Telemedicine for Children With Disabilities

Abstract

We evaluated the efficacy of team-to-team interdisciplinary telemedicine evalua-tions for children with special needs in rural Iowa. A real-time cable system was connected to two public school sites and a small regional hospital from the hospital-based Center for Disabilities and Development. Results from the treatment and con-trol groups suggest that the telemedicine group (parents) reported consultations at least as effective as parents who received on-site evaluations. Providers (multiple professionals) were equally positive about the evaluations. Data suggest that the telemedicine evaluations were viewed as good as face-to-face consultations. Significant cost savings occurred. Children with special needs present a complex array of health care requirements that remain throughout their life span. These needs include chronic health disabil-ities (diabetes, epilepsy, cystic fibrosis), developmental and behavioral disorders (cerebral palsy, spina bifida, attention deficit hyperactivity disorder, mental retar-dation, autism), and traumatic injuries (traumatic brain injury, spinal cord injury). These conditions can and often do have a major impact on the daily functioning of each child. Families travel substantial distances to obtain services from an interdisciplinary team of pediatric experts. Usually a group of professionals relate and consult with local professionals to facilitate treatment recommendations.

Full text

CHILDREN’S HEALTH CARE, 35(1), 11–27
Copyright © 2006, Lawrence Erlbaum Associates, Inc.
Telemedicine for Children
With Disabilities
Dennis C. Harper
Department of Pediatrics
Center for Disabilities and Development
Carver College of Medicine
University of Iowa Hospitals and Clinics
We evaluated the efficacy of team-to-team interdisciplinary telemedicine evalua-
tions for children with special needs in rural Iowa. A real-time cable system was
connected to two public school sites and a small regional hospital from the hospital-
based Center for Disabilities and Development. Results from the treatment and con-
trol groups suggest that the telemedicine group (parents) reported consultations at
least as effective as parents who received on-site evaluations. Providers (multiple
professionals) were equally positive about the evaluations. Data suggest that the
telemedicine evaluations were viewed as good as face-to-face consultations.
Significant cost savings occurred.
Children with special needs present a complex array of health care requirements
that remain throughout their life span. These needs include chronic health disabil-
ities (diabetes, epilepsy, cystic fibrosis), developmental and behavioral disorders
(cerebral palsy, spina bifida, attention deficit hyperactivity disorder, mental retar-
dation, autism), and traumatic injuries (traumatic brain injury, spinal cord injury).
These conditions can and often do have a major impact on the daily functioning
of each child. Families travel substantial distances to obtain services from an
interdisciplinary team of pediatric experts. Usually a group of professionals relate
and consult with local professionals to facilitate treatment recommendations.
Correspondence should be sent to Dennis C. Harper, Department of Pediatrics, Center for
Disabilities and Development, 213-D, University of Iowa Hospitals and Clinics, 100 Hawkins Drive,
Iowa City, IA–52242–1011. E-mail: dennis-harper@uiowa.edu

