Definition Telehealth /Telemedicine
As defined by the American Telemedicine Association (ATA) “telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status”. The Agency for Healthcare Research and Quality (AHRQ) states, “telehealth is the use of telecommunications technologies to deliver health-related services and information that support patient care, administrative activities, and health education”. The Centers for Medicare & Medicaid Services (CMS) define it as “a two-way, real- time interactive communication between a patient and a physician or practitioner at a distant site through telecommunications equipment that includes, at a minimum, audio and visual equipment.”1 The terms telemedicine and telehealth are considered synonymous and are used interchangeably to describe use of electronic information and telecommunications technologies to support clinical health care, patient and professional health-related education, public health and health administration2.
Telemedicine encompasses a growing number of applications and technologies including two-way live or streaming video, videoconferencing, store-and-forward imaging along with the internet, email, smart phones, wireless tools and other forms of telecommunication. These technologies facilitate the leverage the latest innovations in computer, network and peripheral equipment to promote the health of children around the world.
Telemedicine is an integral component of change processes that will align with the future of healthcare and improve the outcomes in all facets of medicine. While the explosive growth of interactive technologies has the potential to provide great benefits such as improving access to care, while reducing costs and increasing convenience3,4 it is also fraught with risk, as evidenced by the rapid proliferation of online virtual pediatric providers and retail based clinics.5,6 While the novelty, convenience and affordability of these options are appealing to the consumer, practitioners need to remain cognizant of the potential for the erosion of the comprehensive quality care that facilitates partnerships between patients, clinicians, medical staff, and families in the medical home.5,6
To most effectively utilize the vast advantages provided by of telehealth and its myriad applications while sustaining the medical home will require careful and continuous ongoing monitoring. Future efforts need to be focused in the areas of operational excellence, population health, clinical partnerships, liaison at the state and federal level, alignment with payors and ongoing advocacy.7,8
The explosive growth of telehealth seen today has its roots in programs developed over fifty years ago by the National Aeronautics and Space Administration (NASA) with the monitoring of physiological data of astronauts during space flights utilizing satellite technology.9 Based on this successful concept, NASA continued to fund ongoing telehealth related research projects.10
In the 1970’s NASA conducted the first regional telemedicine project, STARPAHC (Space Technology Applied to Rural Papago Advanced Health Care), a health care delivery system for the isolated Papago Indian Reservation in Arizona by utilizing two-way microwave transmission. In 1989, NASA conducted the first international telemedicine project, following an earthquake to the Soviet Republic of Armenia, and showed the ability to share clinical expertise on an international platform.10
Within the AAP, telehealth has its roots in telephone medicine, established in the 1990’s with the development of “after hours” call centers.5 Initially as a special interest group and subsequently a section in the AAP, telemedicine was successful in improving the organization, efficiency, and cost-effectiveness of pediatric care through telephone management protocols and technologies.11 In 2008, the name and scope of the Section were extended to encompass telehealth as the Section on Telehealth Care (SOTC).
Telemedicine lends itself to a broad range of applications including tele-education, tele-consultation, tele-practice, and tele-research.
Tele-education supports a communication link for essential programing for providers, learners, patient and families that can be delivered through live interactive AV links, live streaming video, and by viewing stored educational material.11 Tele-education programs allow physicians to stay current with evidence based medicine, obtain continuing medical education (CME), foster relationships between academic and community-based physicians, and establish widespread peer groups.11 In addition, tele-education can rapidly disseminate educational tools, such as clinical care guidelines and best practice recommendations.
Tele-consultation supports a communication link between doctors who request consultations for patients under their care and experts at a distant site. Tele-consultation can occur via a live AV link or through store-and-forward technology that allows for the recording of a patient interaction or testing that can be viewed at a later time. It is applicable to both the inpatient and outpatient setting and is efficacious for acute and chronic disease management.13,14
Tele- consultation utilizing a live, interactive AV link has the added capacity of utilizing peripheral devices (e.g. stethoscope, otoscope, ophthalmoscope, ECG and ultrasonography) that can reproduce an in-person bedside evaluation. This is beneficial both in remote areas without access to specialty care as well as in an academic environment to supplement after hours care.15
For children who present to an Emergency Department (ED) or Urgent Care (UC) that may lack pediatric expertise, tele-consultation with a primary care provider, specialist, ICU or NICU can be expeditious in the evaluation, treatment, medical decision making and disposition, including optimal mode of EMS transport if indicated. Studies evaluating this model of care for pediatric patients suggest that tele- consultation can result in improved parent satisfaction, improved ED physician satisfaction, and higher quality of care. Data also suggest this model results in an overall reduction in costs due to both lower rates of transport and less frequent use of aeromedical transport.16,17,18
Tele-consultation is valuable in routine consultations for patients, parents, provider and consultants. Patients can remain in their medical home and community, thus increasing the utility and importance of the medical home. Inclusion of the provider in the visit enhances opportunities for care coordination and collaboration. For consultants, appointments are more efficient and easier to schedule with decreased risk of patients failing to keep their appointments.
Best practice for tele-consultation includes tele-ICU and tele-psychiatry, both of which have shown to be efficacious in the literature.
Tele-practice supports a communication link between doctors and their patients in a non-office setting, including patient home, day care center, preschool or school setting, summer camp, group home or detention facility. In these situations tele-practice implies added value to an established relationship within the medical home. Tele-practice has the potential to increase convenience while reducing health care system costs by diminishing parental work force absenteeism and lessening the need for ED and UC visits. The evolution of tele-practice in the medical home can enhance long-term integrity, continuity and quality while providing an alternative to retail clinics and online virtual pediatric providers.
