This article details the numerous benefits of telehealth to CMC with an emphasis on its use as an extender of the medical home, describes the venues in which telehealth augments access to safe, high-quality care, presents best practices in engaging in telehealth encounters, and enumerates barriers that may exacerbate current health inequities. We review current published telehealth patient-/caregiver-level, clinician-level, and payor-level outcomes while revealing research gaps and opportunities. [Pediatr Ann. 2024;53(3):e74-e81.].

Telehealth Coverage for a Pediatric Gastroenterology Consult Service at a Regional Hospital: An Accepted, Useful, and Sustainable Model of Care

OBJECTIVE

To evaluate a novel telehealth inpatient pediatric gastroenterology (GI) consult service at a regional children's hospital in regard to acceptance, utility, quality, sustainability, and provider resiliency.

STUDY DESIGN

Patients requiring GI care at a regional children's hospital between July 2020 and June 2021 were treated by an in-person or telehealth physician with physician assistant support, randomly assigned based on a weekly preset staffing schedule. A retrospective, multidomain program evaluation was performed based on the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) and STEM (SPROUT Telehealth Evaluation and Management) frameworks, using statistical analysis to compare the patient cohorts and anonymous surveys to assess provider perceptions.

RESULTS

In total, 1051 patient-days of GI care were provided for 348 patients, 17% by telehealth and 83% in-person. There were no significant differences in diagnosis, transfer, or readmission rates between the cohorts. No transfers occurred for reasons other than need to access specialized services not available at the regional hospital. Daily consult workload was slightly greater for telehealth physicians. Primary and consult team providers accepted the practice. The model continued beyond the first year. In total, 75% of local GI physicians reported greater Brief Resilience Scores in the context of shifting 20% of their inpatient call weeks to another campus's physicians.

CONCLUSION

Episodic pediatric GI consult service coverage via telehealth at a regional hospital was well accepted, useful, and sustainable, with improved physician resilience and no adverse outcomes seen. Telehealth holds promise for leveraging pediatric subspecialty physicians across hospitals, allowing complex patients to be admitted closer to home while reducing inpatient coverage requirements for smaller physician groups.

A pediatric virtual care evaluation framework and its evolution using consensus methods

BACKGROUND

The use of virtual care has increased dramatically in response to the COVID-19 pandemic, yet evidence is lacking regarding the impact of virtual care on patient outcomes, particularly in pediatrics. A standardized evaluation approach is required to support the integration of virtual care into pediatric health care delivery programs. The objective of this work was to develop a comprehensive and structured framework for pediatric virtual care evaluation. This framework is intended to engage and guide care providers, health centres, and stakeholders towards the development of a standardized approach to the evaluation of pediatric virtual care.

METHODS

We brought together a diverse multidisciplinary team, including pediatric clinicians, researchers, digital health leads and analysts, program leaders, a human factors engineer, a family advisor and our manager of health equity and diversity. The team reviewed the literature, including published evaluation frameworks, and used a consensus-based method to develop a virtual care evaluation framework applicable to a broad spectrum of pediatric virtual care programs. We used an iterative process to develop framework components, including domains and sub-domains, examples of evaluation questions, measures, and data sources. Team members met repeatedly over seven months to generate and provide feedback on all components of the framework, making revision as needed until consensus was reached. The framework was then applied to an existing virtual care program.

RESULTS

The resulting framework includes four domains (health outcomes, health delivery, individual experience, and program implementation) and 19 sub-domains designed to support the development and evaluation of pediatric virtual care programs. We also developed guidance on how to use the framework and illustrate its utility by applying it to an existing pediatric virtual care program.

CONCLUSIONS

This virtual care evaluation framework expands on previously developed frameworks by providing additional detail and a structure that supports practical application. It can be used to evaluate a wide range of pediatric virtual care programs in a standardized manner. Use of this comprehensive yet easy to use evaluation framework will inform appropriate implementation and integration of virtual care into routine practice and support its sustainability and continuous improvement.

Implementation and Evaluation of a Wraparound Virtual Care Program for Children with Medical Complexity

Objectives: Children and adolescents with medical complexity benefit from care coordination and specialized pediatric care, but many access barriers exist. We implemented a virtual wraparound model to support patients with medical complexity and their families and used an economic framework to measure outcomes. Methods: Children with medical complexity were identified and enrolled in a virtual complex care program with a dedicated multidisciplinary team, which provided care coordination, education, parental support, acute care triage, and virtual visits. A retrospective pre- and postanalysis of data obtained from the Hospital Industry Data Institute (HIDI) database measured inpatient, outpatient, and emergency department (ED) utilization and charges before implementation and during the 2-year program. Results: Eighty (n = 80) children were included in the economic evaluation, and 75 had sufficient data for analysis. Compared to the 12 months before enrollment, patients had a 35.3% reduction in hospitalizations (p = 0.0268), a 43.9% reduction in emergency visits (p = 0.0005), and a 16.9% reduction in overall charges (p = 0.1449). Parents expressed a high degree of satisfaction, with a 70% response rate and 90% satisfaction rate. Conclusions: We implemented a virtual care model to provide in-home support and care coordination for medically complex children and adolescents and used an economic framework to assess changes in utilization and cost. The program had high engagement rates and parent satisfaction, and a pre/postanalysis demonstrated statistically significant reduction in hospitalizations and ED visits for this high-cost population. Further economic evaluation is needed to determine sustainability of this model in a value-based payment system.

