Jackie is a working mother of five children who works as a teacher's aide and cooks for the childcare center that her youngest two children attend. Three of her kids have asthma, and her youngest has recurrent otitis, which added together have required 15 medical visits (pediatrician, pulmonologist, emergency department) in a three-month period. As with many low-paying service jobs, Jackie does not get paid if she is not at work and feels caught in a no-win situation. She either feels guilty for being a bad mom if she doesn’t take her children in for their medical appointments or lets her family down by not getting paid when she takes off work but then doesn’t have enough money at the end of the month to pay her bills. Her childcare center director appreciates her dilemma and is excited to tell her about a new telemedicine service that will allow her children to see their primary care medical home without having to leave school or the childcare center. Jackie can now stay at work and have her kids get the medical attention they deserve. She still has to come to the hospital for her specialist visits and well-child visits but is able to schedule those for later in the afternoon after her breakfast and lunchtime duties at the childcare center are completed. So far, her youngest has avoided getting pressure equalization tubes with careful management by her primary care provider, and her older children with asthma have improved their attendance at school with better asthma control and an earlier response to exacerbations.
Children younger than 18 years of age in the United States made 127.5 million office visits in 2012 for problem-focused concerns. 1 These visits account for 75% of all office visits for children and represent the leading cause of parents having to miss time from work. 1,2 Fewer than 50% of working women in the United States believe that they can avoid conflict between family and work responsibilities the next time one of their children is sick. 2 Clearly, the social and economic burden associated with caring for ill children is substantial, but there may be opportunities to rethink how and when children receive medical care. Telemedicine offers new options for evaluating and treating children with both acute and chronic illnesses with potential efficiencies for patients, parents, providers, and payors. 3
Telemedicine models for schools and childcare centers have evolved as the technology and connectivity have improved in the new millennium. State regulations and insurance company expectations have tried to keep up with the growing direct-to-consumer telemedicine applications, and terms like “face to face” have been replaced with “real-time video interaction” to distinguish virtual connections from in-person physical interactions. The idea of telemedicine providing an “in-office equivalent” visit allows providers to choose a telemedicine platform that allows them to conduct a history and physical that is the same as what they would conduct in person. For acute illness visits, that might include peripherals to look in the child's ears, eyes, and throat; an electronic stethoscope for listening to the child's lungs; and a general camera for observing the child's behavior or looking at a rash. For behavioral health follow-up visits, the provider may be satisfied with a simple webcam to provide two-way video communication for counseling and education. Telemedicine units may be fixed in the school nurse's office or may be mobile with laptop computers and a suitcase of attachments traveling with a telepresenter from one school to another as the need arises.
Pediatric researchers have contributed to the scientific evidence base establishing that telemedicine visits for children can be conducted safely, effectively, conveniently, and economically. In one of the few head-to-head comparisons of pediatric telemedicine versus in-person examination for common acute childhood illnesses, there was 86% agreement in diagnosis and treatment between the telemedicine and in-person providers compared to a 92% agreement for duplicate in-person examinations. 4 Ninety-six percent of school- and childcare-based telemedicine visits were able to be completed in a model using telepresenters connecting to primary care pediatric offices and diagnostic capabilities of otoscope, stethoscope, videoconference, and point-of-care testing (rapid strep tests). 5
Satisfaction surveys of patients and providers rank telemedicine high for convenience, quality of interaction, clarity of images, and confidentiality of information being discussed. After just one telemedicine encounter, 98% of parents of preschoolers would choose a childcare center that offered telemedicine if given a choice over a similar center without telemedicine services. 6 Absence due to illness from childcare in Rochester, New York, was decreased by 63% during an 18-month period after telemedicine was implemented in five inner-city childcare centers. 6 On average, parents report a savings of 4.5 work hours that would have otherwise been lost if telemedicine had not been available to their ill child. 6
Evaluation and management of children with chronic conditions can also be enhanced with school-based telemedicine. Children with type 1 diabetes ages 5 to 14 years receiving remote diabetes care management via telemedicine at school were able to lower their hemoglobin A1c levels and experience fewer hospital and emergency department visits during the school year. 7 Other programs in Kansas and Georgia have shown the effectiveness of using school-based telemedicine to enhance psychiatry services to treat attention deficit hyperactivity disorder (ADHD), depression, and autism spectrum disorders. 8,9
Utilization studies show a slight increase in overall use of health services when telemedicine access is made available in elementary schools and childcare centers during the day. 10 This may represent an increase in nonessential convenience-driven visits, or more likely, fulfillment of a previously unmet need (ie, underutilization of health care in a vulnerable population). The cost associated with this slight increase in primary care visits was more than offset by a 22% reduction in costly emergency room visits for children. 10
Reimbursement for telemedicine services for children in school and childcare varies greatly from state to state. In the best case, school-based telemedicine visits are reimbursed at the same rate as an in-person office visit plus a small fee for the originating site to help cover the infrastructure cost of equipment and personnel at the school. Many states have passed legislation for “parity” bills that require insurers to cover a telemedicine visit if that service would be otherwise eligible for payment if conducted in person in the office. Some states have different rules for commercial insurers and Managed Medicaid programs. Pediatricians are finding that parity of coverage does not equal parity in reimbursement rates, with insurers gladly reimbursing for telemedicine services but at only half the local rate of an office visit. In the worst case are states that adopt the Centers for Medicare and Medicaid (CMS) guidelines for Medicare and apply them to services for children. These guidelines restrict the geographic location of the originating site, require licensed providers to act as telepresenters, and define the type and location of the telemedicine provider, essentially eliminating any chance of setting up a school-based telemedicine program. Quality metrics for asthma and ADHD have shifted the focus from patient adherence to population management, with providers having a greater incentive to deliver timely, high-quality care. As pay-for-performance metrics become a larger part of primary care reimbursement, some providers are using telemedicine visits in the school to help meet or exceed goals for chronic care management, especially in urban practices with notoriously high no-show rates.
As is the case in all pediatric care, good communication is at the core of any telemedicine encounter. Policies and procedures must specifically address the need for secure, private communication with both the child and his or her guardian. Consideration must be given to the educational laws called Family Educational Rights and Privacy Act (FERPA) in addition to health system Health Insurance Portability and Accountability Act (HIPAA) regulations. Confidential adolescent care is another challenge for telemedicine providers to know the specific rules of their state and sometimes of their school district when it comes to obtaining consent for evaluation and treatment for mental health, substance abuse, or reproductive health issues. Contingency plans should be developed in the event of technologic failures or medical emergencies that require immediate intervention at the originating site.
Operating procedures and guidelines are being developed to address the unique aspects of delivering pediatric telemedicine care. The American Telemedicine Association has published multiple guidelines to help establish a safe and effective telemedicine program. They have also helped define the core terms used to describe and differentiate the spectrum of services that can be delivered under the heading of telemedicine. Pediatric providers and program managers are encouraged to check with their regional telemedicine resource center and professional organizations to keep abreast of any changes that may affect your ability to perform telemedicine services. The following websites will help: