Remote Patient Monitoring and Telemedicine in Neonatal and Pediatric Settings: Scoping Literature Review

The adaptation of a single institution diabetes care platform into a nationally available turnkey solution

Digital decision support and remote patient monitoring may improve outcomes and efficiency, but rarely scale beyond a single institution. Over the last 5 years, the platform Timely Interventions for Diabetes Excellence (TIDE) has been associated with reduced care provider screen time and improved, equitable type 1 diabetes care and outcomes for 268 patients in a heterogeneous population as part of the Teamwork, Targets, Technology, and Tight Control (4T) Study (NCT03968055, NCT04336969). Previous efforts to deploy TIDE at other institutions continue to face delays. In partnership with the diabetes technology non-profit, Tidepool, we developed Tidepool-TIDE, a clinic-agnostic, turnkey solution available to any clinic in the United States. We present how we overcame common technical and operational barriers specific to scaling digital health technology from one site to many. The concepts described are broadly applicable for institutions interested in facilitating broader adoption of digital technology for population-level management of chronic health conditions.

Assessing the potential for virtualizable care in the pediatric emergency department

INTRODUCTION

There is increasing interest for patient-to-provider telemedicine in pediatric acute care. The suitability of telemedicine (virtualizability) for visits in this setting has not been formally assessed. We estimated the proportion of in-person pediatric emergency department (PED) visits that were potentially virtualizable, and identified factors associated with virtualizable care.

METHODS

This was a retrospective analysis of in-person visits at the PED of a Canadian tertiary pediatric hospital (02/2018-12/2019). Three definitions of virtualizable care were developed: (1) a definition based on "resource use" classifying visits as virtualizable if they resulted in a home discharge, no diagnostic testing, and no return visit within 72 h; (2) a "diagnostic definition" based on primary ED diagnosis; and (3) a stringent "combined definition" by which visits were classified as virtualizable if they met both the resource use and diagnostic definitions. Multivariable logistic regression was used to identify factors associated with telemedicine suitability.

RESULTS

There were 130,535 eligible visits from 80,727 individual patients during the study period. Using the most stringent combined definition of telemedicine suitability, 37.9% (95% confidence interval (CI) 37.6%-38.2%) of in-person visits were virtualizable. Overnight visits (adjusted odds ratio (aOR) 1.16-1.37), non-Canadian citizenship (aOR 1.10-1.18), ethnocultural vulnerability (aOR 1.14-1.22), and a consultation for head trauma (aOR 3.50-4.60) were associated with higher telemedicine suitability across definitions.

DISCUSSION

There is a high potential for patient-to-provider telemedicine in the PED setting. Local patient and visit-level characteristics must be considered in the design of safe and inclusive telemedicine models for pediatric acute care.

Telemedicine in nutritional management of children with severe neurological impairment: implication for quality of life

Children with severe neurological impairment (SNI) frequently present feeding problems requiring a close monitoring of their nutritional status. In addition to constant clinical monitoring of body composition and nutritional indexes in these patients, frequent reports of dietary intake and weight gain variations are useful to ensure proper nutritional management. Furthermore, non-oral feeding is often needed to avoid malnutrition or aspiration pneumonia, constantly necessitating medical assistance. Despite their necessity for frequent hospital accesses, these patients' disabilities represent an important obstacle to accessing care, generating anxiety and concern in children and their families. Telemedicine has proven to be a promising instrument for improving pediatric patients' healthcare in several fields. By breaking down geographical and temporal barriers, telehealth may represent a valuable tool to implement in clinical practice, in order to improve patients' outcomes and quality of life. The aim of this narrative review is to provide an overview of the main nutritional issues in children with SNI, the potential implications of telemedicine in their management and the available evidence regarding the effects and benefits of telehealth.

Enhancing Internet of Medical Things security with artificial intelligence: A comprehensive review

Over the past five years, interest in the literature regarding the security of the Internet of Medical Things (IoMT) has increased. Due to the enhanced interconnectedness of IoMT devices, their susceptibility to cyber-attacks has proportionally escalated. Motivated by the promising potential of AI-related technologies to improve certain cybersecurity measures, we present a comprehensive review of this emerging field. In this review, we attempt to bridge the corresponding literature gap regarding modern cybersecurity technologies that deploy AI techniques to improve their performance and compensate for security and privacy vulnerabilities. In this direction, we have systematically gathered and classified the extensive research on this topic. Our findings highlight the fact that the integration of machine learning (ML) and deep learning (DL) techniques improves both the performance of cybersecurity measures and their speed, reliability, and effectiveness. This may be proven to be useful for improving the security and privacy of IoMT devices. Furthermore, by considering the numerous advantages of AI technologies as opposed to their core cybersecurity counterparts, including blockchain, anomaly detection, homomorphic encryption, differential privacy, federated learning, and so on, we provide a structured overview of the current scientific trends. We conclude with considerations for future research, emphasizing the promising potential of AI-driven cybersecurity in the IoMT landscape, especially in patient data protection and in data-driven healthcare.

