Telemedicine in Pediatrics: Increasing Access and Quality (Text Version)

Slide Presentation from the AHRQ 2008 Annual Conference

On September 9, 2008, James P. Marcin, made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (5.4 MB; Plugin Software Help).

Slide 1

Telemedicine in Pediatrics: Increasing Access & Quality

James P. Marcin, MD, MPH
University of California (UC), Davis Children's Hospital
Sacramento, CA
jpmarcin@ucdavis.edu
916-734-4726

Slide 2

Disclosures

• I have NO financial interest or arrangement or affiliation with any organizations related to commercial products or services to be discussed.
• My presentation does NOT include discussion of "off-label" uses of Food and Drug Administration (FDA) approved pharmaceutical products or medical devices.

Slide 3

Why Telemedicine

The slide shows an image of a balancing weighing scale. On one side is "Regionalization improves efficiency and quality," and on the other, "Telemedicine allows our expertise to be everywhere."

Slide 4

The slide shows the UC Davis Telemedicine Network for the state of California.

Slide 5

The Federal Communications Commission (FCC) Telehealth Grant

The slide shows a map of the U.S. marked to show facility locations taking part in the "Rural Health Care Pilot Program."

• 600 Healthcare Centers for Health Broadband.
• $417 Million in 42 States.

Slide 6

Telemedicine: Applications in Pediatrics

• Outpatient specialty consultations.
• Emergency Medical Services (EMS): Scene, Transport, Emergency Department (ED) consultations.
• Inpatient specialty consultations.
• Procedure-Study interpretation (Electroencephalographic [EEG], Echo).
• Intensive Care Unit consultations.
• Surgical and Trauma consultations.
• Other uses:
  • Home Health.
  • Physician-nurse education.
  • Video-interpreting.
  • Chronic care facilities.
  • Child care centers.
  • Connecting families.
  • Hospice.
  • International.
  • Interpreting services.

Slide 7

Telemedicine in the ED

• Non-Children's Hospitals EDs are:
  • Less prepared with regards to equipment, training.
• Rural EDs are less likely to have access to:
  • Pediatricians, pediatric subspecialists, ancillary services.
  • Centers for Disease Control and Prevention (CDC) Report (Feb 2006): 40% of EDs lack 24/7 access to pediatricians.
• Institute of Medicine (IOM): Future of Emergency Care—Key Findings:
  • "Children make up 27% of all ED visits, but only 6% of EDs in the US have all of the necessary supplies for pediatric emergencies."
• 50% of all EDs see less than 10 children per day.

Slide 8

The photograph shows a typical hospital examining room.

Slide 9

The photograph shows a hospital examining room equipped with working telemedicine.

Slide 10

The photograph shows five various styles of telemedicine carts.

Slide 11

The photograph shows various telemedicine equipment.

Slide 12

The slide shows a black screen.

Slide 13

Telemedicine vs Telephone

The table presents the "Quality of Care Scores" for various "Aspects of Quality of Care."

• Initial data gathering:
  • Telemed Consult (n=53): 5.7
  • Telephone Consult (n=105): 5.8
  • No Consult (n=233): 5.5
  • Non-Telemed )n=338): 5.6
• Integration of data and diagnosis:
  • Telemed Consult (n=53): 5.7
  • Telephone Consult (n=105): 5.8
  • No Consult (n=233): 5.5
  • Non-Telemed )n=338): 5.6

*Telemedicine Consultations Typically Occurs Here*

• Initial treatment plan:
  • Telemed Consult (n=53): 5.5
  • Telephone Consult (n=105): 5.3
  • No Consult (n=233): 5.0*
  • Non-Telemed )n=338): 5.1*
• Plan for disposition and follow-up:
  • Telemed Consult (n=53): 6.1
  • Telephone Consult (n=105): 6.1
  • No Consult (n=233): 5.6*
  • Non-Telemed )n=338): 5.7
• Overall Quality of Care:
  • Telemed Consult (n=53): 5.7
  • Telephone Consult (n=105): 5.4*
  • No Consult (n=233): 5.2*
  • Non-Telemed )n=338): 5.3*

Slide 14

Parent Satisfaction

The bar graph presents the results for parent's satisfaction with telemedicine consultations, which are in purple, and non-telemedicine consultations, which are in yellow. The measures include the parent's score for:

• Courtesy of remote nurses.
• Courtesy of remote physicians.
• Skills of referring physician.
• Explanation of what was being done for their child.
• Overall quality of care, and their.
• Overall experience in the Emergency Department.