Traditional service models include the child and family visiting multiple individuals
in different clinics or teams of professionals in clinics and the communication of
information in a standard written report, whenever it arrives. Much time, energy,
often great distances, costs, long waits for appointments, and late communica-
tions characterize these traditional evaluation and treatment service systems
(Glueckauf, 2002). Care coordination between providers and the local schools
following evaluations is often the major challenge. These systems of care are fre-
quently overburdened, difficult to access, and costly for parents. One parent con-
sumer noted, “We are still going through the same thing as parents did 30 years
ago … there is all this new technology. … If we had telemedicine none of this
would happen” (Wheeler, 1998, p. 16).
It is not surprising that telemedicine would be considered for providing multi-
specialty health care services for children with special needs. As early as the
1990s, professionals in rural New York (Wheeler, 1998) and rural Georgia (Karp
et al., 2000) began offering multidisciplinary services to children with special
health care needs at remote locations from hospital settings. Remote health care
may be an important part of the future for much of rural America (Antezana,
1997) for at least some aspects of coordinated care. The Specialized Inter-
disciplinary Consultation Telemedicine Project provides an 8-year history of con-
sultation services for children with complex neurodevelopmental disorders in
rural Iowa communities, particularly in their school environments. This special-
ized interdisciplinary team consultation service for children with chronic health
and developmental disorders is presently ongoing, with all disciplines participat-
ing. This clinical service is unique in that an interdisciplinary team of profession-
als at both sites (hospital and remote) completes the evaluations with parents and
children present. This team-to-team consultation permits comprehensive parent
and professional dialogue, professionally guided evaluation procedures, real-time
discussion of evaluation results, treatment recommendations, and coordination of
care (Harper, 2001b).
This National Library of Medicine project utilized three studio sites in south-
western rural Iowa, approximately 100 miles from University Hospitals in Iowa
City, Iowa, with a population base of 75,000 families. The three sites (two in educa-
tional settings, one in a small regional hospital) had studios with push-to-talk
microphones, Sony large-screen monitors, and ceiling-mounted cameras or Sony
handheld cameras. Real-time communication was achieved by using Iowa’s
Communication Network, a DS3 fiber optic cable network linking 99 counties to
840 sites throughout Iowa located in hospitals, schools, and select public buildings.
This project is unique in that the evaluation of these consultation services focused
on parents and professional consumers located in these rural Iowa communities.
The study answered two questions: Are telemedicine consultations viewed as effec-
tive as “face-to-face” consultations by parents and providers, and will rural patients,
families, and providers be satisfied with telemedicine consultations? The study’s
12 HARPER

contribution to literature is its emphasis on evaluating the efficacy of the telemedicine
medium for coordinated, team-to-team based care. Presently we are unaware of
data evaluating the efficacy of interdisciplinary pediatric specialized consultations
using a telemedicine strategy dealing with rural settings.
THE IOWA TELEMEDICINE EXPERIENCE
Iowa is a rural state of approximately 3 million residents with an estimated
70,000 children who have a variety of developmental disabilities. Parents and
professionals often travel long distances to Iowa’s tertiary center, the Center for
Disabilities and Development (CDD), for evaluation and treatment of children
who exhibit complex health care concerns. The location for the specialized con-
sultation telemedicine service is the CDD (formerly University Hospital School),
which is a specialized rehabilitation hospital and outpatient clinic and is part of
the medical complex of the University of Iowa Hospitals and Clinics, providing
treatment and evaluation for people with chronic health care concerns and disabil-
ities. The CDD has 235 faculty and staff providing a wide range of services for
children and youth with neurodevelopmental disorders.
Location and Overview of the Program
In 1994, the National Library for the Study of Rural Telemedicine was estab-
lished at the University of Iowa Hospitals and Clinics. This facility is a large, 800-
bed, high-tech tertiary care hospital with 7,000 hospital professionals serving
Iowa and the Midwest. This effort was supported by multiple grants from the
National Library of Medicine, and its purpose was to evaluate health care delivery
needs in a rural setting, develop technical approaches toward their solution, and
test these applications in community settings. This cooperative National Library
of Medicine project lasted 6 years and provided comprehensive telemedicine ser-
vices with a major focus on evaluation of delivery systems. A complete report of
this extensive project is available at http://telemed.medicine.uiowa.edu.
Program Components
The National Library of Medicine project developed five major clinical telemedi-
cine projects: (a) Pediatric Echo Network—a statewide Tele-echocardiographic
consultation network; (b) Emergency Department Support for Vascular
Ischemia—a Web-based consultation network for rapid diagnosis and treatment
of acute cardiac and brain infarction; (c) Tele Psychiatry Consultation—a real-
time, two-way video conferencing psychiatry service for rural clients; (d) Diabetes
TELEMEDICINE 13