A single centre study of the level of parents' satisfaction with the COVID-19 telemedicine consultation

Telemedicine is an effective tool for video consultation of COVID-19 patients in the setting of the COVID-19 pandemic. We prospectively determined the level of parents' satisfaction with the COVID-19 telemedicine consultation. This was a single centre prospective study. COVID-19 paediatric patients who were seen in the children's emergency department of KK Women's and Children's Hospital, Singapore, and deemed fit for home recovery were discharged with a COVID-19 telemedicine follow-up in two to three days' time. Paediatric patients who were seen in the COVID-19 telemedicine visits were included in the parents' satisfaction survey. We excluded patients who defaulted their telemedicine visits. The telemedicine satisfaction survey was conducted using an online form consisting of 16 Likert scale questions, sent via text messaging. Our primary outcome was telemedicine satisfaction scores. Our secondary outcome was children's emergency department reattendance or hospital admission within 10 days after the telemedicine consultation. 1238 patients attended the COVID-19 video consultation clinic from 15 December 2021 till 25 March 2022, out of which 476 parents of the COVID-19 patients completed the survey questionnaire. The mean age of the COVID-19 patients was 3.6 years. There was a high level of overall satisfaction among parents of the COVID-19 patients, with a mean score of 6.1 out of 7. 12 out of 16 questions had a positive response (mean score of 6 or more). There was a total of 9 reattendances to children's emergency department, out of which 3 cases needed hospital admission.    Conclusion: There was a high level of overall satisfaction with the use of telemedicine in symptomatic COVID-19 paediatric patients. What is Known: • Telemedicine is a cost-effective and feasible mode of delivering health care for conditions such as diabetes, heart disease, and depressive disorder, especially in the setting of the COVID-19 pandemic. What is New: • To gauge the parents' satisfaction with the COVID-19 telemedicine visit, in order to improve the patient and caregiver experience with telemedicine, and to improve the telemedicine service delivery. • Information from this study is crucial in order to prevent unnecessary hospital reattendance due to parental concern from poor telemedicine delivery.

Insight into the Digital Health System of Ukraine (eHealth): Trends, Definitions, Standards, and Legislative Revisions

Purpose

This article aims to provide an in-depth examination of the digital health system of Ukraine, focusing on the emerging trends, precise definitions, established standards, and recent legislative revisions that shape the practice and implementation of eHealth solutions within the country.

Background

The digital health landscape in Ukraine has witnessed significant transformations, especially in the wake of the COVID-19 pandemic and subsequent military conflicts. These events have catalyzed the expansion of telemedicine services, leading to innovative approaches in healthcare delivery. The national strategy underscores the necessity for human-centric and accessible telemedicine, reinforced by technological neutrality, and harmonization with global standards.

Methods

A review of the current literature, national strategies, and legal documents was conducted, alongside an analysis of data usage and service provision patterns in various Ukrainian regions. Participation in the "Science for Safety and Sustainable Development of Ukraine" competition facilitated project initiatives like the development of a cloud-based platform for patient-centered telerehabilitation for oncology patients.

Findings

The utilization of telemedicine has significantly increased in conflict-affected regions, demonstrating the need for, and the effective deployment of, digital health strategies under crisis conditions. Private health facilities and entrepreneurs have been pivotal in the provision of telemedicine services. Legislative efforts have been geared toward framing telemedicine as an integral component of the national eHealth system, ensuring interoperability, and aligning with international standards and the Internet of Medical Things (IoMT).

Interpretation

The findings underscore the resilience and adaptability of the Ukrainian healthcare system in the face of adversity. There is a clear trend towards a more integrated, patient-focused, and technologically advanced healthcare model, aligning with international trends and prioritizing public health goals over private profits. This progress, however, is contingent upon continuous development, investment in technological infrastructure, and legislative support to sustain and advance digital health initiatives.

Mobile Device-Based Video Screening for Infant Head Lag: An Exploratory Study

INTRODUCTION

Video-based automatic motion analysis has been employed to identify infant motor development delays. To overcome the limitations of lab-recorded images and training datasets, this study aimed to develop an artificial intelligence (AI) model using videos taken by mobile phone to assess infants' motor skills.

METHODS

A total of 270 videos of 41 high-risk infants were taken by parents using a mobile device. Based on the Pull to Sit (PTS) levels from the Hammersmith Motor Evaluation, we set motor skills assessments. The videos included 84 level 0, 106 level 1, and 80 level 3 recordings. We used whole-body pose estimation and three-dimensional transformation with a fuzzy-based approach to develop an AI model. The model was trained with two types of vectors: whole-body skeleton and key points with domain knowledge.

RESULTS

The average accuracies of the whole-body skeleton and key point models for level 0 were 77.667% and 88.062%, respectively. The Area Under the ROC curve (AUC) of the whole-body skeleton and key point models for level 3 were 96.049% and 94.333% respectively.

CONCLUSIONS

An AI model with minimal environmental restrictions can provide a family-centered developmental delay screen and enable the remote monitoring of infants requiring intervention.

Parent experiences of a remote patient monitoring program enabling early discharge from the neonatal intensive care unit with nasogastric tube feeding

BACKGROUND

This exploratory study examined parents' experiences with "Growing at Home" (G@H), a remote patient monitoring program for stable infants discharged from the Neonatal Intensive Care Unit (NICU) with continued need for nasogastric tube feeding.

METHODS

We used classical content analysis to identify and refine emergent themes from 13 semi-structured key informant interviews.

RESULTS

The primary emergent theme was the desire to return to normalcy, which was expressed as a primary motivator for participating in G@H. Parents reported G@H assisted them in transitioning from the NICU's highly medicalized setting to establishing a new normal with incorporation of their infant into their lives and families. Parental preparation is important, as some parents experienced challenges that indicate the program may not be suitable for all families.

CONCLUSIONS

Parental experiences offer insight into benefits and challenges of early discharge from the NICU and highlight opportunities to support families beginning in the NICU and as they transition home.

Screening left ventricular systolic dysfunction in children using intrinsic frequencies of carotid pressure waveforms measured by a novel smartphone-based device

Objective.Children with heart failure have higher rates of emergency department utilization, health care expenditure, and hospitalization. Therefore, a need exists for a simple, non-invasive, and inexpensive method of screening for left ventricular (LV) dysfunction. We recently demonstrated the practicality and reliability of a wireless smartphone-based handheld device in capturing carotid pressure waveforms and deriving cardiovascular intrinsic frequencies (IFs) in children with normal LV function. Our goal in this study was to demonstrate that an IF-based machine learning method (IF-ML) applied to noninvasive carotid pressure waveforms can distinguish between normal and abnormal LV ejection fraction (LVEF) in pediatric patients.Approach. Fifty patients ages 0 to 21 years underwent LVEF measurement by echocardiogram or cardiac magnetic resonance imaging. On the same day, patients had carotid waveforms recorded using Vivio. The exclusion criterion was known vascular disease that would interfere with obtaining a carotid artery pulse. We adopted a hybrid IF- Machine Learning (IF-ML) method by applying physiologically relevant IF parameters as inputs to Decision Tree classifiers. The threshold for low LVEF was chosen as <50%.Main results.The proposed IF-ML method was able to detect an abnormal LVEF with an accuracy of 92% (sensitivity = 100%, specificity = 89%, area under the curve (AUC) = 0.95). Consistent with previous clinical studies, the IF parameterω1was elevated among patients with reduced LVEF.Significance.A hybrid IF-ML method applied on a carotid waveform recorded by a hand-held smartphone-based device can differentiate between normal and abnormal LV systolic function in children with normal cardiac anatomy.

Utilization of Remote Patient Monitoring Within the United States Health Care System: A Scoping Review

Introduction: Limited information exists on the landscape of studies and policies for remote patient monitoring (RPM) in the United States. Methods: We conducted a scoping review to assess (1) for which adult patient populations and health care needs is RPM being used and (2) the landscape of national- and state-level reimbursement policies for RPM. This study was guided by the Arksey and O'Malley methodological framework for scoping reviews and the Joanna Briggs Institute Manual for Evidence Synthesis. Results: A total of 399 articles were included in our final sample: 268 study articles and 131 articles of gray literature (e.g., websites, legislative bills). RPM-related articles rose drastically from 2015 to 2021, and the vast majority of articles were peer-reviewed journal articles. Of the study articles, prospective cohort studies were the most common study method, with m-health/smart watches being the most common RPM modality. RPM was found to be most commonly tested within patients with cardiovascular diseases, and the most common outcomes measured were usability and feasibility. Gray literature found 36 U.S. state Medicaid programs had reimbursement policies for RPM in 2021; however, 28 of those had at least one restriction on reimbursement (e.g., limited to specific providers). Conclusions: Despite the rapid growth in the literature on RPM and the adoption of reimbursement policies, retrospective, population-level studies, large randomized controlled trials, studies with a focus on additional favorable outcomes (e.g., quality of life), and studies evaluating trends in RPM reimbursement policies are lacking in the current literature.

