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Patient Evaluation of an Acute Care Pediatric Telemedicine Service in Urban Neighborhoods
Abstract and Figures
Background:
Telemedicine has enhanced care for children with illness in Rochester, NY, since May 2001, enabling 13,568 acute illness visits through December 2013. Prior findings included high parent satisfaction with childcare- and school-based telemedicine ("school telemedicine") and potential to replace 85% of office visits for illness. Urban neighborhood telemedicine ("neighborhood telemedicine") was designed to offer convenient care for illness episodes that school telemedicine often cannot serve because illness arises when children are at home or symptoms preclude attendance. This study was designed to characterize health problems prompting neighborhood telemedicine use and to assess parent perceptions of its value.
Materials and methods:
A parent satisfaction instrument was developed with input from parents and providers. Neighborhood telemedicine was initiated in January 2009 and totaled 1,362 visits through November 2013. During a 29-month survey period through January 2012, 3,871 acute illness telemedicine visits were completed, 908 (23.5%) of them via neighborhood telemedicine. Instruments were completed for 392 (43.2%) of the 908 visits.
Results:
Neighborhood telemedicine comprised 27% of all telemedicine visits during the year of peak neighborhood activity. Almost all survey respondents were satisfied or highly satisfied with neighborhood visits (97.6%) and endorsed greater convenience than alternatives (94.5%).
Conclusions:
Family preferences and the high value placed on neighborhood telemedicine suggest such service is important, especially in health systems driven by patient values. Service provided by neighborhood telemedicine holds potential to meet a large demand for care of acute childhood illness. Financing reform to support patient-centered care (e.g., bundled payments) should encompass sustainable business models for this service.
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... 10 Descriptive studies of physicians' perceptions of the use of telemedicine-particularly with regard to barriers-have been documented across adult populations; however, few have evaluated the use of pediatric tele-emergency services. [11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28] Therefore, this study sought to address knowledge gaps in the pediatric tele-emergency literature and to evaluate GEM physicians' opinions on the use of tele-emergency services for children. ...
... A PubMed literature review including the years 2005-2017 was conducted to identify surveys used to measure user experience in telemedicine. [11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28] Using this process, we selected relevant questions in the fields of pediatrics, critical care, and emergency medicine. A new survey was created ( Fig. 1) that consisted of 27 questions: 17 questions based on a 7-point Likert scale and 10 open-and closed-ended questions. ...
Introduction: This study evaluated general emergency medicine (GEM) physicians' opinions on the barriers, perceptions, and utility of pediatric tele-emergency services, or the use of telemedicine for critically ill children in the emergency department (ED).
Methods: Based on previously published surveys, a 27-item survey was created to assess GEM physicians' perspective on tele-emergency services provided by a regional group of pediatric critical care physicians. The survey was distributed to ED medical directors at 15 hospitals who actively participate in tele-emergency services.
Results: Twelve of the 15 medical directors responded to the survey (80%). Results demonstrated that GEM physicians consider the pediatric critical care tele-emergency consultations clinically helpful (92%), particularly for the management of patients with respiratory distress, congenital anomalies, and cardiovascular processes. The most common barriers to using tele-emergency services included limited time (42%), integrating new technology and processes in existing workflows (42%), and the lack of clinical utility (42%), particularly for patients with nonacute and/or routine conditions. Lastly, half of GEM physicians felt that families preferred telemedicine to telephone consultations (50%).
Conclusion: GEM physicians support the premise that pediatric tele-emergency services help with the clinical management of critically ill children. However, physicians do not consistently believe that tele-emergency services are always clinically necessary and time constraints continue to be a significant barrier. Selected use on specific clinical conditions and improving the integration in workflow processes would help increase the appropriate use of tele-emergency services in the ED.
... Telemedicine has been well-received as a modality for patient visits. Caregivers and care providers alike report high satisfaction in both the convenience and the care provided by the service (McIntosh et al., 2014). ...