Slide 15

Referring Provider Satisfaction

The bar graph presents the results for the referring provider's satisfaction with telemedicine consultations, which are in purple, and telephone consultations only, which are in yellow. The measures include the referring provider's:

• Consult Experience.
• Assistance of Telemedicine or Telephone Consultations in the medical management of the patient.
• And the referring provider's impression of the clinical skills of the UC Davis specialist.

Slide 16

Recommended Additions to Care

The bar graph presents the results for the referring provider's impression of whether the telemedicine consultation versus telephone consultation resulted in:

• Additional diagnostic studies.
• Additional medications administered.
• And whether the consultation resulted in a change in patient disposition.

Slide 17

Telemedicine for Inpatients

• CDC Report (Feb 2006): 50% of hospitals admit children without a specialized pediatric ward.
  • In NY: Non-pediatric hospitals admitted 33% of all hospitalized children.
• Pediatric subspecialists are regionalized.
  • Children may not receive specialist consultations and left for follow-up.
  • Children may be transported only for the consultation.
• Hypothesis: Providing inpatient consultations may increase the quality of care and obviate a transport.

Slide 18

Pediatric Inpatient Telemedicine Services

• Cardiology (+ echo reads).
• Hematology - Oncology.
• Pulmonology.
• Infectious disease.
• Neurology.
• Gastroenterology.
• Endocrinology (known DM).
• Others.
• Points to make.
  • Must fill clinical need.
  • Need privileges.
  • Great model if there is regional bed shortage and/or competition.

Slide 19

The slide shows a black screen.

Slide 20

"Robo-doctor"

The slide shows a black screen.

Slide 21

Telemedicine in the pediatric intensive care unit (PICU)-neonatal intensive care unit (NICU)

• Some select "less critically ill" children can be cared for in hospitals without PICUs and NICUs.
• In several states, minimal standards for Pediatric ICUs have been established (volume, intensivists, etc.)
• Spectrum of models:
  • Continuous oversight (eICU).
  • Consultative model.

Slide 22

The slide shows a black screen.

Slide 23

The slide shows a black screen.

Slide 24

PICU Telemedicine Results

• UC Davis PICU-ICU model:
  • Assist in the care of "less sick" children at remote site.
• Compared to non-telemedicine patients, telemedicine patients are:
  • Younger.
  • More ill (higher PRISM III).
  • Higher rates of mechanical ventilation.
  • Excellent severity adjusted outcomes.
• Have higher parent satisfaction.
  • 55% parents ranked local care "extremely important" versus 20% for local physicians.

Slide 25

Financial Impact of Telemedicine

• Saved costs using telemedicine.
  • $117,000 (23 pts, 71 days).
  • $200,000 (� Children in ICU, 43 pts, 105 days).
• Actual revenue kept in Redding.
  • $186,000 (23 pts, 71 days).
  • $279,000 (� Children in ICU, 43 pts, 105 days).

Slide 26

Family Link

The slide shows a black screen.

Slide 27

Video-Interpreting Services

• Links hospitals and clinics to bank of interpreters.
• Increase efficiency.
• Improve patient satisfaction.

• Note: The slide shows a photograph of a telemedicine cart.

Slide 28

Pediatric Telehealth Colloquium

The slide shows a header entitled, "2008 ATA Mid-Year Meeting: September 15-16, 2008; Tampa, FL."

Slide 29

Thank You!!

James P. Marcin, MD, MPH
UC Davis Children's Hospital
Sacramento, CA
jpmarcin@ucdavis.edu
916-734-4726