Contactless Cardiovascular Assessment by Imaging Photoplethysmography: A Comparison with Wearable Monitoring

Despite the notable recent developments in the field of remote photoplethysmography (rPPG), extracting a reliable pulse rate variability (PRV) signal still remains a challenge. In this study, eight image-based photoplethysmography (iPPG) extraction methods (GRD, AGRD, PCA, ICA, LE, SPE, CHROM, and POS) were compared in terms of pulse rate (PR) and PRV features. The algorithms were made robust for motion and illumination artifacts by using ad hoc pre- and postprocessing steps. Then, they were systematically tested on the public dataset UBFC-RPPG, containing data from 42 subjects sitting in front of a webcam (30 fps) while playing a time-sensitive mathematical game. The performances of the algorithms were evaluated by statistically comparing iPPG-based and finger-PPG-based PR and PRV features in terms of Spearman's correlation coefficient, normalized root mean square error (NRMSE), and Bland-Altman analysis. The study revealed POS and CHROM techniques to be the most robust for PR estimation and the assessment of overall autonomic nervous system (ANS) dynamics by using PRV features in time and frequency domains. Furthermore, we demonstrated that a reliable characterization of the vagal tone is made possible by computing the Poincaré map of PRV series derived from the POS and CHROM methods. This study supports the use of iPPG systems as promising tools to obtain clinically useful and specific information about ANS dynamics.

Inter-hospital cardiorespiratory telemonitoring of newborns and infants: a wellworking example of a hub and spoke network

BACKGROUND

Patients who experience cardiorespiratory events usually have to be moved to specialized centers to perform cardiorespiratory studies. To avoid the transfer of these patients to specialized centers, a network has been created based on an interchange system, where the recordings were uploaded in unspecialized centers (spokes) and downloaded by the Sleep Disorders Breathing (SDB) Center (hub) to be analyzed.

METHODS

The inter-hospital network was established in November 2008. Initially only 3 non-tertiary hospitals in the Tuscany Region joined the network. Currently, 12 Tuscany hospitals are included.

RESULTS

From November 2008 to December 2020, 625 recordings were collected belonging to 422 infants. No recurrent life-threatening episode or infant death occurred in the study population and none of the infants needed to be readmitted or be moved to a tertiary center, except infants who underwent home monitoring. The discharge diagnoses belong to the following categories: apnoea, respiratory problem of the newborn, syncope, gastroesophageal reflux, altered consciousness, transient loss of consciousness and cyanosis.

CONCLUSIONS

This study shows that the inter-hospital network is an efficient system that allows accurate and safe management of infants at risk for apnoea, bradycardia, and hypoxemia to remain in unspecialized centers, avoiding unnecessary transfers of patients and over - hospitalizations.

How Useful Are Digital Health Terms for Outcomes Research? An ISPOR Special Interest Group Report

OBJECTIVES

This study aimed to review definitions of digital health and understand their relevance for health outcomes research. Four umbrella terms (digital health, electronic health, mobile health, and telehealth/telemedicine) were summarized in this article.

METHODS

PubMed/MEDLINE, Embase, Cochrane Library, and EconLit were searched from January 2015 to May 2020 for systematic reviews containing key Medical Subject Headings terms for digital health (n = 38) and synonyms of "definition." Independent pairs of reviewers performed each stage of the review, with reconciliation by a third reviewer if required. A single reviewer consolidated each definition for consistency. We performed text analysis via word clouds and computed document frequency-and inverse corpus frequency scores.

RESULTS

The search retrieved 2610 records with 545 articles (20.9%) taken forward for full-text review. Of these, 39.3% (214 of 545) were eligible for data extraction, of which 134 full-text articles were retained for this analysis containing 142 unique definitions of umbrella terms (digital health [n = 4], electronic health [n = 36], mobile health [n = 50], and telehealth/telemedicine [n = 52]). Seminal definitions exist but have increasingly been adapted over time and new definitions were created. Nevertheless, the most characteristic words extracted from the definitions via the text analyses still showed considerable overlap between the 4 umbrella terms.

CONCLUSIONS

To focus evidence summaries for outcomes research purposes, umbrella terms should be accompanied by Medical Subject Headings terms reflecting population, intervention, comparator, outcome, timing, and setting. Ultimately a functional classification system is needed to create standardized terminology for digital health interventions denoting the domains of patient-level effects and outcomes.

Intelligent Remote Photoplethysmography-Based Methods for Heart Rate Estimation from Face Videos: A Survey

Over the last few years, a rich amount of research has been conducted on remote vital sign monitoring of the human body. Remote photoplethysmography (rPPG) is a camera-based, unobtrusive technology that allows continuous monitoring of changes in vital signs and thereby helps to diagnose and treat diseases earlier in an effective manner. Recent advances in computer vision and its extensive applications have led to rPPG being in high demand. This paper specifically presents a survey on different remote photoplethysmography methods and investigates all facets of heart rate analysis. We explore the investigation of the challenges of the video-based rPPG method and extend it to the recent advancements in the literature. We discuss the gap within the literature and suggestions for future directions.