The global coronavirus disease-2019 (COVID-19) pandemic has changed the prevalence and management of many pediatric infectious diseases, including acute otitis media (AOM). Coronaviruses are a group of RNA viruses that cause respiratory tract infections in humans. Before the COVID-19 pandemic, coronavirus serotypes OC43, 229E, HKU1, and NL63 were infrequently detected in middle ear fluid (MEF) specimens and nasopharyngeal aspirates in children with AOM during the 1990s and 2000s and were associated with a mild course of the disease. At times when CoV was detected in OM cases, the overall viral load was relatively low. The new severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is the causative pathogen responsible for the eruption of the COVID-19 global pandemic. Following the pandemic declaration in many countries and by the World Health Organization in March 2020, preventive proactive measures were imposed to limit COVID-19. These included social distancing; lockdowns; closure of workplaces; kindergartens and schools; increased hygiene; use of antiseptics and alcohol-based gels; frequent temperature measurements and wearing masks. These measures were not the only ones taken, as hospitals and clinics tried to minimize treating non-urgent medical referrals such as OM, and elective surgical procedures were canceled, such as ventilating tube insertion (VTI). These changes and regulations altered the way OM is practiced during the COVID-19 pandemic. Advents in technology allowed a vast use of telemedicine technologies for OM, however, the accuracy of AOM diagnosis in those encounters was in doubt, and antibiotic prescription rates were still reported to be high. There was an overall decrease in AOM episodes and admissions rates and with high spontaneous resolution rates of MEF in children, and a reduction in VTI surgeries. Despite an initial fear regarding viral shedding during myringotomy, the procedure was shown to be safe. Special draping techniques for otologic surgery were suggested. Other aspects of OM practice included the presentation of adult patients with AOM who tested positive for SARS-2-CoV and its detection in MEF samples in living patients and in the mucosa of the middle ear and mastoid in post-mortem specimens.
... In a study of telehealth visits conducted as part of the Health e-Access Telemedicine Program (which provides telehealth visits in schools and neighborhood locations in low-income, inner-city neighborhoods), 84% of parents were highly satisfied with the care they or their children received and 79% to 83% would be interested in using telehealth for their or their child's routine health care. Additionally, over 95% of parents felt that the telehealth visit was more or much more convenient (McIntosh et al., 2014). ...
Non-partisan analysis of the medical effectiveness, cost and utilization, and public health impacts of insurance coverage for Telehealth: Access.
... In a study of telehealth visits conducted as part of the Health e-Access Telemedicine Program (which provides telehealth visits in schools and neighborhood locations in low-income, inner-city neighborhoods), 84% of parents were highly satisfied with the care they or their children received and 79% to 83% would be interested in using telehealth for their or their child's routine health care. Additionally, over 95% of parents felt that the telehealth visit was more or much more convenient (McIntosh, 2014). ...
Non-partisan analysis of the medical effectiveness, cost and utilization, and public health impacts of insurance coverage for telephonic and electronic patient management.
... So, peer support initial assessment found improvements in symptom management, diet, blood pressure, body mass index, and blood sugar levels for many of those taking part in the programs, and psychiatric interviews conducted over videoconferencing were reliable for assessment and treatment recommendations [20]. In the field of pediatrics, parents and children supported by care providers reported that primary care school-based telehealth was an acceptable alternative to traditional health care delivery systems [21]. ...
Background:
Telemedicine has revolutionized health-care services with its unprecedented abilities to connect patients with health-care professional across the distances. Patient satisfaction is an important measure of the quality and effectiveness of health-care services.
Aim:
The goal of this systematic review is to investigate patient satisfaction with telemedicine in acute care setting.
Methods and results:
Four sources of data were searched PubMed, Cumulative Index of Nursing and Allied Health Literature, Scopus, and Web of Science. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis as our basis of organization. Our analysis has showed that acute telemedicine was effective in managing a broad spectrum of acute medical conditions while achieving high levels of patient satisfaction.
Conclusion:
Patient satisfaction is a complex product of expectations and experiences. Furthermore, it is an important indicator of the quality of the service. Despite the challenging nature of acute medicine, telemedicine services were successful in improving the quality of the service and achieving high levels of patient satisfaction.
Relevance for patients:
Telemedicine is rapidly evolving as an essential component of our healthcare system. Implementing telemedicine in acute care is a relatively new concept and patient satisfaction in these settings needs to be evaluated.
