To improve the level of emergency care provided to children presenting to rural and underserved hospitals in Northern California, the University of California Davis Children’s Hospital (UCDCH) has created a pediatric telemedicine program. Even though this program has a relatively low volume of patients, it has provided high impact services and high satisfaction scores from family members.

“The telemedicine program has allowed rural physicians like trauma surgeons, neurosurgeons, and adult intensivists to access pediatric critical care consultations for their patients,” said Yael Harris, Ph.D., director of the Office of Health IT & Quality, HRSA, during an eHealth Initiative Telemedicine webinar, on Feb. 29.

UCDCH is Northern California’s only Level 1 Trauma Center for adults and pediatrics, and is one year into its three-year, $600,000 Health Resources and Services Administration (HRSA) grant to expand its program to offer high-resolution video-conferencing critical care consults. HRSA’s Office of Advancement of Telemedicine administered 36 telehealth/telemedicine projects, totaling more than $10.3 million in awarded funds, during Oct. 1, 2009 through Sept. 30, 2011. The grant’s principal investigator is James Marcin, M.D., professor, pediatric critical care medicine, and director, Pediatric Telemedicine Center for Health and Technology, UCDCH, with the IT support led by Juan Trujano, IT supervisor, Department of Pediatrics, UCDCH.

UCDCH is halfway through that process of linking up 11 new network partners from several counties in Northern California to join the existing Pediatric Emergency Telemedicine Network of eight emergency departments (EDs), which has been operational since 1999. The EDs are relatively small, but diverse, ranging from small (annual volume of 3,776 patients) to medium (annual volume of 23,980 patients). Each site in the Pediatric Emergency Telemedicine Network has a high resolution video-conferencing unit that uses using Internet Protocols (IP) and a Virtual Private Network (VPN) tunnel to establish an encrypted, secure link between the two sites.

Beyond increasing access to pediatric critical care and emergency medicine specialists, UCDCH will be tracking the frequency of pediatric critical care consults to show the potential for increase of access to care. UCDCH will also be measuring the quality of healthcare delivered through blinded chart review by comparing patients who received a video-conference consultation, telephone consultation, and no consultation. Charts will also be analyzed using the Pediatric Risk of Hospital Admission (PRISA) II score (a second-generation severity-of-illness score that is applicable to pediatric emergency patients) to evaluate the appropriateness of transfer and admission to UCDCH.

As part of their participation in the Pediatric Emergency Telemedicine Network, the 11 new EDs will receive 24/7 access to pediatric specialists at UCDCH. After the rural physician calls the toll free consult number, the UCDCH pediatric critical care physician is paged and within 15 minutes, a two-way telemedicine consultation with live interactive audiovisual communications is initiated. The UCDCH pediatric critical care physician is able to review the child’s history, vital signs, lab results, radiographs, monitoring info and therapeutic devices like ventilator and intercranial pressure monitoring and perform a full exam remotely.

To keep the information exchange component between the rural hospital and UCDCH inexpensive and sustainable, the physician asks the treating physician or nurses for vitals or lab results via phone, fax, or by simply looking at the monitors via video-conference. There are ways to have more IT integration within the program, but it adds expense and complications, says Marcin. “You theoretically have a repository where all the sites can come in and be standardized and give it to the doctor, get the labs in a standard way, but those are resource-intensive programs,” he adds.

“At the end of the consultation, a comprehensive note is written by the pediatric critical care physician and faxed to the rural hospital to be included in the patient’s medical record,” said Harris. “Where the rural hospital has an electronic health record it can also be transmitted or incorporated as part of the electronic health record via a health information exchange.”

Low Frequency, High Impact
So far, 84 patients have been a part of the UCDCH pediatric emergency telemedicine program, which Marcin is quick to put into perspective. He says that many of the rural EDs, which have two to three beds, might only get three to five critical pediatric cases per year. So the critical care consults may be infrequent, but the impact of the program is high.

Even though Marcin and his team are waiting to publish their first satisfaction studies in a peer-reviewed journal, early results look good, he says. “Pretty much across the board we have statistically higher satisfaction from the parents and their perceptions of quality of care are higher when video conferencing is used compared to telephone,” says Marcin. He also notes there is a “step-wise increase of quality of care” when video-conferencing is used. Additional analyses will be performed to see if the program reduces medical errors.

UCDCH has had a robust telemedicine program since the ’90s that includes inpatient infectious disease consultations and audiology consultations. Marcin sees a recent California bill mandating that care providers other than physicians (i.e. occupational and physical therapists) can bill for telehealth services will likely expand the program further. “I feel like anywhere healthcare is delivered, by doctor, nurse, therapist, whatever, they have the potential for video conferencing if it makes sense for them, to make their jobs easier,” says Marcin.