1. A View Into The Future: Telemedicine in the Pediatric Setting
Suzanne Paul, BSN, MSN, FNP-C
Duke Johnson and Johnson Nurse Leadership Fellow
Children’s Hospital Immunodeficiency Program

2. Objectives Define Telemedicine
Explore modes of Telehealth in the 21st century
How to Engage Clients in Telemedicine
Identify Barriers in implementing Telemedicine Clinics
Recognize Legal Obstacles of Telehealth

3. Technology News

4. 10 Most Promising Telehealth Solutions of 2017

5. Health Care Tech

6. Patient Care that utilizes technology
Telemedicine
Patient Care that utilizes technology
Telehealth
Health Care Services that utilize technology

7. Examples of Telehealth
Store and forward e- consults
Remote patient monitoring
Video conferencing
Real time patient encounters

8. Children’s Hospital Colorado Service Locations

9. Current Efforts Children’s Hospital Colorado
Telemedicine
Audiology/Speech Therapy
Concussion Psychology
Burn Consults
Transplant
Psychology and Med Adhere
Cardiology Aftercare Management Pulmonary Hypertension Support
Child Abuse and Neglect Evaluation
Clinical Nutrition
CHIP Clinic
Down Syndrome Multi-disciplinary Clinic Developmental Pediatrics (Autism Spectrum)
Eating Disorder Psychological Support
Emergency Psychiatry
Endocrinology
Endocrinology w/Diabetes
Fetal ECHO
Gastro
Genetics
Infectious Disease
Neonatal Transfer Support
Neurology
Neurology Epilepsy
Orthopedic Surgery Consultation and Surgery Prep
Primary care -Integrated Psychiatry and Behavioral Health
Psychiatry
Pulmonary
Sleep Medicine

10. Current Projects ECHO Clinical Population Health Patient Navigation
Developmental Behavioral Pediatric
Hepatitis C
Child Abuse and Neglect
HIV
Complex Care Pediatrics
Neurology
Behavioral Health
Nursing Practice Support
TB Management
Cancer Survivorship
Pediatric Epilepsy
Population Health
Patient Navigation
Pharmacy Integration in PCMH
Obesity Prevention and Nutrition
Quality Improvement for Local Public Health
Food Safety
Tobacco Control
Research & Grants
CoYoT1 (Helmsley Trust), AHRQ MAT, Subspecialty Care in Primary Care Medical Home, PCORI RCT

11. Telemedicine for Subspecialty Care
For many who live in rural areas and have chronic conditions, receiving regularly scheduled visits with their pediatric subspecialist can be an extraordinary and expensive burden, often resulting in suboptimal care.
Many children with chronic conditions have periodic exacerbations and debilitating symptoms that require consistent care and coordination with primary care.
One potential solution is telemedicine

12. Subspecialty care in rural Colorado
Started telemedicine May 2012
Current sites:
- Casper, Cheyenne, Jackson Hole, WY
Billings, MT
- Durango, CO, Grand Junction, CO, Rifle, CO, Glenwood Springs, CO, Montrose, CO, etc.
Participants complete a questionnaire regarding:
- Their experience with telemedicine
Demographics: age, zip code, # visits, type of visits
Jackson Hole
Casper
Cheyenne
Durango

13. Patient Satisfaction Overall Satisfaction of Patients/Guardians
Table 3 demonstrates the means and standard deviation for patient satisfaction with effectiveness, efficiency and overall acceptability of care via telemedicine.
Variable N Mean StdDev Min Max
Overall Acceptability
“Overall I felt comfortable using technology for visit
“Technology easy to use for appointment”
“Rating of ability to SEE and HEAR”
Effectiveness
“Confident it meets needs/would use again”
“I will recommend its use to others”
Efficiency
“Compared to in person visit, reduced inconvenience
of unnecessary travel”
“Likely to reduce time missed from school and work”
“Likely to reduce delays for next avail appointment”

14. Decreased time off work/ school
Table 2. Estimated Patient Travel Costs and Cost Differences for Telemedicine-enabled service. CHCO=Children’s Hospital Colorado. PPSW=Pediatric Partners of the Southwest
Average travel time (RT) for in person visit to Children’s Colorado in Denver
840 minutes
Average Miles for in person visit to CHCO
348.27, SD 47.21, range:
Round trip Miles for in person visit to CHCO prior to telemedicine availability
Less than 20
Greater than 20 and less than 100
Greater than 100 and less than 200
Greater than 200 and less than 1,000
120 (100%)
Average travel time (RT) for local travel for telemedicine visit at PPSW in Durango
70 minutes
Average Miles for care via telemedicine PPSW
31, SD 46.92, range: 1 – 424
Round trip Miles to/from telemedicine enabled appointment in PPSW
45 (37.2%)
54 (44.6%)
14 (11.6%)
(6.6%)
Average time lost from work/school for traditional, in person clinic visit at CHCO
1.68 days
Average time lost from work/school for telemedicine appointment
0.08 days
Average family cost per in person visit to Children’s Colorado (wages, general travel expenses: mileage, hotel, food).
$570.00
Total savings attributable to families for trips saved through telemedicine
$94,555.26
Total time savings gained by families through telemedicine
270 days
Total miles saved
107,237

