The face of telehealth: Serving children in health care “deserts”

pediatric telehealthAt least 15 million children reside in Health Professional Shortage Areas (HPSAs) that average fewer than one health professional for every 3,500 people. In these health care deserts, time and transportation barriers prevent even children with health insurance have trouble getting timely care, particularly specialty care. Children in poor, rural areas are most at risk.

So health problems fester and get worse — and more expensive when finally addressed.

Telehealth can solve many of these problems. Through remote video/voice/data connections, dermatologists can view images of rashes and moles sent by primary care providers; cardiologists can patch into local emergency rooms and listen to heart sounds and read EKG tracings; critical care physicians and neonatologists can see and hear newborns in distress, listen to lung sounds, read their vital signs and view images. They can advise local clinicians and guide them through next steps.

However, pediatric telehealth hasn’t been adopted as widely as it could be. A white paper presented by the Children’s Health Fund at a Congressional briefing last week enumerated the obstacles:

  • legal and licensing barriers preventing telehealth from crossing state lines
  • lack of access to the internet or smart phones
  • the inability of some health care systems and small practices to afford the new telehealth technologies
  • lack of a system of reimbursement (for both the consulting specialist and the primary care team)
  • quality assurance and regulatory concerns.

Some states have taken steps to solve these problems; others still lag behind. These case examples from the white paper illustrate telehealth’s benefits and challenges.

  • Life-saving remote care: In Massachusetts, a 2½-year-old boy arrived at a community hospital emergency room choking on a pretzel, in severe respiratory distress. The hospital lacked the child-sized equipment needed to secure his airway. Transporting him to nearby Boston Children’s Hospital was not an option: a major blizzard was underway. Through a telemedicine connection, intensive care specialists at Boston Children’s could see the patient, his cardiac monitor and his ventilator settings in real time. They helped the local team stabilize the boy until it was safe to transport him to Boston — saving his life. In a similar case in California, a neonatologist at UC Davis remotely viewed a week-old baby in an emergency room two hours away and identified a heart condition. He recommended interventions and medications to stabilize him until the transport team could arrive.
An early prediction of telemedicine
The TeleDactyl, 1925: “a future instrument by which it will be possible for us to ‘feel at a distance.”
  • Chronic specialty care: A pediatrician in Arizona describes a baby born with hypothyroidism, a treatable condition but one that requires periodic blood tests to adjust medication doses. His grandmother and primary caretaker couldn’t manage the frequent, long trips to the specialist — a 125-mile drive each way, for a 15-minute visit. The pediatrician’s cobbled-together solution involved doing the blood tests locally and having periodic phone calls with the specialist to provide updates and discuss the infant’s care. The community health center now has a grant to pilot a pediatric telehealth endocrinology clinic.
  • Spotting and treating rare conditions: A newborn in rural West Virginia was having difficulty breathing. He was transferred to a community hospital in Virginia, just across the state line, where he was found to have congenital heart disease. His echocardiogram was sent via telemedicine to the University of Virginia Medical Center, where a pediatric cardiologist identified several other critical heart defects. With this doctor’s help, the community hospital staff stabilized the baby until he could be transferred to UVA to repair his heart. His care was successful because the transactions all took place in Virginia where there were a set of contracts and formal relationships between the two hospitals. Had the boy remained West Virginia, writes one of his doctors, regulatory and reimbursement issues could have stood in the way.
  • Gaining parents’ trust: A case in New Mexico of a 3-month-old baby who stopped breathing illustrates how a “Child-Ready Virtual Pediatric Emergency Department” can reassure parents about the need to transfer their child to tertiary care. In this case, a physician who spoke Spanish was able to examine the baby through a telehealth connection and allay the family’s concerns about the costs and logistics of the transfer. Via telehealth, the family was also able to meet the nurse who would be waiting to receive the baby.
  • School-based care: Robert, an 11-year-old North Carolina boy with elevated blood pressure and high cholesterol, was seeing specialists at the children’s hospital 60 miles away. But over time, his family decided the visits weren’t worth the travel expense and lost work time. The hospital’s preventive cardiology team began offering telehealth services through Robert’s middle school, targeting children who had been “lost to follow-up,” and Robert’s lifestyle and health began to improve. But as Steve North, MD, MPH, of the Center for Rural Health Innovation, writes, financial support for the program is a challenge in the current fee-for-service environment.
  • Avoiding unnecessary office and emergency department visits: In Rochester, NY, the Health-e-Access Connected Care Model (HeA) offers telehealth through schools, daycare and neighborhood access sites. Images, sounds, simple lab tests and video clips can be transmitted to the child’s medical home and diagnosis and management discussed with the family. If needed, the telehealth clinician can facilitate an emergency department or office visit — but the program’s data show that the need for such visits can be cut at least in half. Among inner-city childcare centers with telemedicine, absence due to illness dropped 63 percent. In real life, that might save the mother of a child coughing with a mild fever at daycare from having to pick him up (risking her job) and wait for hours in an ED. Instead, his pediatrician could patch in to the daycare center, see the child is alert and energetic, and rule out ear infection, asthma, pneumonia or serious transmissible respiratory infection.
  • Virtual housecalls: Children’s Health in Dallas, Texas, is hosting a Virtual Visit platform that is allowing more than 300 physicians to become telehealth providers directly to patients.

The recently introduced bipartisan Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act, now before the House and Senate, would expand telehealth services through Medicare. The white paper calls for going even further, by also providing coverage through Medicaid and commercial insurers. These efforts deserve support: This technology already exists, reduces costs and can save lives.

Download the white paper.