Pediatric Telemedicine: Lessons Learned During the Coronavirus Disease 2019 Pandemic and Opportunities for Growth

The accelerated uptake of telemedicine during the coronavirus disease 2019 pandemic has resulted in valuable experience and evidence on the delivery of telemedicine for pediatric patients. The pandemic has also highlighted inequities and opportunities for improvement. This review discusses lessons learned during the pandemic, focusing on provider-to-patient virtual encounters. Recent evidence on education and training, developing and adapting clinical workflows, patient assessment and treatment, and family-centered care is reviewed. Opportunities for future research in pediatric telemedicine are discussed, specifically with regard to engaging pediatric patients, improving and measuring access to care, addressing health equity, and expanding the evidence base.

Utility of Fitbit devices among children and adolescents with chronic health conditions: a scoping review

Background

While Fitbit® devices were initially intended for leisurely, consumer use, there has been recent interest among scientific and medical communities in the prospective use of Fitbit devices for clinical and research purposes. Those who have chronic health conditions are often required to spend considerable amounts of money and time undergoing physiological tests and activity monitoring to support, stabilize, and manage their health. This disease burden is only amplified in pediatric populations. Devices that are used to collect these data can be invasive, uncomfortable, and disconcerting. Using the Fitbit tracker to acquire such biometric data could ease this burden. Our scoping review seeks to summarize the research that has been conducted on the utilization of Fitbit devices in studies of children and adolescents with chronic health conditions and the feasibility, accuracy, and potential benefits of doing so.

Methods

Searches were conducted on PubMed for articles relating pediatric health to Fitbit device usage (using a Boolean search strategy). The eligibility criteria included trials being clinical and/or randomized controlled and articles being in English. Once articles were obtained, they underwent screening and exclusion processes and were charted for their titles, authors, objectives, results, and respective chronic illnesses. In the subsequent full-text review, further charting was conducted, collecting study designs, Fitbit parameters, feasibility, accuracy, and related health and clinical outcomes.

Results

Fitbit trackers were unanimously demonstrated to be feasible devices in this population for physical activity monitoring and were determined to be potentially beneficial in measuring and improving overall wellbeing and physical health in children with chronic illness. Nevertheless, sufficient evidence was not found in support of Fitbit accuracy. Additional biases were identified against the population of children with chronic health conditions that may further enable inaccurate data.

Conclusions

While Fitbit devices may be beneficial for those interested in improving physical health, discretion is advised for those seeking to collect accurate and/or medically necessitated data. Given the existing literature evaluated, medical-grade technologies are preferred in instances of the latter, as Fitbit devices have not been found to provide reliably accurate data.

Current Applications of Telemedicine in Gastroenterology

Telemedicine generally refers to the use of technology to communicate with patients and provide health care from a distance. Advances in technology, specifically computers, cellphones, and other mobile devices, have facilitated healthcare providers' growing ability to virtually monitor and mentor patients. There has been a progressive expansion in the use of telemedicine in the field of gastroenterology (GI), which has been accelerated by the COVID-19 pandemic. In this review, we discuss telemedicine-its history, various forms, and limitations-and its current applications in GI. Specifically, we focus on telemedicine in GI practice in general and specific applications, including the management of inflammatory bowel disease, celiac disease, and colorectal cancer surveillance and its use as an aid in endoscopic procedures.

Child Health, Vulnerability, and Complexity: Use of Telehealth to Enhance Care for Children and Youth With Special Health Care Needs

Telehealth, or the use of telecommunications technology and infrastructure to deliver health-related services and information that support patient care, has the potential to improve the quality of care, particularly deficiencies related to access and patient experience of care. Telehealth may also reduce disparities for children and youth with special health care needs (CYSHCN) with barriers to accessing in-person care, for example, those residing in rural areas and children with medical complexity who are particularly fragile. While important foundational work has been done to study telehealth's effectiveness and implementation, key gaps remain regarding its use for CYSHCN. The CYSHCNet national research agenda development process, described in a companion article, identified as key priority areas for future research telehealth as an innovative care delivery model for all CYSHCN and as a mechanism to address rural-urban disparities in health care access. Here, we review the current knowledge around telehealth, identify populations for whom telehealth could be especially beneficial, discuss the important gaps identified, and make recommendations for specific studies that will move the field forward. There are ample opportunities for telehealth to improve health and patient/family experience of care and quality of life for CYSHCN while requiring less time and resources from families accessing this care. Innovative research to inform best practices around incorporation and implementation of telehealth will improve its efficiency and effectiveness and achieve optimal outcomes.

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.

