Madan Dharmar

Background: Infants who do not pass their newborn hearing screen require diagnostic follow-up visits but often face access barriers such as travel distance and shortage of pediatric audiologists. Telemedicine (tele-audiology) is a potential solution to provide diagnostic hearing evaluations for families of infants facing access barriers. We determined the feasibility and impact of a tele-audiology program that provided comprehensive diagnostic evaluations to a region with a high lost to follow-up rate among newborns who did not pass their newborn hearing screen. Materials and Methods: We evaluated the tele-audiology program using parent and provider surveys to determine the perception of quality and satisfaction of care. We also compared the lost to follow-up rate of the tele-audiology program with the loss to follow-up in the region before the implementation of the program. Results: Twenty-two infants who did not pass their newborn hearing screen were referred to the tele-audiology program for diagnostic evaluation. Among these infants, 59.1% were diagnosed with some form of hearing loss. The mean quality score rated by both parents and providers on the telemedicine interaction was over 6.5 on a 7-point Likert scale. All parents rated the importance of tele-audiology as 7 (extremely important) for their family, whereas the provider rated the mean importance as 6.4 (95% confidence interval, 5.9, 6.9) on a 7-point Likert scale. Almost all parents actively participated or were engaged during history taking and counseling and were comfortable in discussing their child's hearing status remotely over telemedicine. All infants completed their diagnostic evaluation with no loss to follow-up compared with 22% loss to follow-up in the region before the implementation of the program. Conclusions: Tele-audiology is a feasible solution that reduces the loss to follow-up among infants who do not pass their newborn hearing screen and have access barriers to qualified audiologists for diagnostic evaluations.

To compare the frequency of physician-related medication errors among seriously ill and injured children receiving telemedicine consultations, similar children receiving telephone consultations, and similar children receiving no consultations in rural emergency departments (EDs). We conducted retrospective chart reviews on seriously ill and injured children presenting to 8 rural EDs with access to pediatric critical care physicians from an academic children’s hospital. Physician-related ED medication errors were independently identified by 2 pediatric pharmacists by using a previously published instrument. The unit of analysis was medication administered. The association of telemedicine consultations with ED medication errors was modeled by using hierarchical logistic regression adjusting for covariates (age, risk of admission, year of consultation, and hospital) and clustering at the patient level. Among the 234 patients in the study, 73 received telemedicine consultations, 85 received telephone consultations, and 76 received no specialist consultations. Medications for patients who received telemedicine consultations had significantly fewer physician-related errors than medications for patients who received telephone consultations or no consultations (3.4% vs 10.8% and 12.5%, respectively; P < .05). In hierarchical logistic regression analysis, medications for patients who received telemedicine consultations had a lower odds of physician-related errors than medications for patients who received telephone consultations (odds ratio: 0.19, P < .05) or no consultations (odds ratio: 0.13, P < .05). Pediatric critical care telemedicine consultations were associated with a significantly reduced risk of physician-related ED medication errors among seriously ill and injured children in rural EDs.

Introduction: This study evaluates the financial impact of telemedicine outreach in a competitive healthcare market from a tertiary children's hospital's perspective. We compared the number of transfers, average hospital revenue, and average professional billing revenue before and after the deployment of telemedicine. Materials and Methods: This is a retrospective review of hospital and physician billing records for patients transferred from 16 hospitals where telemedicine services were implemented between July 2003 and December 2010. Hospital revenue was defined as total revenue minus operating costs. Professional billing revenue was defined as total payment received as the result of physician billing of patients' insurance. We compared the number of transfers, average net hospital revenue per year, and average professional billing revenue per year before and after the deployment of telemedicine at these hospitals. Results: There were 2,029 children transferred to the children's hospital from the 16 hospitals with telemedicine during the study period. The average number of patients transferred per year to the children's hospital increased from 143 pre-telemedicine to 285 post-telemedicine. From these patients, the average hospital revenue increased from $2.4 million to $4.0 million per year, and the average professional billing revenue increased from $313,977 to $688,443 per year. On average, per hospital, following the deployment of telemedicine, hospital revenue increased by $101,744 per year, and professional billing revenue increased by $23,404 per year. Conclusions: In a competitive healthcare region with more than one children's hospital, deploying pediatric telemedicine services to referring hospitals resulted in an increased market share and an increased number of transfers, hospital revenue, and professional billing revenue.

Telehealth at the University of California Health System began as a telefetal monitoring connection with a rural hospital in 1992 and evolved to become the Center for Health and Technology (CHT) in 2000. The Center supports the vision of the University of California Davis (UC Davis) Health System—a healthier world through bold innovation. The CHT focuses on the four pillars of the academic health center: clinical services, research and scholarly work, education, and public service. Since 1996, the Center has provided more than 33,000 telemedicine consultation (excluding teleradiology, telepathology, and phone consultations) in over 30 clinical specialties and at more than 90 locations across California. Research and continuous evaluation have played an integral role in shaping the telehealth program, as well as strategic collaborations and partnerships. In an effort to expand the field of telehealth the CHT provides telehealth training for health professionals, technical specialists, and administrators. Furthermore, it also plays an integral role in workforce development through the education of the next generation of community primary care physicians through Rural Programs In Medical Education (Rural PRIME) and continuing educational programs for working health professionals through videoconferencing and Web-based modalities. The Center is supported through a variety of funding sources, and its sustainability comes from a mix of fee-for-service payment, contracts, grants, gifts, and institutional funding. Together with key partners, UC Davis has educated and informed initiatives resulting in legislation and policies that advance telehealth. Looking toward the future, UC Davis is focused on technology-enabled healthcare and supporting synergy among electronic health records, health information exchange, mobile health, informatics, and telehealth.

There are few outcomes experienced by children receiving care in the Emergency Department (ED) that are amenable to measuring for the purposes of assessing of quality of care. The purpose of this study was to develop, test, and validate a new implicit review instrument that measures quality of care delivered to children in EDs. We developed a 7-point structured implicit review instrument that encompasses four aspects of care, including the physician's initial data gathering, integration of information and development of appropriate diagnoses; initial treatment plan and orders; and plan for disposition and follow-up. Two pediatric emergency medicine physicians applied the 5-item instrument to children presenting in the highest triage category to four rural EDs, and we assessed the reliability of the average summary scores (possible range of 5–35) across the two reviewers using standard measures. We also validated the instrument by comparing this mean summary score between those with and without medication errors (ascertained independently by two pharmacists) using a two-sample t-test. We reviewed the medical records of 178 pediatric patients for the study. The mean and median summary score for this cohort of patients were 27.4 and 28.5, respectively. Internal consistency was high (Cronbach's alpha of 0.92 and 0.89). All items showed a significant (p < 0.005) positive correlation between reviewers using the Spearman rank correlation (range 0.24 to 0.39). Exact agreement on individual items between reviewers ranged from 70.2% to 85.4%. The Intra-class Correlation Coefficient for the mean of the total summary score across the two reviewers was 0.65. The validity of the instrument was supported by the finding of a higher score for children without medication errors compared to those with medication errors which trended toward significance (mean score = 28.5 vs. 26.0, p = 0.076). The instrument we developed to measure quality of care provided to children in the ED has high internal consistency, fair to good inter-rater reliability and inter-rater correlation, and high content validity. The validity of the instrument is supported by the fact that the instrument's average summary score was lower in the presence of medication errors, which trended towards statistical significance.