15. Access to care for rural pediatric subspecialty care patients is increased with telemedicine
Patient/ family satisfaction is high for telemedicine experience and most return for future visits
Further study is needed to determine how telemedicine affects chronic disease control over time and if telemedicine can help to reduce the risk of complications and emergent care

16. CHIP Telemedicine Clinic
Identification of a problem:
Children’s Hospital Immunodeficiency (CHIP) Clinic –
only clinic serving HIV positive children, adolescents, and pregnant women in the Rocky Mountain Region
Service Large Geographic Area
Largest population of CHIP clients - El Paso County
CHIP reimburses cost for travel, meals overnight accommodations

17. CHIP Telemedicine Clinic
Project Description:
Collaboration
Telemedicine Department
Children’s Hospital Briargate Location located in El Paso County
Clinic Scheduling
Once monthly
Patients successfully scheduled into the future

18. CHIP Telemedicine
CHIP Telemedicine Protocol
Collaboration
Training
HIV Education
Telehealth Equipment
Clinic Work Flows
Surveyed Before and After visits

19. Procedures of Telemedicine Clinic
Patient arrives in Children’s Hospital Colorado Springs Briargate Location
CHIP Staff logs in from Children’s Hospital Colorado in Aurora
HIPAA-compliant, web-based, video platform
Vital signs obtained by originating site
Both sites able to access patient’s record in EPIC

20. Procedures of CHIP Telemedicine
CHIP staff
obtain history from patient and family
Full physical exam
Stethoscope can transmit sound to telehealth site
Otoscope exam
Vaccinations
Lab Work
Emla Cream

21. Survey Results Question Pre- Visit (N=7) Post- Visit (N=7)
Fear of Technology
4/7 (57%) Disagree
1/7 ((14%) Strongly Disagree
2/7 (29%) Neutral
7/7 (100%) Agreed they would recommend to others in the future
Previous Use of Telemedicine
0/7 (0%) NA
Loss of Time from Work
1/7 (14%) Strongly Agree
3/7 (43%) Agree
3/7 (43%) Neutral or disagree – not working
7/7 (100%) Reduced inconvenience from travel
Hours lost from work*
5.25 hours (0.5)
X = 2.67 hours (0.94 )
Hours lost from school*
6 hours (1.01)
X = hours (1.30)
Money Spent on Travel*
$ (7.86)
X = $1.00 (4.47)
Money Spent on Meals*
$18.00 (9.27)

22. CHIP Telemedicine Locations
Laramie, Wyoming
Glenwood Springs, CO
Partnered with local pediatricians
Primary Care Providers
Physician Champion in the region
Future Sites
Casper, Wyoming
Nebraska

23. Barriers to Implementing Telemedicine
Licensure
Provider must be licensed in the state where the visit originates
Regulations vary state to state
Insurance Reimbursement
Verify with family prior to the visit
Site of Practice Agreement
General inexperience with Telemedicine

24. Legal Aspects of Telemedicine
American Telemedicine Association
HIPPA Compliant Equipment
Informed Consent
School Based Health Centers – special considerations
Patient Safety

25. 14-20% of children experience a behavioral health issue annually
The Clinical Utility of Telemedicine in Pediatric Mental Health Emergencies in the ED/UC Setting
Background
Pediatric mental health emergencies (MHE’s) represent an escalating segment of psychiatric emergency services (PES)
14-20% of children experience a behavioral health issue annually
Pediatric Emergency Departments (ED) and Urgent Care (UC) sites are vital for initial stabilization of patients with MHEs in conjunction with evaluation and disposition by trained mental health specialists (MHS)
A system that provides safe and timely evaluation of MHEs is challenging from a resource perspective, especially when patients present at multiple sites distant from MHS
Telemedicine offers a synchronous consultation link between patients with MHEs and MHSs
The combination of telemedicine-enabled behavioral health consultation is described as tele-behavioral health

