Telemedicine: An Update for Pediatricians

Educational Objectives

The goal of this program is to improve the use of telemedicine in pediatrics. After hearing and assimilating this program, the clinician will be better able to:

1. Identify regulatory changes affecting telemedicine brought about by the coronavirus disease 19 (COVID-19) pandemic.

2. Elaborate on evidence supporting the use of telemedicine in pediatrics.

Summary

Telehealth: refers to the use of digital technologies to aid in improving the health of patients

Telemedicine (TM): a subset of telehealth; remote clinical care facilitated by technology; includes encounters that recreate in-person visits, interactive telementoring, patient care, and remote monitoring; encounters can occur in real time or asynchronously; visits may be between a provider and a patient or a provider and another provider; visits also may be conducted through messaging

Regulations in Maryland before the coronavirus disease 2019 (COVID-19) pandemic: coverage of telehealth by insurance was sparse; only live video interactions and specific originating sites (not homes) were covered; cross-state licensure restrictions were in place

Regulatory changes during the COVID-19 pandemic: insurance coverage — all insurers cover telehealth services, including at-home video consultations; only professional fees (not facility fees) can be billed; licensure requirements — waived by many states; providers may provide TM services across state lines to established and new patients; the list of providers allowed to participate in TM has been expanded (to, eg, speech-language pathologists, therapists); video platforms — expanded; the use of non–public-facing video platforms (eg, FaceTime, Skype) for telehealth visits is allowed

Real-time virtual visits between provider and patient at Johns Hopkins Medicine: the number increased exponentially because of the COVID-19 pandemic; made up ≈54% of the total ambulatory volume in March and April 2020; all pediatric specialties participated

Lessons learned: patient satisfaction — level is high; the majority of patients indicated that virtual visits should continue after the pandemic; video platform — technology must be easy to use by patients and providers; ensuring access for unique populations and those who have challenges is important to ensure that TM does not exacerbate disparities in health care; need for customized education — providers and staff need self-learning modules and information related to technical issues, insurance, billing, compliance, and legal and regulatory issues; educational materials for patients must be developed

Benefits of TM: improved access for patients, potentially reduced overall cost of care, improved patient experience, greater convenience, and overall improved outcomes

Risks associated with TM: potential for misdiagnosis, litigation based on new standards of care, and increase in use and cost

Earlier evidence for benefits of TM

Flodgren et al (2015) study: found strong evidence for use of TM in management of chronic diseases in adults and children; heart failure — health outcomes for patients who experienced TM and in-person care were similar; quality of life was improved for those with TM care; diabetes mellitus — compared with in-person care, TM promoted better control of blood glucose levels and lower glycosylated hemoglobin levels; mental health and substance abuse — there was no difference in therapeutic effect with TM, and patient convenience was improved; control of blood pressure and respiratory conditions (eg, asthma) — improved with TM

Barrier to research: technology is evolving rapidly

2016 review of remote vs face‐to‐face check‐ups for asthma: did not find any important differences; information to rule out differences in efficacy or to determine whether remote asthma check-ups are a safe alternative to face-to-face consultations is insufficient

TM in pediatrics before the COVID-19 pandemic: rate of use was relatively low; higher for children living in rural areas; children identified as Hispanic and black were less likely to have TM visits

School-based TM

Effect on absences for acute illness (McConnochie et al [2005]): evaluation of a TM program in 5 urban childcare centers found a 63% reduction in absences because of illness (mean missed days went from 8.7 to 4.1/100 days)

Children who have asthma: a large randomized controlled trial by Halterman et al (2018) noted more symptom-free days at 6 mo and fewer visits to the emergency department (ED) and hospitalizations in the TM group compared with usual care; Bian et al (2019) found that after a school-based telehealth program was initiated in South Carolina, use of TM was associated with fewer visits to the ED for patients who had asthma, but not for those who had other conditions

Telementoring: can enhance the impact of primary care; Extension for Community Healthcare Outcomes (ECHO) was launched in 2003 by a specialist in liver disease to improve care of patients who have hepatitis C infection in New Mexico; a free educational model and mentoring community for providers of patients in New Mexico who have hepatitis C infection; a study found that hepatitis C care provided by those mentored in project ECHO was as good as care provided by specialists at a university; patient satisfaction and access to care also were improved; telementoring is a guided practice model in which participating clinicians retain responsibility for the patient under the guidance of a specialist; uses technology, shared best practices to reduce disparities, a case-based learning model, and Internet-based tracking of outcomes; the American Academy of Pediatrics (AAP) offers project ECHO models

Resources: American Telemedicine Association — a policy statement endorsed by the AAP includes specifications on privacy and confidentiality, informed consent, school health regulations, patient safety concerns, presence of parents and legal guardians, and clinical encounters (eg, equipment, environment, licensing, credentialing); National Consortium of Telehealth Resource Centers (TRC) — federally funded; its aim is to promote use of distance care to help improve care for vulnerable populations and rural patients; Center for Connected Health Policy — provides summaries of policies; resources (eg, Medicaid reimbursement model) are listed by state; AAP — offers a guide to starting a telehealth practice and sample documents

Readings

Arora S et al. Outcomes of treatment for hepatitis C virus infection by primary care providers. N Engl J Med. 2011; 364:2199-2207. doi: 10.1056/NEJMoa1009370; Bian J et al. Association of a school-based, asthma-focused telehealth program with emergency department visits among children enrolled in South Carolina Medicaid. JAMA Pediatr. 2019;173:1041-1048; Flodgren G et al. Interactive telemedicine: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2015;7.CD002098; Halterman J et al. Effect of the School-Based Telemedicine Enhanced Asthma Management (SB-TEAM) program on asthma morbidity. JAMA Pediatr. 2018;172(3):e174938; McConnochie KM et al. Telemedicine reduces absence resulting from illness in urban child care: evaluation of an innovation. Pediatrics. 2005;115:1273-82; Reed ME et al. Real-time patient-provider video telemedicine integrated with clinical care. N Engl J Med. 2018;379(15):1478-1479. doi:10.1056/NEJMc1805746.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Hughes was recorded at the 35th Annual Pediatrics for the Practitioner: Update 2020, held October 15-16, 2020, and presented over the Internet by the Johns Hopkins University School of Medicine, Division of General Pediatrics and Division of Adolescent and Young Adult Medicine; the Johns Hopkins Children’s Center; and the American Academy of Pediatrics, Maryland Chapter. For information about upcoming CME opportunities from this sponsor, please visit www.hopkinscme.cloud-cme.com. Audio Digest thanks the speakers and the Johns Hopkins University School of Medicine, Division of General Pediatrics and Division of Adolescent and Young Adult Medicine; the Johns Hopkins Children’s Center; and the American Academy of Pediatrics, Maryland Chapter, for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

PD672002

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.