Education—a computer, Web-based, and Web TV in-home consultation and
management system for rural clients; and (e) Specialized Interdisciplinary
Consultations—a real-time, two-way video conferencing service for children
with special health and behavioral needs in rural Iowa communities (Harper,
2001a). These projects and the project investigators provided an amazing test bed
of clinical applications of telemedicine research evaluating a wide range of clini-
cal problems, populations, and technology.
TELEMEDICINE ENCOUNTERS
Overview of Scheduling and Procedures
Our hospital-based scheduling center and a local (distant site) predesignated
coordinator scheduled children and families of the CDD telemedicine consulta-
tions cooperatively. On scheduling, the child and family as well as local profes-
sionals with a designated local coordinator provided a brief orientation
concerning the planned telemedicine consultation with all the specialists at both
sites. When the child and the family arrived at the telemedicine site, the coordina-
tor or team leader of the distant site was responsible for reviewing procedures for
the telemedicine conference and dealing with information related to confidential-
ity, parental consent, and specific session record keeping. The team leader acted
as both case manager and facilitator for the telemedicine encounter.
PROTOCOL DEVELOPMENT
A series of protocols for patient presentation and consultation was established
prior to the encounters for each clinical area in the study. This cooperative and
prior consultation became a fundamental aspect of ensuring successful telemedi-
cine encounters. A general consultation protocol was developed collaboratively
and covered the detailed etiquette of telemedicine encounters. This protocol was
the guiding template for all evaluation sessions and was the basis for training new
local providers prior to specific consultations. The general consultation protocol
outlined the following: logistics for sessions, designated leadership, specific
responsibilities of participants, processing of confidential releases and reports,
summaries of clinical consultation, and follow-up arrangements.
In addition, four subspecialty protocols were developed collaboratively
between the hospital (CDD) team and the distant-site team in rural Iowa. These
protocols focused on children with severe behavior disorders; children with swal-
lowing disorders (dysphagia); children needing assistive technology services; and
children with specialized unmet health needs, primarily traumatic brain injury.
14 HARPER

The protocols were prearranged with local professionals and defined specific
aspects of assessment, data collection, and what needed to occur beforehand to
make the encounter successful. Details are supplied at http://telemed.medicine.
uiowa.edu. Each of these clinical protocols included a review of the clinical refer-
ral questions from a consensus of parents and local professionals; a brief restate-
ment of historical findings from prior evaluations when available; a prearranged
sequence of steps and procedures to complete the evaluation (e.g., a standard
medical examination by a local nurse guided by a physician at the CDD; predeter-
mined interview-based questions and procedures for the child, parents, and often
the local educator to be given by other examiners (including psychologists,
speech therapists, physical therapists); a summative, interpretive, and interactive
conference following a traditional case conference format; and a written report
followed to all participants. Each of the subspecialty protocols and specific
patient data were frequently reviewed by phone prior to the evaluation session by
social work staff. Initially much effort with all local teams was focused on pre-
arranged clinical plans for the evaluation session. Generally after one or two
interactions (e.g., case consultations), the protocols were mutually finalized, and
the sessions proceeded more efficiently over time.
TEAM-TO-TEAM CONSULTATION
As noted, this project was based on an interdisciplinary delivery model that focused
on collaboration between teams of professionals assisting children and their
families. The team-to-team effort was not contrasted with a single discipline
approach; this was not feasible. The model of delivery enabled many unplanned
opportunities. Care coordination was enhanced because a majority of local
providers were involved in the case consultation. Parents frequently felt empowered
by participating in the evaluation and in the discussion of recommendations with all
providers present. The team-to-team process enabled sharing of expertise among all,
mutually enhancing professionals’ skill levels. Finally, the respective teams at the
CDD and local professionals developed an increased sense of familiarity and per-
sonal rapport. A formal process evaluation was not conducted but based on the anec-
dotal comments, these aforementioned benefits were clearly noted (Harper, 2002).
CONSULTATION SERVICE FLOW CHART
The schematic in Figure 1 shows the process of telemedicine consultation. This
figure depicts the multiple steps of the teleconsultation process. We acknowledged
that not all requests for this teleconsultation process were suitable; as we dialogued
TELEMEDICINE 15

