PEDIATRICS Vol. 105 No. 4 April 2000, pp. 843-847

SPECIAL ARTICLE:
Use of Telemedicine for Children With Special Health Care Needs

Warren B. Karp, PhD, DMD^*, R. Kevin Grigsby, DSW, LCSW, Maureen McSwiggan-Hardin, RN, MS, CS, Suzanne Pursley-Crotteau, RN, PhD, CARN§; Laura N. Adams, BS, Wyndolyn Bell, MD, Max E. Stachura, MD, and William P. Kanto, MD^*

From the Department of ^* Pediatrics,  Telemedicine Center, and ^§ Department of Community Health Nursing, Medical College of Georgia; and  Division of Public Health, Georgia Department of Human Resources, Children's Medical Services, Atlanta, Georgia.

	ABSTRACT

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Objective.  In 1995, the Children's Medical Services (CMS) of the State of Georgia contracted with the Department of Pediatrics of the Medical College of Georgia (MCG) and the MCG Telemedicine Center to develop telemedicine programs to provide subspecialty care for children with special health care needs. This article presents project statistics and results of client evaluation of services, as well as physician faculty attitudes toward telemedicine.

Design.  A demonstration project using telemedicine between a tertiary center and a rural clinic serving children with special health care needs was established. Data were collected and analyzed for December 12, 1995 to May 31, 1997, during which 333 CMS telemedicine consultations were performed.

Results.  Most CMS telemedicine consultations (35%) involved pediatric allergy/immunology. Other subspecialties included pulmonology (29%), neurology (19%), and genetics (16%). Overall, patients were satisfied with the services received. Initially, physician faculty members were generally positive but conservative in their attitudes toward using telemedicine for delivering clinical consultation. After a year's exposure and/or experience with telemedicine, 28% were more positive, 66% were the same, and only 4% were more negative about telemedicine. The more physicians used telemedicine, the more positive they were about it (r = .30).

Conclusions.  In terms of family attitudes and individual care, telemedicine is an acceptable means of delivering specific pediatric subspecialty consultation services to children with special health care needs, living in rural areas distant to tertiary centers. Telemedicine is more likely to be successful as part of an integrated health services delivery than when it is the sole mode used for delivery of care.  Key words:  telemedicine, special healthcare, attitudes, consultation, rural health.

In Georgia, the Children's Medical Services (CMS) Program, a Title V health care program, insures access to medical care for children with special health care needs from birth to 21 years of age.¹ Although the CMS system has been generally successful in providing subspecialty care, gaps remain because of the difficulty of providing access to pediatric subspecialty service for patients who live at long distances.² Rural patients and their families must often travel long distances to tertiary centers for medical care or to purchase specialized medical equipment. In an attempt to reduce the burden of travel on these patients and their families, CMS developed a network of subspecialty clinics staffed by traveling physicians, in selected communities in Georgia. Children with special health care needs are thus served in subspecialty clinics at either the tertiary center or in a rural locale. Associated travel expenses are borne by families, providers, or both.

In 1995, CMS contracted with the Department of Pediatrics of the Medical College of Georgia (MCG) and the MCG Telemedicine Center to develop a program using telemedicine to provide better access and increased services to children with special health care needs. As used in this project, telemedicine specifically refers to the Georgia Statewide Telemedicine Program (GSTP), which allows health care providers to electronically provide medical consultations and/or services to patients at remote sites throughout the state.³

The purpose of this article is to describe a CMS-Telemedicine Project between the Department of Pediatrics of MCG and a health department in Waycross, Georgia, 177 miles away. Data presented include project statistics, client evaluation of services, and physician faculty attitudes about telemedicine.

	METHODS

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GSTP is a division of the Georgia Statewide Academic and Medical System. GSTP is managed by the MCG Telemedicine Center in Augusta, Georgia. It provides a dedicated T-1 (1.544Mbps) network that is operational 24 hours a day, 7 days a week. The telemedicine system provides fully interactive audio and video combined with diagnostic quality cameras and medical instrumentation enabling consultants to examine a patient at a distance and render appropriate health care. Some of the more frequently used medical instrumentation includes the stethoscope, ophthalmoscope, and otoscope. Additionally, the telemedicine system provides for image capture, storage, transfer, and interactive collaboration, thereby enhancing the effectiveness of the delivery of health care, while simultaneously providing an educational format for rural health care providers.³

This article describes data collected from December 12, 1995 through May 31, 1997. Information collected on each pediatric telemedicine consultation or service included the age of the patient, presenting problem, number of subspecialty consultations provided, total duration of the telemedicine consultation or service, and disposition. In addition, between November 27, 1996 and May 15, 1997, a subset of information was collected using the Client Satisfaction Questionnaire⁴ for 141 caregivers and patients who used CMS telemedicine. This valid and reliable instrument measures client satisfaction without reference to the method of care delivery. The instrument was used in this study because of its stability across populations and modalities of care. Caregivers and CMS children were asked to complete the 8-question survey at the completion of each telemedicine encounter.