A Telehealth and Telepsychiatry Economic Cost Analysis Framework: Scoping Review

Introduction: Despite a good evidence base for telepsychiatry (TP), economic cost analyses are infrequent and vary in quality. Methods: A scoping review was conducted based on the research question, "From the perspective of an economic cost analysis for telehealth and telepsychiatry, what are the most meaningful ways to ensure a study/intervention improved clinical care, provided value to participants, had population level impact, and is sustainable?" The search in seven databases focused on keywords in four concept areas: (1) economic cost analysis, (2) evaluation, (3) telehealth and telepsychiatry, and (4) quantifiable health status outcomes. The authors reviewed the full-text articles based on the inclusion (Medical Subject Headings [MeSH] of the keywords) and exclusion criteria. Results: Of a total of 2,585 potential references, a total of 99 articles met the inclusion criteria. The evaluation of telehealth and TP has focused on access, quality, patient outcomes, feasibility, effectiveness, outcomes, and cost. Cost-effectiveness, cost-benefit, and other analytic models are more common with telehealth than TP studies, and these studies show favorable clinical, quality of life, and economic impact. A standard framework for economic cost analysis should include: an economist for planning, implementation, and evaluation; a tool kit or guideline; comprehensive analysis (e.g., cost-effectiveness or cost-benefit) with an incremental cost-effectiveness ratio; measures for health, quality of life, and utility outcomes for populations; methods to convert outcomes into economic benefits (e.g., monetary, quality of adjusted life year); broad perspective (e.g., societal perspective); sensitivity analysis for uncertainty in modeling; and adjustments for differential timing (e.g., discounting and future costs). Conclusions: Technology assessment and economic cost analysis-such as effectiveness and implementation science approaches-contribute to clinical, training, research, and other organizational missions. More research is needed with a framework that enables comparisons across studies and meta-analyses.

Modeling the Cost of Teleneonatology from the Health System Perspective

Introduction: Teleneonatology (TN) allows remote neonatologists to provide real-time audio-video telemedicine support to community hospitals when neonates require advanced resuscitation or critical care. Currently, there are no published economic evaluations of U.S. TN programs. Objective: To evaluate the cost of TN from the perspective of the health care system. Methods: We constructed a decision tree comparing TN to usual care for neonates born in hospitals without a neonatal intensive care unit (NICU) who require consultation. Our outcome of interest was total cost per patient, which included the incremental cost of a TN program, the cost of medical transport, and the cost of NICU or non-NICU hospitalization. We performed threshold sensitivity analyses where we varied each parameter to determine whether the base-case finding reverted. Results: For neonates requiring consultation after birth in a hospital without a NICU, TN was less costly ($16,878) than usual care ($28,047), representing a cost-savings of $11,168 per patient. Sensitivity analyses demonstrated that at least one of the following conditions would need to be met for TN to no longer be cost saving compared to usual care: transfer rate with usual care <12% (base-case = 82%), TN reducing the odds of transfer by <8% (base-case = 52%), or TN cost exceeding $12,989 per patient (base-case = $1,821 per patient). Conclusions: Economic modeling from the health system perspective demonstrated that TN was cost saving compared to usual care for neonates requiring consultation following delivery in a non-NICU hospital. Understanding the cost savings associated with TN may influence organizational decisions regarding implementation, diffusion, and retention of these programs.

Telehealth: Opportunities to Improve Access, Quality, and Cost in Pediatric Care

The use of telehealth technology to connect with patients has expanded significantly over the past several years, particularly in response to the global coronavirus disease 2019 pandemic. This technical report describes the present state of telehealth and its current and potential applications. Telehealth has the potential to transform the way care is delivered to pediatric patients, expanding access to pediatric care across geographic distances, leveraging the pediatric workforce for care delivery, and improving disparities in access to care. However, implementation will require significant efforts to address the digital divide to ensure that telehealth does not inadvertently exacerbate inequities in care. The medical home model will continue to evolve to use telehealth to provide high-quality care for children, particularly for children and youth with special health care needs, in accordance with current and evolving quality standards. Research and metric development are critical for the development of evidence-based best practices and policies in these new models of care. Finally, as pediatric care transitions from traditional fee-for-service payment to alternative payment methods, telehealth offers unique opportunities to establish value-based population health models that are financed in a sustainable manner.

Remote Monitoring of Patient- and Family-Generated Health Data in Pediatrics

In this article, we provide an overview of remote monitoring of pediatric PGHD and family-generated health data, including its current uses, future opportunities, and implementation resources.