Lo scopo principale di questa ricerca è di fornire una revisione sistematica della letteratura scientifica in merito all'uso della telemedicina rivolta a pazienti caratterizzati da situazioni di morbilità (in alcuni casi di vera e propria cronicità), cercando di mettere in evidenza come questa sia accolta dai pazienti, la sua efficacia nelle cure e in che modo essa incrementi l'accesso ai servizi sanitari e con quali tecnologie.La review di letteratura è stata condotta utilizzando l'approccio Tranfield (2003), metodo efficiente e di alta qualità per selezionare e valutare in maniera oggettiva e quantitativa gli studi presi in esame. La metodologia è stata seguita passo dopo passo, analizzando parole chiave, argomenti, qualità delle riviste e giungendo, alla fine, alla selezione di alcuni paper che sono stati analizzati in dettaglio. Tali lavori, inoltre, vengono confrontati tra loro e classificati secondo metriche significative, valutando anche le tecnologie e le metodologie utilizzate.A valle della review sistematica è stato possibile riscontrare che la maggior parte dei pazienti coinvolti nei programmi di telemedicina è propensa all'utilizzo di questo nuovo modello di erogazione di servizi sanitari e i risultati clinici sembrano essere incoraggianti.Gli stessi risultati suggeriscono che i servizi di telemedicina sono apprezzati dai pazienti, aumentano l'accesso alle cure e potrebbero rappresentare un modo efficace ed efficiente per affrontare al meglio emergenze e pandemie, abbassando i costi complessivi e promuovendo, altresì, l'inclusione sociale.
Background
In response to the COVID-19 pandemic, local and institutional guidelines restricted non-emergent, in-person visits in outpatient specialty clinics. Nurse practitioners (NPs) in pediatric gastroenterology clinics immediately shifted their practice to telehealth (TH).
Local problem
The shift to TH necessitated a change in practice. This quality improvement project was designed to define factors influencing family's perceptions of TH and secure feedback on the TH experience. TH is remaining an option for accessing care even as restrictions are being lifted. Feedback is necessary to ensure that quality of care and high patient satisfaction are maintained in a virtual environment.
Methods
The Unified Theory of Acceptance and Use of Technology was used to frame the project. Surveys were collected from NPs related to services provided and complexities of each encounter. Post-visit surveys were conducted with families to assess their perceptions of the visit. Findings were discussed to identify and address gaps in service.
Results
Parent/family surveys were consistent with NP feedback. Results indicated that parents were satisfied with care provided via TH, but that these visits were limited by incomplete assessments, lacked the intimacy of in-person encounters and were often difficult to access due to technological issues.
Conclusions
It is anticipated that TH will be used in the post pandemic era to provide routine and non-emergent acute care. Institutions and providers need to consider factors influencing the patient experience learned during the pandemic and implement evidenced-based strategies that ensure quality care that meets patients' needs.
Objective:
Patients with a new diagnosis of attention-deficit/hyperactivity disorder (ADHD) who are prescribed stimulant medication need regular follow-up. Guidelines recommend follow-up within 30 days of stimulant initiation or change but this goal is seldom achieved. This quality improvement (QI) study in an urban academic outpatient practice aimed to: 1) assess whether use of school-based telemedicine increases rates of follow-up within 30 days and decreases the number of days to follow-up for ADHD, and 2) compare rates of 30-day follow-up via in-person vs telemedicine visits.
Methods:
We performed three Plan-Do-Study-Act cycles over a 12-month period: QI interventions included clinic wide education, paper prompts for clinicians, and creation of a database to track ADHD patients. We measured days from the index visit to the follow-up visit, and the mode of both visits (in-person or telemedicine). Data were collected for 6 months pre-intervention and 12 months post-intervention.
Results:
Follow-up within 30 days increased from 19% (of 191 visits) to 33% (of 661 visits) (p<0.001). The time to follow-up decreased from 67 to 34 days (p<0.001). Follow up visits by telemedicine were more also more likely to be within 30 days (62% vs. 32%, p<0.001).
Discussion:
A QI intervention for ADHD care increased rates of follow-up within 30 days, particularly when telemedicine was used, and decreased the number of days to follow-up. This intervention could serve as a model to improve follow-up for ADHD in other settings.