"Another Tool in Your Toolkit": Pediatric Occupational and Physical Therapists' Perspectives of Initiating Telehealth during the COVID-19 Pandemic

AIMS

Pediatric occupational and physical therapy service delivery via telehealth increased during the COVID-19 pandemic. Real-world experience can guide service improvement. This study explored experiences, barriers, and facilitators of initial telehealth implementation from the therapist's perspective.

METHODS

Qualitative descriptive approach. Semi-structured interviews were conducted with occupational therapists (n = 4) and physical therapists (n = 4) between May-June 2020. Interviews were recorded, and transcribed verbatim. Data were coded inductively to generate themes, then re-coded deductively to classify barriers and facilitators to telehealth acceptance and use using the Unified Technology Acceptance Theory.

RESULTS

Participants had 16.5 [(2-35); median (range)] years of experience (3 months with telehealth) and predominantly worked with preschool children. Three themes about telehealth were identified: a practical option; requires skill development and refinement; beneficial in perpetuity. Most frequently cited barriers were the lack of opportunity for 'hands-on' assessment/intervention and the learning curve required. Most frequently cited facilitators included seeing a child in their own environment, attendance may be easier for some families, and families' perception that telehealth was useful.

CONCLUSION

Despite rapid implementation, therapists largely described telehealth as a positive experience. Telehealth facilitated continued service provision and was perceived as relevant post-pandemic. Additional training and ensuring equitable access to services are priorities as telehealth delivery evolves.

Simulating Telehealth Experiences in the Neonatal Care Environment: Improving Access to Care

Telehealth in the neonatal environment can improve remote medical care and access to specialized care and training eliminating barriers for effective health care delivery. Clinicians are utilizing telehealth in their practice to provide specialized care and training in areas that have little access. Educating health care clinicians on the basics of telehealth is an essential component of clinical training programs. Use of simulation-based telehealth experiences as part of that training can provide hands-on learning in a safe, realistic environment. Simulation can prepare health care teams in using telehealth technology in managing patient care, postdischarge care, and specialized care programs.

The Waiting Room Assessment to Virtual Emergency Department pathway: Initiating video-based telemedicine in the pediatric emergency department

The COVID-19 pandemic has presented pediatric emergency departments with unique challenges, resulting in a heightened demand for adapted clinical pathways. In response to this need, the Montreal Children's Hospital pediatric emergency department introduced the WAVE (Waiting Room Assessment to Virtual Emergency Department) pathway, a video-based telemedicine pathway for selected non-critical patients, aiming to reduce safety issues related to emergency department overcrowding, while providing timely care to all children presenting and registering at our emergency department. The objective of the WAVE pilot phase was to evaluate the feasibility and acceptability of telemedicine in our pediatric emergency department, which was previously unfamiliar with this mode of care delivery. During the six-week, three-evening per week deployment, we conducted 18 five-hour telemedicine shifts. In total, 27 patients participated in the WAVE pathway. Results from this pilot phase met four of five a priori feasibility and acceptability criteria. Overall, participating families were satisfied with this novel care pathway and reported no disruptive technological barriers.

Remote patient monitoring after cardiac surgery: The utility of a novel telemedicine system

Objective

We examined cardiac surgery patients who underwent monitoring of postoperative vital parameters using medical monitoring devices which transferred data to a mobile application and a web‐based software.

Methods

From November 2017 to November 2020, a total of 2340 patients were enrolled in the remote patient monitoring system after undergoing cardiac surgery. The medical devices recorded vital parameters, such as blood pressure, pulse rate, saturation, body temperature, blood glucose, and electrocardiography were measured via the Health Monitor DakikApp and Holter ECG DakikApp devices which reported data to web‐based software and a mobile application (DakikApp Mobile Systems, Remscheid, Germany). During the follow‐up period, patients were contacted daily through text and voice messages, and video conferences. Remote Medical Evaluations (RMEs) concerning patients' medical states were performed. Medication reminders, daily treatment were communicated to the patients with the DakikApp Mobile Systems Software.

Results

During a mean follow‐up period of 78.9 ± 107.1 (10–395) days, a total of 135,786 patient contacts were recorded (782 video conferences, 2805 voice messaging, and 132,199 text correspondence). The number of RMEs handled by the Telemedicine Team was 79,560. A total of 105,335 vital parameter measurements were performed and 5024 hospital application requests (6.3% per RME) were addressed successfully and hospitalization was avoided. A total of 144 (6.1%) potentially life‐threatening complications were found to have been diagnosed early using the Telemedicine System.

Conclusion

Remote Patient Monitoring Systems combined with professional medical devices are feasible, effective, and safe for the purpose of improving postoperative outcomes.

Usefulness of video recordings for validating neonatal encephalopathy exams: a population-based cohort study

OBJECTIVE

To determine the usefulness of video recordings for validating neonatal encephalopathy (NE) exams.