26. Objective
Evaluate impact of telemedicine (tele-behavioral health) for evaluation of pediatric patients with MHEs at distant NOC ED/UC sites by a MHS at a central location within a CHCO system vs. traditional EMS transfer and in person evaluation at ACED
Measures
Evaluate differences in tele-behavioral health v. traditional evaluation
Quality of care
Transfer vs. discharge disposition from NOC location
Length of Stay
Patient, family and provider satisfaction with tele-behavioral health
Economic efficiency
Operational costs of establishing program
Cost Comparisons

27. Data Collection Data Analysis
Retrospective chart review from the hospital EMR (EPIC) evaluating
Demographics
Diagnosis(es)
ED/UC arrival time and LOS
Patient disposition
Patient, family and provider satisfaction
10-item survey addressing efficiency, effectiveness and overall acceptability
Encounter charges
telemedicine operational costs (fixed and variable) to establish program
ED/urgent care visit charges
EMR transfer expenses
hospital treatment charges
physician charges
Data Analysis
Statistical analysis using SAS software, version 9.4(SAS Institute, Cary, NC, USA)
Descriptive, multivariate and cost-effectiveness analyses (CEA)

28. Telemedicine Mean (SD)
Results
494 patients enrolled
Telemedicine Mean (SD)
n = 232
Traditional Mean (SD)
n = 268
p - val
Age in years, M (SD)
1- 6
7-11
12-15
16 -19
13.1 (2.7)
5 (2.2%)
(21.7%)
(60.6%)
36 (15.6%)
13.3(2.5)
2 (0.8%)
50 (18.7%)
174 (65.2%)
41 (15.4%)
.34
.45
Gender, N (%)
Male
Female
100 (43.1%)
132 (56.9%)
100 (37.3%)
168 (62.7%)
.19
Race, N (%)
Caucasian
Other
179 (77.2%)
53 (22.8%)
(69.0%)
83 (31.0%)
.04
Insurance Status
Private
Public
Self Pay/Uninsured
Yes No
134 (57.8%)
91 (39.2%)
7 ( 3%)
152 (70.4%)
64 (29.6%)
127 (47.4%)
132 (49.3%)
9 ( 3.4%)
147 (59.5%)
100 (40.5%)
.12
.015
Discharge Dianosis (es) N (%)
Suicide intent with plan
Self harm (no plan)
Other – harm
Depression/Anxiety
Hallucination/Delusion
Unknown
66 (28.5%)
94 (40.5%)
25 (10.8%)
33 (14.2%)
8 (3.5%)
6 (2.6%)
64 (23.9%)
124 (46.3%)
21 (7.8%)
40 (14.9%)
12 (2.6 %)
10 (3.7 %)
.25
.20
.26
.82
.58
.47

29. Results: Transfer Rate
Near 50 % decrease in need for patient transfer with telemedicine

30. Results: Length of Stay
29% of telemedicine patients had a length of stay of less than 4 hours compared to 11.6% who received traditional care
29% vs 11.6%, p < .0001
75% of telemedicine patient had a length of stay of less than 8 hours
52% of traditional care patients had a length of stay of over 8 hours

31. Results: Length of stay
The mean total time to disposition was significantly less for telemedicine patients
7 hours telemedicine vs hours for traditional care, p < .0001

32. Results: Patient & Provider Satisfaction
Over 98% of patients, parents and providers were very to extremely satisfied with the tele-behavioral health program

33. Results: Economic Efficiency
Median charges for the two groups were significantly different
($3,493 vs. $8,611, p<.001)

34. Conclusions
Tele-behavioral health can be used to provide pediatric specialty evaluations in a distant ED/UC setting and provide
Lower cost compared to traditional care
Improved outcomes: reducing both length of stay and transfer rate
Excellent patient, family and providers satisfaction with the efficiency, effectiveness and overall acceptability of tele-enabled care
While further research is required to assess the types of MHEs most suitable for pediatric tele-behavioral health, this improved process may represent the optimal modality for evaluating patients presenting with behavioral health issues in a distant ED/UC setting

35. CoYoT1 Clinic – Colorado Young Adults with T1D
Young adults with type 1 diabetes
Disconnected from care + poor diabetes outcomes
Increased independence – focus on school, work, social life
Barriers to diabetes care
Limited research using technology to increase access and care
CoYoT1 Clinic
Designed to meet the medical care needs of young adults with T1D in a technology driven, group visit model
Objective
To investigate use of web-based video conferencing to increase access and reduce barriers to evidence-based diabetes care in young adults with T1D
Meet them where they are…

36. Methods CoYoT1 Clinic Individual appointment – MD/NP, ~30 minutes
Group session facilitated by CDE, ~30 minutes
4 patients per clinic
Complete visit from home, work, school, or other location of their choosing
HIPAA-compliant, web-based, video platform