Telehealth in the broadest sense has been used by pediatric clinicians for over a century, as telephone triage has been and continues to be an essential part of pediatric practice. Utilizing more advanced technology including video communication, although available, was generally underutilized until the onset of the COVID-19 pandemic. Telehealth presents the opportunity to bridge many divides including geographical and logistical challenges. Many acute pediatric conditions can be managed safely and effectively through telehealth especially when remote physical exam equipment is used. Telehealth can also be especially useful in medical care of children with medical complexity. Traveling with medical equipment to multiple subspecialists can be incredibly challenging and often a similar quality visit can be conducted through telehealth in the comfort of a child's home environment. Well child care presents a unique problem while trying to maintain social distancing. Integrating a hybrid model using both an in-person exam and history through video conferencing can help balance limited face to face time with the need to ensure a full and appropriate physical exam. Integration of telehealth into the pediatric patient centered medical home can enable families to gain convenience while maintaining the essential relationship with their primary care office.
Acute illness challenges all families with young children. The Health-e-Access Telemedicine Network in Rochester, NY, has enabled >7,000 telemedicine visits since 2001 among children in childcare or elementary schools, predominantly from Rochester's inner city. Large reductions in illness-related absence and emergency department use among Health-e-Access participants have occurred.
The study was aimed to assess parent perception of telemedicine as a means to reduce burdens associated with childhood illness.
A total of 800 parents were surveyed before (578) or after (318) a child had at least one Health-e-Access visit. Queries addressed access to healthcare, conflicts between work/school and child's care during illness, and concerns and likes about telemedicine. Perceptions were elicited through open-ended and direct queries.
Among all respondents, 16% had high-school education and 25% had a college education. Race/ethnicity of the respondents included black (43.6%), Hispanic (22.9%), white (30.0%), and other (3.5%). All identified a primary care practice as a source for well childcare. Most (58%) had given antipyretics to their child to avoid being called by childcare or elementary school staff about illness. Likert scale interview items addressing quality of care elicited low levels of worry or concern. Worry scores trended lower after experience. Among 532 comments about Health-e-Access elicited through open-ended probes, positive ones (likes) predominated (84.6%). Likes most commonly included convenience/time saved (33.6% of all comments), parent stayed at work (13.5%), drug delivered to child site (7.1%) or called ahead to pharmacy (4.9%), and confidence in care (2.3%). Negative responses (concerns) totaled 15.4% of comments and most commonly included reliability of diagnosis (2.6%), technical problems (1.3%), and preference for in-person care (0.8%).
Health-e-Access was well accepted by a substantial, diverse group of parents despite unfamiliarity with this approach to care. Convenience and convenience-related experience dominated perceptions. This model enables service beyond that mandated by payers and beyond that generally provided by medical practices.
Health-e-Access, a telemedicine service providing care for acute illnesses in children, has delivered >6500 telemedicine visits from 10 primary care practices in Rochester, New York, by using telemedicine access at 22 child care and school sites. The goal was to assess the hypotheses that children served by Health-e-Access received health care more often for acute illnesses but had fewer emergency department (ED) visits and lower health care expenditures than did children without access through this service.
By using insurance claims, this case study compared utilization (starting in May 2001) of telemedicine, office, or ED care for children with versus without telemedicine access. Children included in analyses had > or =6 consecutive insurance-covered months through July 2007. Claims data captured all utilization. A total of 19 652 child-months from 1216 children with telemedicine access were matched with respect to age, gender, socioeconomic status, and season with child-months for children without telemedicine availability.
The mean age at utilization was 6.71 years, with 79% of all child-months being covered by Medicaid managed care. The overall utilization rate was 305.1 visits per 100 child-years. In multivariate analyses with adjustment for potential confounders, overall illness-related utilization rates (in-person or telemedicine visits per 100 child-years) for all sites were 23.5% greater for children with telemedicine access than for control children, but ED utilization was 22.2% less.
The Health-e-Access telemedicine model holds potential to reduce health care costs, mostly through replacement of ED visits for nonemergency problems.