DESIGN

Population-based prospective cohort study. NE was assessed and recorded at 1, 3 and 5 hours after birth by the attending physician. Recordings were reviewed blindly after the recruitment period by two specialists. Outcome was assessed at 36 months of age.

SETTING

Twelve intensive care units in Spain.

PATIENTS

Infants of ≥35 weeks' gestational age with perinatal asphyxia.

MAIN OUTCOMES MEASURES

Weighted kappa to measure disagreement between the two specialists and between the attending physician and the specialists' classification agreed on by consensus. Regression models to test the association of disagreement on NE assessment and outcome.

RESULTS

Of the 32 325 liveborn infants, 217 met the inclusion criteria. Video-recordings were not available for 43 infants (20%). Weighted kappa statistic was 0.74 (95% CI 0.67 to 0.81) between the specialists and the attending physicians. Disagreement occurred in 93 of the 417 (22%) videos, specifically in 39 (14%), 43 (47%), 11 (34%) and 0 exams categorised as no, mild, moderate and severe NE, respectively. According to the specialist consensus assessment, there was disagreement on the therapeutic hypothermia decision in 10 infants.When there was consensus among the specialists assessing a more severe NE degree compared with the attending physicians in 170 infants, those infants had lower cognitive scores with a median of -5.33 points (95% CI -9.85 to -8.16; p=0.02).

CONCLUSIONS

This study supports the feasibility and benefit of using video recordings to identify NE in infants with perinatal asphyxia.

Telemedicine in Pediatrics: Systematic Review of Randomized Controlled Trials

BACKGROUND

Telemedicine modalities, such as videoconferencing, are used by health care providers to remotely deliver health care to patients. Telemedicine use in pediatrics has increased in recent years. This has resulted in improved health care access, optimized disease management, progress in the monitoring of health conditions, and fewer exposures to patients with illnesses during pandemics (eg, the COVID-19 pandemic).

OBJECTIVE

We aimed to systematically evaluate the most recent evidence on the feasibility and accessibility of telemedicine services, patients' and care providers' satisfaction with these services, and treatment outcomes related to telemedicine service use among pediatric populations with different health conditions.

METHODS

Studies were obtained from the PubMed database on May 10, 2020. We followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. In this review, we included randomized controlled trials from the last 10 years that used a telemedicine approach as a study intervention or assessed telemedicine as a subspecialty of pediatric care. Titles and abstracts were independently screened based on the eligibility criteria. Afterward, full texts were retrieved and independently screened based on the eligibility criteria. A standardized form was used to extract the following data: publication title, first author's name, publication year, participants' characteristics, study design, the technology-based approach that was used, intervention characteristics, study goals, and study findings.

RESULTS

In total, 11 articles met the inclusion criteria and were included in this review. All studies were categorized as randomized controlled trials (8/11, 73%) or cluster randomized trials (3/11, 27%). The number of participants in each study ranged from 22 to 400. The health conditions that were assessed included obesity (3/11, 27%), asthma (2/11, 18%), mental health conditions (1/11, 9%), otitis media (1/11, 9%), skin conditions (1/11, 9%), type 1 diabetes (1/11, 9%), attention deficit hyperactivity disorder (1/11, 9%), and cystic fibrosis-related pancreatic insufficiency (1/11). The telemedicine approaches that were used included patient and doctor videoconferencing visits (5/11, 45%), smartphone-based interventions (3/11, 27%), telephone counseling (2/11, 18%), and telemedicine-based screening visits (1/11, 9%). The telemedicine interventions in all included studies resulted in outcomes that were comparable to or better than the outcomes of control groups. These outcomes were related to symptom management, quality of life, satisfaction, medication adherence, visit completion rates, and disease progression.

CONCLUSIONS

Although more research is needed, the evidence from this review suggests that telemedicine services for the general public and pediatric care are comparable to or better than in-person services. Patients, health care professionals, and caregivers may benefit from using both telemedicine services and traditional, in-person health care services. To maximize the potential of telemedicine, future research should focus on improving patients' access to care, increasing the cost-effectiveness of telemedicine services, and eliminating barriers to telemedicine use.

The Impact of the COVID-19 Pandemic and the Importance of Telemedicine in Managing Acute ST Segment Elevation Myocardial Infarction Patients: Preliminary Experience and Literature Review

The coronavirus disease 2019 (COVID-19), which is caused by a novel coronavirus (SARS-COV-2), has compromised health care systems and normal management of patients with cardiovascular diseases [1-3]. Patients with non-communicable diseases, including acute myocardial infarction (AMI) are vulnerable to this stress [4, 5]. Acute ST segment elevation myocardial infarction (STEMI), the most critical type of AMI, is associated with high mortality even with modern medicine [6-8]. Timely reperfusion therapy is critical for STEMI patients because a short ischemia time is associated with better clinical outcomes and lower acute and long -term mortality [9-12]. The COVID-19 pandemic placed the management of STEMI patients in a difficult situation due to the need to balance timely reperfusion therapy and maintaining strict infection control practices [13, 14]. Telemedicine, which is used to deliver health care services using information or communication technology, provides an opportunity to carry out the evaluation, diagnosis, and even monitor the patients after discharge when social distancing is needed [15]. In this article, we reported our preliminary experience with the usefulness of telemedicine in managing STEMI patients during the COVID-19 pandemic. We also provided a review of this topic.