Patients for the CMS telemedicine encounters were scheduled by the CMS nurse, in consultation with the pediatric subspecialist at the tertiary care center. When scheduling the patient, the CMS nurse provided the caregiver and patient with a brief orientation concerning the planned telemedicine visit with the subspecialist. When the child and family arrived at the telemedicine site, the CMS nurse was responsible for reviewing the procedures for a telemedicine encounter, including information related to confidentiality, parent consent, and record keeping. The CMS nurse acted as both the case manager and the facilitator for both the child and caregiver during the telemedicine encounters. An appropriate protocol for patient presentation was established for each subspeciality. As part of the facilitation of the assessment, the CMS nurse used the medical camera and electronic stethoscope to provide eye, ear, nose, throat, heart, and chest examination for the subspecialist as needed. The CMS nurse was also available to provide follow-up health teaching, completion of medical testing, and other follow-up procedures as necessary.

Transportation costs were captured by calculating the mileage (MapLinx for Windows, Version 3.0, MapLinx, Dallas, TX) from the remote site (Waycross) to the tertiary care center (MCG in Augusta). For patients seen in Waycross, actual mileage was calculated from a local map. Round-trip mileage was multiplied by $.31/mile for families and patients using personal transportation (Internal Revenue Service business mileage rate, 1996).

Attitudes of the physician faculty members of the MCG Department of Pediatrics were measured in August 1996, using a survey created specifically for this purpose. The 4-part instrument contained 21 items. Part 1 of the instrument explained the nature of the study and instructions for completing the questionnaire. Part 2 contained 15 statements focused on attitudes toward telemedicine. Faculty members were asked to indicate their agreement or disagreement with the statements using a 5-point Likert scale ranging from strongly agree to strongly disagree. Part 3 of the instrument asked faculty members whether their attitudes about telemedicine had changed over the past year and the reasons for the change. Faculty members were presented with a choice of potential reasons for any observed change. In an open-ended format, they were also permitted to list additional reasons and make comments about telemedicine. Part 4 was designed to gather demographic information (gender, age, telemedicine consultations completed, and educational background). Data were coded and to protect the identity of the participants, the code was known only to the secretary. Instruments were distributed by the campus mail service and included a cover letter, the instrument, and an addressed return envelope. Three weeks after the initial mailing, a follow-up letter and duplicate instrument were sent to nonrespondents. A week after the second mailing, remaining nonrespondents were contacted by telephone and encouraged to return the questionnaire. Data were analyzed and descriptive statistics used to summarize the demographics, attitudes, and feelings of the respondents.

	RESULTS

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Between December 12, 1995 and May 31, 1997, a total of 333 CMS telemedicine consultations were performed. Of the 333 telemedicine encounters, 119 (36%) involved female patients and 214 (64%) involved male patients. These telemedicine encounters included 201 individual patients who were seen between 1 and 6 times via telemedicine. Of these 201 individual patients, 73 (36%) were female and 128 (64%) were male. Patients ranged in age from .5 to 20 years old, with a mean age of 8.3 years. Follow-up consultations accounted for 95% of all the telemedicine encounters. As shown in Table 1, most telemedicine consultations (35%) involved the pediatric allergy/immunology subspecialty. All health professionals at the remote site were registered nurses and all consulting subspecialists at the MCG site were physicians. Fourteen pediatric subspecialists participated in the CMS Telemedicine Project. The mean consultation duration was 20.1 ± 9.7 (mean ± standard deviation) minutes (range: 5-45 minutes). One 93-minute session was held for a pediatric genetics patient with a cleft lip and palate and was not included in the analysis.

The diagnoses related to the 333 telemedicine encounters are presented in Table 2. Genetic disorders included diagnoses, such as phenylketonuria, Sanfillipo's disease, galactosemia, macrocephaly, Bannaya-Riley-Smith syndrome, hypotonia, Ehlers-Danlos syndrome, Cornelia de Lange syndrome, autosomal chromosome deletion, hypochrondrodysplasia, osteogenesis imperfecta, cerebral palsy, Marfan's syndrome, multiple pterygium syndrome, Down syndrome, Williams syndrome, Duchenne's muscular dystrophy, profound mental retardation, congenital rubella syndrome, spina bifida, Stickler's syndrome, chromosome translocation, sex chromosome aneuploidy, unbalanced chromosome transference, and syndactyly. Neurological diagnoses included peripheral neuropathy, spastic displegia, autism, Tourette syndrome, Rett's syndrome, and myotonia.