FIGURE 1 The process of telemedicine consultations.
16

TELEMEDICINE 17
with local referrants, the needs of children may change. Consequently, we developed
a series of steps to review referrals, verify status, and ensure availability of local
professionals at both sites. This process was completed by scheduling personnel and
increased our general success in delivering what was needed. Data gathering and the
clinical report became two crucial steps in this process. As with any evaluation, there
was a need for specific clinical data, and this need is more significant when using
a long-distance care system. Rather important, the need for a timely and concise
clinical summary (hard copy) ensured a record of the session and was provided to
parents and providers within an average of 5 days from the session.
EVALUATION OF PATIENT AND CAREGIVER AND
PROFESSIONAL SATISFACTION
A comprehensive patient and professional satisfaction survey (available from the
author) was developed cooperatively and administered by the Iowa Institute for
Social Sciences, an independent social science consulting firm at the University
of Iowa. This phone-based survey consisted of 55 items for each parent and pro-
fessional area and reviewed multiple areas of patient and professional satisfaction
with the telemedicine encounter. For professionals, questions focused on the
quality of information using the telemedicine venue in comparison to traditional
face-to-face on-site evaluations or consultations. Multiple response scales were
used (Likert and specific categories) in the survey.
Content of the specific questions focused on parents’satisfaction with multiple
aspects of telemedicine sessions; cost reduction; whether telemedicine was as
good as face-to-face evaluations; and technical quality of the telemedicine ses-
sions, professionals’ satisfaction with the telemedicine session from a diagnostic
or evaluation perspective, whether it was as good as face-to-face consultation,
telemedical quality, and time savings. The interview took 30 to 45 min.
Treatment groups consisted of parents/caregivers and professionals who partici-
pated in telemedicine encounters, whereas control groups consisted of parents/
caregivers and professionals who had no experience with telemedicine encounters
but had prior clinical experience with the CDD treatment system. Selecting an
appropriate control group for this study was viewed as an important goal. The
primary goal of the study was to evaluate the vehicle of telemedicine—that is, can
we offer a service “as good as face to face” in the opinion of parents and providers.
We used the center’s patients as the group who had received prior interdisciplinary
service on-site and carefully matched this group to those who participated in the
telemedicine project. Groups were matched for age, gender, socioeconomic status,
and problem type, not diagnosis per se. We were interested in a functional compari-
son of referrals. Exclusive diagnostic comparison was not viewed as relevant to the
use of our services model or the efficacy of telemedicine evaluations.

TREATMENT SAMPLE
The study treatment sample was obtained as a convenience sample based on local
need and referral from the designated catchment area. The catchment area was
selected as a rural and distant location (approximately 100 miles) from the CDD
in Iowa City, Iowa, as the focus of the initial telemedicine proposal. The Area
Education Agency 15 (a large, administrative, multicounty unit serving 3,575
children with disabilities) and the Ottumwa Regional Health Center 100 miles
from the CDD served as target sites, providing services for approximately 70,000
predominantly rural residents in southeastern Iowa.
Four cohorts of children with specific preselected disabilities were included:
(a) children with disabilities who had unmet health care needs (primarily brain
injuries) and children with neuromuscular disorders; (b) children with develop-
mental disorders and severe behavior disorders; (c) children with swallowing dis-
orders; and (d) children who, because of their disabilities, had a need for assistive
technology or augmentative communication assistance.
Study participants in the treatment group consisted primarily of parents of the
children with disabilities and professionals providing services to these children in
their respective rural community areas. Specific numbers of these families are
noted in Table 1. The final treatment sample consisted of 54 treatment children
and families and 50 control children and families.
CONTROL SAMPLE
Controls consisted of two sample types: families who had a child with disabilities
and had previous (nontelemedicine) contact with the CDD, and local providers who
did not participate in this telemedicine project but who had previous contact with
the CDD in referring specific patients. The family controls were selected based on
18 HARPER
TABLE 1
Child’s Condition/Referral Need
Telemedicine Control
Age (M,SD) 7.5 (5.4) 6.5 (3.7)
Referral question (n,%)
Special health care needs 23 (42.6%) 29 (58%)
Severe behavior disorder 11 (20.4%) 6 (12%)
Swallowing disorder 5 (9.0%) 6 (12%)
High need assistive technology 15 (28.0%) 9 (18%)
Total 54 50