Common acute illness challenges everyone involved in child care. Impoverished inner-city families, whose children are most burdened by morbidity and whose reliance on child care is most important, are those least equipped to deal with this challenge.
To assess the impact of telemedicine on absence from child care due to illness (ADI).
A before-and-after design with historical and concurrent controls was used to study ADI in 5 inner-city child care centers in Rochester, New York, between January 1, 2001, and June 30, 2003. Enrollment averaged 138 children per center, of whom Medicaid covered 66%. Center 5 provided only concurrent controls. Telemedicine service began in the first 4 centers in a staggered fashion starting in May 2001. Baseline data on ADI before availability of telemedicine were collected in each center for a minimum of 18 weeks. The telemedicine model for diagnosis and treatment of common acute problems involved both real-time and store-and-forward information exchange between a child and telemedicine assistant in child care and an office-based telemedicine clinician. Devices used were an all-purpose digital camera (with attachments designed to facilitate capture of ear, nose, throat, skin, and eye images) and an electronic stethoscope. ADI indexed illness that had interrupted care and education for children and burdened both parents and the community with work loss and health care-related costs. Detailed attendance records and staff and parent interviews provided data. The total number of days of attendance expected from all registered children over the course of a week (total child-days) served as the denominator in calculating rates for ADI. The center-week served as the primary unit of analysis. This study is descriptive in character; statistics are not inferential but instead serve to summarize observations.
For the 400 weeks of valid observations contributed by the 5 centers, the mean ADI was 6.41 absences per 100 child-days per week. In bivariate analysis, predictors of ADI were children's mean age, child care center, proportion of children covered by Medicaid, season of the year, and availability of telemedicine. ADI during weeks with telemedicine (4.07 absences per 100 child-days) was less than half that during weeks without telemedicine (8.78 absences per 100 child-days). After adjusting for potentially confounding variables using the generalized estimating equations method, telemedicine remained the strongest predictor of ADI. A 63% reduction in ADI was attributable to telemedicine, an effect similar to the 59% variation in ADI with season of the year. During the 201 total weeks that telemedicine services were available, 940 telemedicine encounters occurred. Telemedicine clinicians for these 940 encounters recommended exclusion from child care for 7.0% and in-person visits for 2.8% of the children. In surveys, parents indicated that 91.2% of telemedicine contacts allowed them to stay at work and that 93.8% of problems managed by telemedicine would otherwise have led to an office or emergency department visit.
Telemedicine holds substantial potential to reduce the impact of illness on health and education of children, on time lost from work in parents, and on absenteeism in the economy.
For the purpose of reducing the social and economic burden imposed by common acute childhood illness, we developed a telemedicine model to enable diagnosis and treatment of illness episodes presenting in pediatric office settings. The study objective was to assess the effectiveness of this telemedicine model in replacing illness visits to traditional healthcare settings and to compare effectiveness of this model (base model) with that of alternative models including simple office laboratory tests and albuterol administration (simple model) or a complete complement of tests and procedures (extended model). Eligible subjects had an acute problem and were seen in the pediatric primary care practice or pediatric emergency department of the University of Rochester Medical Center. All subjects were seen by the setting's usual physician. Subjects were also evaluated, based on random assignment, by a study physician in person or by a study physician via telemedicine. Effectiveness was defined as completion of the visit to the point that diagnosis was made. Forms completed by study physicians, and standard medical records indicating the tests and procedures requested for the purpose of completing the visit, were used to identify the model used in completing the visit. Effectiveness (proportion of visits completed) of the base model was assessed and its effectiveness was compared to that of simple and extended telemedicine models. Among 520 randomized visits, 492 were evaluated by study physicians in person (253) or via telemedicine (239). Using the base model, study physicians completed 74.1% of visits via telemedicine compared to 76.7% for study physicians in person and 76.0% for usual physicians. The simple model increased completion rates substantially. Using this model, study physicians completed 84.9% of visits via telemedicine compared to 86.6% for study physicians in person and 85.2% for usual physicians. The extended model increased effectiveness in completing visits still more, with telemedicine study physicians completing 97.1% of visits compared to 96.8% for in-person study physicians and 100% for usual physicians. Approximately 85% of illness visits presenting to primary care pediatric practice could be completed using a telemedicine model that included only simple office laboratory testing and albuterol administration.