Telemedicine and Medical Education in the Age of COVID-19

The COVID-19 pandemic has offered medical schools an opportunity to incorporate telemedicine training into the curricula in a timely and practical manner. Telemedicine has grown exponentially in the United States, and the shift toward remote care to align with social distancing guidelines is fueling this growth. Training medical students to deliver high-quality, secure, and personalized health care through telemedicine will prepare the next generation of physicians to conscientiously use these technologies and meet a growing need for telehealth services. Telemedicine-specific educational goals can be incorporated into curricula and integrated with existing clinical experiences to provide students with core telemedicine and clinical skills to prepare them for current and future pandemics. Medical educators could explore 5 major telemedicine domains: (1) access to care, (2) cost, (3) cost-effectiveness, (4) patient experience, and (5) clinician experience. Schools could use the following learning vehicles to help medical students explore these domains: (1) asynchronous lectures covering telehealth history; (2) discussions on applications, ethics, safety, etiquette, and patient considerations; (3) faculty-supervised standardized patient telehealth encounters; and (4) hands-on diagnostic or therapeutic procedures using telehealth equipment. Incorporating telemedicine into the medical school curriculum exposes students to the application of telemedicine across specialties as well as its limitations.

The Opportunities for Telehealth in Pediatric Practice and Public Health

Telehealth can be delivered asynchronously, synchronously, or through remote patient monitoring. The cost of telehealth, patient use, and effectiveness vary by the technology deployed and by specialty. Telehealth use requires patient and provider adaptability. The improvement of telehealth is restricted by state and federal policies as well as privacy and security concerns. Current telehealth literature provides more consistent evidence of benefits for communication and counseling, and from remote patient monitoring of chronic conditions. However, the benefits and costs of telehealth programs are highly dependent on the technology used, the medical condition studied, and the health care context.

Travel Avoidance Using Telepediatric by Patients and Healthcare Providers: a Review of the Literature

Introduction:

Telepediatric is one of the subspecialties of telemedicine that can be defined as the use of information and communication technology tools to offer healthcare services to children at a distance.

Aim:

The use of telepediatric healthcare services for children living in rural or deserved areas may reduce the cost and time of travel to access these services. This study aims to review published papers that assess the percentage of avoided travel or referrals with the use of telepediatric.

Methods:

This is a systematic review study. PubMed database was searched in September 2019 to retrieve the published papers. The final 24 retrieved papers were assessed based on the variables such as modality, referral setting, specialty, continent, weight, and percentage of avoided travel. The multivariate linear regression model was used to estimate the percentage of travel avoidance by telepediatric.

Results:

The linear regression model was determined based on the provided specialty for telepediatric (cardiology, general (multi), and other (rehabilitation, dermatology, psychiatry, respiratory)) with R2 =0.41. The results showed that the mean percentage of avoided travel in cardiology specialty as a baseline was 56%. The use of telepediatric in the general (multi) and other specialties can avoid travel for 26.5% (p=0.02) and 85% (p=0.03) respectively.

Conclusion:

This study showed that telepediatric could reduce travel at least 26.5% and maximal 85%. These results can be used by healthcare providers to decide on the implementation of successful telepediatric systems to reduce referrals.

Telemedicine for pediatric physiatry: How social distancing can bring physicians and families closer together

The coronavirus (COVID-19) pandemic triggered wide scale implementation of telemedicine in the United States. The government response, Coronavirus Aid, Relief, and Economic Security (CARES) Act, permitted loosening of existing restrictions on telemedicine enabling its rapid incorporation into the delivery of medical care for children and adults. Prior to COVID-19, few pediatric physiatrists had opportunities to access high fidelity telemedicine platforms to provide health care for patients with special needs, mobility impairments, developmental delays, neuromuscular disorders or other complex medical conditions. This literature review will explore how telemedicine can optimize health care delivery options for pediatric physiatrists in various inpatient and outpatient settings such as consultations, acute inpatient units, outpatient clinics and long-term care facilities. Detailed analysis of the current research in telemedicine applications as well as a critical review of the limitations and barriers for its use offers a plethora of opportunities for enhancement of continuity and coordination of care. Telemedicine may decrease healthcare disparities and increase access of care for children with special needs. Additional research is needed to assess the efficacy of telemedicine when addressing complex medical conditions in children.