child problem referrals, similar socioeconomic circumstances, and a location
outside of the research catchment area. Although an attempt was made to match for
both child problem and severity of disability, this proved formidable and generally
unsuccessful. Controls were defined as parents who had prior contact (treatment or
evaluation) with the CDD but no telemedicine experience. Professional controls
were defined as those professionals (all types) who had made referrals to the CDD
previously, were outside of the research catchment area, and had received consulta-
tion or evaluation reports on these patients and families.
Participation (patients and professional providers) is outlined in Table 2.
FAMILY AND PROVIDER INTERVIEWS OF
TELEMEDICINE AND CONTROL DATA
The Iowa Institute for Social Sciences provided direct phone-based interviews
(30 to 45 min) for all families and professionals involved in this study. One hundred
participants (patients and families) were enrolled, 73 of whom agreed to participate
in the final interviews, for a participation rate of 73%. Complete data were avail-
able on 54 patient families. The control group (family control) consisted of 64
families, 50 of which completed these interviews, for a participation rate of 78%.
TELEMEDICINE 19
TABLE 2
Participant Participation
Family Family Provider Provider
Catchment Control Catchment Control Totals
No. complete 54 50 135 36 275
No. callbacks 7 4 29 7 47
Not eligible 0 2 2 0 4
Problem no. 4 5 5 1 15
Refusal 0 1 0 1 2
Duplicate 0 2 0 0 2
Late enrollment 8 0 21 0 29
Total 73 64 192 45 374
Note. Family catchment =families in the treatment area who received telemedicine consultant;
family control =families who did not receive consultation from telemedicine but did receive prior onsite
services from the Center for Disabilities and Development; provider catchment =professionals in the
treatment area who referred telemedicine patients in the current study; provider control =
professionals who did not receive telemedicine consultations but did have prior consultation contacts
with the Center for Disabilities and Development; complete =completed phone interviews; callbacks =
repeated tries to reach with no success; not eligible =did not meet study criteria; problems =variety of
concerns, unable to reach, incomplete, and so on; refusal =refused to participate; duplicate =repeated
contacts in study group; late enrollment =recontacted after study date concluded.

20 HARPER
Providers in the catchment (research-treatment) area consisted of 4 physicians,
4 nurses, 10 social workers, 33 educational specialists (psychologists, speech
pathologists, educational consultants), and 84 others (teachers and service
providers). Of the 192 available, 135 participated for a participation rate of 71%.
Finally, provider controls consisted of 4 physicians, 2 nurses, 4 educational special-
ists (psychologists, speech pathologists, educational consultants), and 26 others
(teachers and service providers). Of the 45 contacted, 36 agreed to interview, for
a participation rate of 80%. This group (provider control) was the most difficult to
recruit and obtain. We suspect most felt a limited basis for participating.
STATISTICAL COMPARISONS
Statistical analyses consisted of comparisons of multiple subgroups of partici-
pants on key interview comparison questions. Contrasts were made between
telemedicine patient (families) and control (families), attitudes of telemedicine
patient (families) on the telemedicine consultation sessions, and telemedicine
provider group and provider control (nontelemedicine) group. Research analyses
were completed with consultation and analyses from the Biostatistical Consulting
Center of the University of Iowa. All analyses were completed by contrasting
matching groups (treatment vs. control) using two statistical tests: Fisher’s exact
test and Wilcoxon rank sum test. Significance levels were set at p≤.05 in all
instances.
Telemedicine Patient Versus Control Group
Statistical comparisons evaluating the comparability of the telemedicine patient
(n=54) versus control (n=50) were not significant on child’s health or behav-
ioral referral condition, times a child visited the local doctor in the past year, dis-
tance and travel time to the CDD, parent who attended consultations, age of the
child, parent employment and educational status, age and race of parent, parental
income, and gender of respondent. These comparisons suggest that the telemedi-
cine patient (families) and patient control groups were likely comparable and that
contrasting these groups on key telemedicine efficacy questions was possible.
Statistical contrast between the telemedicine patient and control patient groups
revealed no significant differences on satisfaction with the most current visit,
rated quality of care of the recent visit, amount of time spent with physicians and
professionals, ease of appointment making, and rated quality of the professionals’
concern during the evaluation. These aforementioned comparisons suggest that
there were no significant differences reported between the telemedicine patients’
contact versus the control patients’ report of their on-site clinical contact.