Telemedicine virtually eliminates geography as a barrier to access to health care because it does not require patient and clinician to be in the same place at the same time. Telemedicine models using commercially available technology have enabled high-quality illness care in pediatric primary care settings and markedly improved access. More equitable distribution of health services is a likely result. Potential for children, families, and primary care pediatricians to gain from the access and effectiveness proffered by telemedicine hinges on acceptance by physicians and adoption in the health-care system. Significant organizational and psychological barriers to physician acceptance exist. Health system adoption, in turn, depends on successful organizational innovation and reimbursement from insurance organizations.
Primary care in the United States currently struggles to attract new physicians and to garner investments in infrastructure required to meet patients' needs. We believe that the absence of a robust overall strategy for the entire spectrum of primary care is a fundamental cause of these struggles. To address the absence of an overall strategy and vision for primary care, we offer a framework based on value for patients to sustain and improve primary care practice. First, primary care should be organized around subgroups of patients with similar needs. Second, team-based services should be provided to each patient subgroup over its full care cycle. Third, each patient's outcomes and true costs should be measured by subgroup as a routine part of care. Fourth, payment should be modified to bundle reimbursement for each subgroup and reward value improvement. Finally, primary care patient subgroup teams should be integrated with relevant specialty providers. We believe that redesigning primary care using this framework can improve the ability of primary care to play its essential role in the health care system.
To determine the potential cost savings of decreased emergency department (ED) visits resulting from increased continuity of care provided in a pediatric medical home.
An economic modeling study comparing the cost of ED visits associated with average continuity of care versus the cost of ED visits associated with a 10% point increase in continuity was performed. This model's premise is that increased continuity will decrease care in the ED. Parameters of the model included average continuity of care and expected use of the ED by pediatric patients as well as the relationship between these two variables. Parameters were estimated from the literature. Average continuity, as measured by the Continuity of Care Index by Bice and Boxerman, was determined to be 40%. Average ED use was estimated to be 0.68 visits/child per year. Continuity of care was stratified into low, medium, and high levels. The Medical University of South Carolina's ED charges were used. An average pediatric practice was estimated to contain 2000 patients.
Two hypothetical practices of 2000 patients each were created to represent pediatric medical homes: practice 1 received 40% continuity and practice 2 received 50%. The model's outcome was measured in terms of expected ED charges per practice averted over a 1-year period. Increasing continuity of care by 10% points yielded a decline in expected ED visits from 1362 to 1290 per practice: 19,905 US dollars was saved.
Continuity of care can yield many benefits, including cost savings from decreased charges associated with less frequent ED use.
We designed a telemedicine model for diagnosis of common, acute illness to compare telemedicine and in-person evaluations on reproducibility of diagnosis and treatment.
Subjects were seen by usual physicians in ambulatory settings. Subjects were also evaluated separately by experienced general pediatricians (study physicians), either in person or via telemedicine, based on random assignment. The primary measure of reproducibility was study physician agreement with usual physician on primary diagnosis. Analysis compared reproducibility for telemedicine versus in-person evaluations. Relevance of agreement on primary diagnosis was measured by comparing agreement on prescribed medications.
Agreement on diagnosis of study physicians with usual physicians for the 492 visits studied was 89%. The difference in the proportion of visits with disagreements between telemedicine study and in-person study evaluations (13.8% vs 8.3%, respectively) bordered on significance (P = .051). Disagreement proportions for prescriptions were similar (32.2% vs 27.4%), however. Telemedicine evaluation for children with upper respiratory tract (URI)-ear symptoms involved unique technical requirements and clinical judgments. For this largest subgroup of 202 visits, disagreement on diagnosis for telemedicine occurred more often than for in-person evaluation (17.6 vs 6.3%, P < .02). For the remaining 290 visits, telemedicine and in-person study physicians disagreed on diagnosis about equally (11.5 vs 9.9%).
Excluding the URI-ear group, reproducibility of telemedicine diagnosis did not differ from that of in-person diagnosis. For the URI-ear group, reproducibility of diagnosis by telemedicine and in-person evaluation varied significantly.