37. Methods Patient clinic prep Upload diabetes devices
Glucometer, insulin pump, continuous glucose monitor
Complete hemoglobin A1C (HbA1c) and other labs
Providing data received during regular clinic appointments

39. Conclusions – CoYoT1 Clinic
CoYoT1 Clinic = potentially effective model to engage young adults with T1D in routine diabetes care
High satisfaction using telemedicine technology for diabetes care and desire to complete online visit again
May result in improved engagement in care
Convenience and ease of completing clinic visits from home = 6 hours time saved
Easier for young adults to fit diabetes clinic visits into busy lives
12 month evaluation (including control group) underway
Assess if CoYoT1 Clinic increases access to diabetes care and improves glycemic control in this challenging population

40. Overall Strategies for The Future
Models that focus on value-based payment systems
Medicaid, other capitated contracts, payer incentive-based outcomes
Expanding reimbursement and payment opportunities
Build partnerships with community-based practices and hospitals
Care is connected, streamlined, continuous, seamless and integrated
Communication silos broken down – team approach, focus on transitions of care
Develop “Models of Innovation”
Implementing new and innovative models that define evidence-base, change payment models and inspire replication.
Any-Time-Any-Place Access, “Hello, Dr….your patient will see you now!”
Integrated, evidence-based, improved access, improved outcomes, affordable
Truly less disruptive healthcare
Develop grant proposals and conduct research
Develop models and research that have meaningful impact on child health outcomes

41. Patient-Centered Care, Right time, Right Place, Right Team
Parents/community
Community-based Social Service Organizations
eConsult
Medical Devices
Mobile Apps
Automated Outreach
School Nurse/School-based Clinic
Advanced Analytics
Telemedicine
Primary Care Provider
Remote monitoring
ECHO
myChart
Children’s Hospital Colorado
Care Everywhere

42. ECHO Colorado ECHO – Extension For Community Health Care Outcomes
ECHO NM – experience and evidence that ECHO helped support specialty care delivery as effective as Univ clinic
Support medical home model: Increasing access to subspecialty care in collaboration with primary care practices
Builds capacity by increasing participants’ access to expert and peer knowledge.
DE monopolization of knowledge re: best practices across the healthcare and public health workforce

43. Rational Healthcare Delivery Spectrum Urgent / Ambulatory Care
In Person Care
Telemedicine
eConsult
ECHO
Relationship
Specialist - Patient
Specialist - PCP
Specialist Team –
PCP Cohort
Cost
$$$$
$$$ $$ $
Frequency
1-2 times per year
as needed
Platform
In-Person
Video-Conference
Web-based Software
Location
Hospital or Clinic
Primary Care, School or Home
Anywhere
Convenience
Population Health Connection
Force Multiplier
Urgent / Ambulatory Care

44. The Future is NOW
How can you incorporate Telemedicine in your practice?
What is the best way to REACH your patients?
Are you interested in ECHO?

45. References
Olson, C. A., & Thomas, J. F. (2017). Telehealth: No Longer an Idea for the Future. Advances In Pediatrics, 64(1), doi: /j.yapd
Melton, L., Brewer, B., Kolva, E., Joshi, T., & Bunch, M. (2017). Increasing access to care for young adults with cancer: Results of a quality-improvement project using a novel telemedicine approach to supportive group psychotherapy. Palliative & Supportive Care, 15(2), doi: /S
Hilty, D. M., Shoemaker, E. Z., Myers, K., Snowdy, C. E., Yellowlees, P. M., & Yager, J. (2016). Need for and Steps Toward a Clinical Guideline for the Telemental Healthcare of Children and Adolescents. Journal Of Child And Adolescent Psychopharmacology, 26(3), doi: /cap
McSwain S. David, Bernard Jordana, Burke Bryan L. Jr., Cole Stacey L., Dharmar Madan, Hall-Barrow Julie, Herendeen Neil, Herendeen Pamela, Krupinski Elizabeth A., Martin Amanda, McCafferty Dan, Mulligan Deborah Ann, North Steve, Ruschman Jennifer, Waller Morgan, Webster Kathleen, Williams Sherrie, Yamamoto Susan, and Yeager Brooke. Telemedicine and e-Health. August 2017, ahead of print.
Raymond Jennifer K., Berget Cari L., Driscoll Kimberly A., Ketchum Kaitlin, Cain Cynthia, and “Fred” Thomas John F.. Diabetes Technology & Therapeutics. June 2016, 18(6):

46. Questions? Suzanne Paul, BSN, MSN, FNP Nurse Practitioner CHIP Clinic