TELEMEDICINE 21
Furthermore, regarding the quality of evaluations completed via telemedicine,
including the quality of care, physician and professional time, ease of appoint-
ment making, and perceived physician and professional care delivered, was rated
by the parents as equal to the quality of these indicators during face-to-face direct
clinical consultation.
A group of 36 families completed telemedicine consultations and had at least
one on-site contact prior to the telemedicine consultation. These telemedicine
patients contrasted their pre- (onsite) and post- (off-site) opinions of their evalua-
tion experiences. These on-site and off-site contrasts revealed no significant
differences in the following: quality of on-site versus telemedicine consultation,
amount of time with professionals, ease of appointment making, and perceived
professional’s concern during the evaluation. Statistical data for these compar-
isons are available from the author. Collectively these comparisons of parent’s
experience with their own prior on-site versus telemedicine consultation were all
rated positively with face-to-face consultation at the CDD.
Attitudes of the Telemedicine Group
Parents in the telemedicine group noted the following: Current view of telemedi-
cine experience was the same or more positive, 98% (53/54); quality of care of
the experience was good to excellent, 98% (53/54); quality of provider concern
during consultation was good to excellent, 98% (53/54); and view following con-
sultation was satisfied to very satisfied, 98% (53/54). Some parents (10–12%)
reported technical problems during the telemedicine session, usually with poor
audio and camera movement.
Telemedicine Provider Versus Control Group Provider
Statistical comparisons evaluating the comparability of the telemedicine provider
(n= 135) versus the control group provider (n= 36) did not reveal significant dif-
ferences on the following: time in actual consultation, distance in local commu-
nity from office to telemedicine site, times each provider referred patients to the
center, ease of appointment making, satisfaction with recent consultation, rated
provider concern in the evaluation, and satisfaction with referral access to the
center. These aforementioned comparisons suggest no differences were reported
in the interviews of these telemedicine versus control providers in rated satisfac-
tion, quality of care received, professional time, provider concern, and satisfac-
tion with access to referrals. Telemedicine consultations are rated as comparable
to face-to-face consultations for the services provided in the opinion of the profes-
sionals surveyed.

22 HARPER
Comparison of Attitudes Among Providers on Their
Satisfaction With the Telemedicine Consultation
The interview stated, “Thinking about your most recent telemedicine experience,
on a scale of 1 to 5, 1 is strongly disagree and 5 is strongly agree, please tell me
how much you agree or disagree with each of the following statements.” Question
35 asked participants for their response to this statement: “The consultation
would have been better if it had been conducted in person.” We developed two
groups from the response to the question based on this distribution: 1 and 2 (dis-
agree, in favor of telemedicine consultation) (n=66), and 4 and 5 (agree, in favor
of in-person consultation) (n=41). We then contrasted (on the basis of this
dichotomy of in favor or not in favor) the sample responses based on these two
new groups. Significant differences (p<.05) in relation to this experimental
dichotomy revealed the following findings. Those in favor of telemedicine for
consultation (a) viewed appointment making as more positive, (b) participated
more often in telemedicine consultations, (c) viewed access to high-quality care
as an important issue, (d) viewed telemedicine as more positive with increasing
contact experience, (e) reported that families are more positive about telemedi-
cine than onsite, (f) were more comfortable with telemedicine, (g) reported that
more communication is permitted, (h) reported that they see this as providing
better care, (i) reported it as more positive because it permits productive use of
time, (j) had received more training and were more positive, (k) reported telemed-
icine made it easier to provide care, and (l) recommended this service more when
they were more positive. All data comparisons are available from the author.
These aforementioned comparisons indicate that those who reported telemedi-
cine as more favorable reported that it provided access to higher quality care, gen-
erated positive feedback from patients, had higher participation rates in
telemedicine consultations, and was a productive use of their professional time
(Harper, 2004). Those who were in favor of on-site evaluations indicated a clear
preference for needing more specific evaluated child outcomes that could not be
completed “long distance.” These specifics related to needs for cognitive child
assessment and more detailed and direct physician assessments. It was also noted
by some providers that they did not favor the technology and it was not accessible
to them.
Attitudes of Telemedicine Provider Group Reported
Toward Telemedicine Consultation Experience
Providers in the telemedicine group noted the following: access to high-quality
care as a factor or major factor in use, 88% (97/111); use because of family
finances as a factor or major factor, 53% (52/98); use because of time savings as a
factor or major factor, 96% (105/110); and use because it provided better care:

TELEMEDICINE 23
agree to strongly agree, 81% (106/131). During consultation, between 8% and
12% of providers noted some difficulty with being able to communicate, hear
others, and see others. These concerns centered on poor audio, camera movement,
and general studio problems. Nevertheless, an overwhelming number (88%) of
participants reported no difficulties in these areas.
ECONOMIC ANALYSIS
The economic analysis was viewed as a major issue in the development of the
telemedicine project. Two aspects were emphasized in this analysis: time costs
and travel costs for professionals to come to the center. We also surveyed parents
on the amount of out-of-pocket costs for travel to the center in Iowa City. The
economic analysis focused on how telemedicine can reduce costs related to trans-
portation and reduce time for professionals who provide care for children with
disabilities.
Travel Costs
Travel costs were estimated by calculating the distance and expected amount of
time spent traveling between Iowa City and the referral community and then esti-
mating the transportation cost and opportunity cost of time spent in transit. By
estimating the travel and time costs that would have occurred in the absence of
this telemedicine-based initiative, we were able to estimate the potential savings
attributable to this approach. These costs involve cost of transportation and pro-
fessional costs to participate in this consultation if it were held on-site in Iowa
City at the CDD.
Time Costs
Estimation of time costs proved a difficult task given the large variety of occupa-
tions represented in the sessions. The basic approach involved estimating the
amount of time individuals would have spent traveling between the referral site
and Iowa City and valuing this time based on the individual’s estimated hourly
compensation.
Hourly Compensation Estimates
Session participants were not asked to report their earnings because of concern
that doing so might lessen response rates. Moreover, the nationally representative
compensation estimates we used enhance the generalizability of our estimates

beyond Iowa. Because these wages exclude employee benefits, we adjusted these
mean wage estimates to account for an average benefit of 17% as recommended
by the Centers for Disease Control for economic evaluation in health care.
To estimate earnings for family members and others for whom occupation data
were not available, we used the median annual earnings for full-year, full-time
workers ages 35 to 44 as published by the U.S. Bureau of the Census. Students,
the children being evaluated, and siblings were excluded from the analyses.
Mileage Costs
To estimate mileage costs, we assumed an average of three people per car would
make the trip. We used the U.S. Internal Revenue Service mileage allowance of
$.325 per mile to estimate transportation costs.
Results Costs
Data were obtained on 91 sessions over the period February 24, 1998, to July 8,
1999. Eight sessions, occurring primarily in the first 4 months of the evaluation,
could not be evaluated because of incomplete data, resulting in 83 evaluable cases.
Telemedicine is a major cost saver to local families and local professionals. The
average savings to the local district (professionals and parents) was $971 per
telemedicine session. This cost figure includes costs of on-site team consultation
and travel by the team to the local community if the session was completed in
person by the team. Average savings for parents in out-of-pocket costs (mileage and
meals) was $125 per session. We did not include missed work, which was common.
DISCUSSION
This study evaluated the use of a particular type of telemedicine and system to
deliver specialized interdisciplinary care to rural Iowa and focused on two ques-
tions: Are telemedicine consultations viewed as effective as face-to-face consulta-
tions by rural parents and providers, and will rural parents and providers be
satisfied with telemedicine consultations?
Data presented in this study based on rather extensive and comprehensive inter-
viewing suggest that parents in the telemedicine group viewed these consultations
as at least as effective as direct onsite evaluations. Furthermore, a subgroup of
parents (n=36) who had both on-site and telemedicine experiences reported no sig-
nificant differences in their ratings of these two evaluation experiences, which were
both highly positive. Providers (multiple professionals) who participated in the
telemedicine study and controls who received onsite consultations were equally
24 HARPER