Best practice includes home based visits for diabetic patients where the literature supports cost effectiveness, enhanced patient and provider satisfaction and improved patient outcomes.19
Tele-research supports multiple applications and requires a team approach with collaboration between health care providers, policymakers, engineers, social scientists, health economists, community partners, and government agencies. Venues include public health and emergency preparedness, rapid dissemination of translational research, the ability to broaden a population based study, improved collaboration between researchers, evaluation of simulation technologies and knowledge on how best to train the next generation of tele-health provide.
Best practices in tele-research include a significant body of research supported by the Agency for Healthcare Research and Quality (AHRQ). While recognizing that telehealth applications have been conceived, developed, and deployed in a variety of clinical settings, there is a need for supporting evidence based research. In order to address issues regarding the value, efficacy, and effectiveness of telehealth and to study barriers to implementation and adoption of these technologies, a number of Federal agencies, including the Agency for Healthcare Research and Quality (AHRQ), and private organizations are currently funding telehealth research.20
Telemedicine is NOW
Telehealth care vital to future of medical home
The health care market has seen a rapid expansion in the use of tele-health visits by online and standalone virtual providers linked to retail-based clinics, entrepreneurs, or insurers who provide health care services via web-based cameras on smartphones, laptop computers, tablets, or video kiosks.21
The health care market requires a correction to incorporate tele-practice in the pediatric medical home with new emphasis on community-based health care providers delivering care directly to their patients. This necessary enhancement would eliminate access barriers, increase consumer satisfaction, preserve the integrity of the pediatric medical home, and enhance the quality and consistency of care. Telehealth in the context of the medical home facilitates providers making clinical decisions to have full medical record access and an established relationship, which are the foundation for making appropriate care decisions for the patient which supports quality consistent with an in-person visit.
Outcome studies for outpatient telehealth services demonstrate high parent satisfaction, reduced absenteeism due to illness, reduced travel time and costs, high rates of visit completion, and reduced ED and UC visits. Tele-practice can ease the delivery of chronic medical care for primary care providers and pediatric medical and surgical subspecialists. Conditions necessitating chronic care, including asthma, diabetes, genetic conditions, obesity, congenital cardiac conditions, epilepsy, and mental health disorders, have been shown to be conducive to a telehealth environment.
As new models of payment for health care are explored in ACOs and payments are based on quality and outcome, tele-health may play a bigger role in delivering cost-effective care across a defined population of children.
For more information about the AAP efforts in Telemedicine, visit:
AAP Section on Telehealth Care (SOTC): The mission of the SOTC is to improve the provision of in-person and remote care through the use of telehealth technology in a medical home.
AAP Task Force on Pediatric Practice Change (TFOPPC): The mission of the TFOPPC is to ensure children and families receive sustainable, optimal, and health care in a continuously and rapidly changing health care environment. This mission will be accomplished by:
- Identifying and prioritizing key components of the future of pediatric care delivery.
- Supporting the pediatric care team in efforts to align to the future, catalyze change, and use opportunities to continuously improve practice.
- Inspiring strong leadership that embraces and leverages change and innovation through lifelong learning.
US Department of Health and Human Services, Health Resources and Services Administration (HRSA): Works to increase and improve the use of tele-health to meet the needs of the underserved.
American Telemedicine Association Pediatric Special Interest Group (ATA SIG)
The Pediatric Telehealth Special Interest Group is an integral part of the ATA developed to promote and foster the growth and provision of a broad spectrum of telehealth services for infants, children and adolescents. This group provides a forum for discussion of opportunities for clinical, research and educational collaboration, to generate interest in outreach, research and the reporting of outcomes, and to identify and remove any barriers to the fullest implementation of pediatric telehealth.
Telemedicine. Medicaid.gov. https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Telemedicine.html
Telemedicine Defined. American Telemedicine Association. http://www.americantelemed.org/about-telemedicine/what-is-telemedicine#.VquyglLMbbo
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Whitten PS, Mair FS, Haycox A, et al. Systematic review of cost effectiveness studies of telemedicine interventions. BMJ. 2002;324(7351):1434-7
Kempe, Allison, et al. "Delivery of pediatric after-hours care by call centers: a multicenter study of parental perceptions and compliance." Pediatrics 108.6 (2001): e111-e111.
Mehrotra, Ateev, and Judith R. Lave. "Visits to retail clinics grew fourfold from 2007 to 2009, although their share of overall outpatient visits remains low." Health Affairs 31.9 (2012): 2123-2129
Sia, Calvin, et al. "History of the medical home concept." Pediatrics 113.Supplement 4 (2004): 1473-1478.https://www.aap.org/en-us/about-the-aap/aap-press-room/pages/The-AAP-Advises-Parents-Against-Using-Retail-Based-Clinics.aspx#sthash.N34IhIjE.dpuf
Medical Home Initiatives for Children With Special Needs Project Advisory Committee. "The medical home." Pediatrics 110.1 (2002): 184-186.
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Arora, Sanjeev, et al. "Project ECHO: linking university specialists with rural and prison-based clinicians to improve care for people with chronic hepatitis C in New Mexico." Public Health Reports 122.Suppl 2 (2007): 74
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Spooner, S. Andrew, and Edward M. Gotlieb. "Telemedicine: pediatric applications." Pediatrics 113.6 (2004): e639-e643.
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Marcin, James P., et al. "The use of telemedicine to provide pediatric critical care consultations to pediatric trauma patients admitted to a remote trauma intensive care unit: a preliminary report." Pediatric Critical Care Medicine 5.3 (2004): 251-256.
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