positive about the evaluation received. These data suggest that the telemedicine
evaluations were generally rated and viewed as good as face-to-face consultations.
Problems were noted with audio and video concerns by consumers (parents and
providers) in about 12% of the sessions. Generally, 88% to 90% of the respondents
who participated in the telemedicine sessions noted them as good to excellent.
Costs for such services (excluding equipment) revealed major savings to local
school districts in professional time and travel. Parents on average had modest
reductions in out-of-pocket costs but lesser missed work costs.
FUTURE CHALLENGES FOR TELEMEDICINE
This study did not effectively evaluate in sufficient detail the particular types of
clinical consultations (e.g., new evaluations, screening, care coordination, follow-
up, and counseling) that were best suited to telemedicine in chronic health care.
Initial screening evaluations and follow-up evaluations with chronic health care
monitoring were very well suited to the existing telemedicine program both clini-
cally and functionally. The telemedicine services most utilized by our group were
follow-up and care coordination. Future directions require that we clarify the
limits of telemedicine consultation for specific clinical disorders and types of
treatment options (Bauer & Ringel, 1999). As an example, we need to explore
how providing earlier or unlimited psychological treatment of anxiety disorders is
maximized using the telemedicine format. Further, it would be useful to know if
more frequent follow-up of initial diabetic education of adolescents was more
effective using a telemedicine venue as compared to a face-to-face method.
Reimbursement from private insurance carriers remains slow but is beginning
to support some of these services. Capitated contracts for specific services with
specific agencies are working. The future success of such consultations is related
to broader acceptance of these telemedicine services by parents, professionals,
and the insurance industry (Bashshur, Sanders, & Shannon, 1997). Will telemedi-
cine be a reimbursable service? Payment for service will slowly improve, accord-
ing to a number of experts in the field (Tracy & Edison, 2004). We need to be
aware of the national licensing and credentialing requirements in telemedicine
practice. Most likely, large health care systems will utilize telemedicine for pro-
viding for select “managed” populations such as the military, correctional institu-
tions, and other groups (Effertz, Beffort, Preston, Pullara, & Alverson, 2004).
Is telemedicine effective or efficacious as a clinical tool? Telemedicine in
this study has demonstrated it was able to provide for a variety of diagnostic and
treatment services, screening, counseling, psychosocial management, behavioral
management, interviewing, and general follow-up. Considerable research needs
to focus on identifying the types of clinical problems that are best suited to a
TELEMEDICINE 25

26 HARPER
telemedicine service. Encouraging results are certainly emerging for helping
chronically disabled populations and promoting ongoing health management
(Nelson, 2004; Niederpruem et al., 2004).
Does telemedicine fit into my clinical day? This was a significant concern ver-
balized anecdotally in our study and remains the biggest challenge for most pro-
fessionals: Can I adapt to something entirely different? Telemedicine systems are
best offered as a part of a continuum of services within a clinical array as one
method for some parts of delivery or health care assistance. Professionals repeat-
edly note that success of telemedicine systems is directly related to how easy they
are to use and if they fit into clinical work patterns and client needs. This is funda-
mental and obvious but not easily accomplished for a multitude of reasons.
Providing some aspects of health care to people in more convenient locations
has clear benefits for their health and quality of life. Economic benefits for con-
sumers to improved access are a compelling reason to continue exploring
telemedicine services. If one needs assistance and can get it quicker and easier, it
is reasonable to do so in some situations. It is not always economical or the best
thing to do just because it might be easier. We are not sure about the impact of
such services and their overall efficacy on specific health problems. Telecom-
munications systems can assist problems of the underserved with better disper-
sion of specialists and assistance needed at the right time. The implementation of
telemedicine will likely continue to be an uphill battle. The least of the difficulties
noted by many authors is technology. Education, support, motivation, and train-
ing of providers are critical. A variety of political and social factors often stands
in the way of moving to newer technologies. We need to be sensitive to those
issues and seek solutions. An overall analysis suggests that telemedicine efforts
do work in a number of respects. Complex technologies will continue to assist us
in developing a better quality of life; however, our goal is to learn to manage them
so that this does in fact happen.
ACKNOWLEDGMENTS
This project has been funded with federal funds from the National Library of
Medicine under Contract No. N01–LM–6–3548.
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