Patient and Caregiver Satisfaction

A client satisfaction survey instrument was used to discern patient and caregiver attitudes toward service rendered using telemedicine. Of the 141 caregivers who were asked to fill out the client satisfaction survey, 127 agreed, yielding a response rate of 90%. A Likert scale was used, with a score of 4 indicating a very positive response. Overall, both the children and their caregivers were very positive and satisfied with the services received via telemedicine. In general, they believed that the quality of service was very good (3.8 ± .4), they received the kind of service they wanted (3.8 ± .5), their needs were met (3.7 ± .5), they would choose this type of service again (3.8 ± .5), and they would recommend this service to others (3.8 ± .5). In contrast, it is interesting to note that when physicians were asked in advance how satisfied they predicted their patients and caregivers would be, their estimate of client satisfaction was not high (see below).

Faculty Attitudes

Table 3 presents the results of the faculty attitude survey. Of 60 surveys distributed to physician faculty members at the outset of this project, 56 were returned (92%). The pediatric subspecialties represented in the responses included allergy/immunology (faculty members responding = 4), cardiology (3), critical care (4), endocrinology (1), gastroenterology (1), general pediatrics (10), genetics (2), hematology/oncology (6), infectious disease (3), neonatology (5), nephrology (2), neurology (1), pulmonology (2), rheumatology (1), surgery (3), and other (8). The gender of the respondents was 63% male and 37% female. Thirty-one percent of the respondents were 30 to 39 years old, 45% were 40 to 49 years old, 14% were 50 to 59 years old, and 10% were 60 to 69 years old. Most (68%) had not previously used telemedicine for consulting, 16% had performed 1 to 3 previous telemedicine consultations, 6% had performed 4 to 6 consultations, 2% had performed 6 to 10 consultations, and 8% had performed over 10 telemedicine consultations.

Overall, faculty attitudes concerning telemedicine at the onset of this study were positive. More than 70% of the total physician faculty members surveyed believed that telemedicine could be used successfully for patient consultation and that this technology would make consultation services more available to patients. Forty-four percent of the physician faculty believed that telemedicine was cost-effective and 48% believed it was time effective. However, only 33% of faculty members thought that patients would find telemedicine an acceptable way of receiving medical consultation. Very few faculty members indicated negative feelings about their ability to use telemedicine for initial consultations, follow-up consultations, or for making recommendations. Fifty-eight percent of the faculty had no strong feelings about the ability of the patient to receive good follow-up care in the community after the telemedicine consultation.

Faculty members were also asked how their attitudes about telemedicine had changed over 1 year. Compared with a year before, 28% of the faculty members currently were more positive about telemedicine, with 66% feeling about the same, and 4% feeling more negative. The more experience faculty members had with telemedicine, the more positive they tended to be about it (r = .30; P  .05). When asked about the reason for changed feelings, 9% said that their attitudes had changed because of their own perceptions without any experience with telemedicine, 13% answered that feelings had changed as a result of what had been heard from colleagues at other health science centers, 30% responded that feelings had changed as a result of what had been heard from colleagues on the MCG campus, and 35% indicated that feelings had changed because of personal experience with telemedicine.

Patient Travel Costs

Table 4 presents a comparison between the costs incurred by a patient traveling to a community-based telemedicine clinic versus one who actually makes a trip to be seen by a physician at MCG Hospital and Clinics in Augusta. Costs incurred by a family include direct and indirect costs. The Institute of Medicine categorizes direct costs as those involving travel, food, lodging, and child care expenses; indirect costs include lost income from missing work.⁵ The data in Table 4 assume that the trip involved 3 people: a 10-year-old patient and both parents. The time spent on the road is estimated at 7 hours, round-trip. Clearly, the monetary cost for visiting the Ware County Health Department is far lower than driving to Augusta, resulting in a reduced financial burden placed on the family.

	DISCUSSION

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Provision of subspecialty pediatric services to children with special health care needs in Georgia has been a major focus of CMS. CMS has developed a network of subspecialist providers and uses nurse case managers for patients and their families.

The Department of Pediatrics at MCG participates in the CMS Program in Georgia. The department provides the physician support for CMS clinics in Augusta where MCG is located, as well as at 13 CMS sites located throughout the state of Georgia. Thus, depending on their location, children and their families travel to Augusta for services or visit 1 of the CMS sites. However, the logistics of arranging a 354-mile round-trip journey can be so overwhelming for the patient's family that the appointment may be postponed or abandoned altogether. The patient's chronic condition might, as a result, deteriorate further. In such a scenario, if the patient subsequently requires hospitalization and/or emergency department care, even greater health care costs are incurred by the system.

The use of telemedicine was intended to complement and expand the CMS services which were already being offered in the Waycross CMS clinic. The clinic services offered through telemedicine were not new services but expansions of services already provided on-site. The one change that the availability of telemedicine created at the onset of the project was the relocation of the pediatric pulmonology and pediatric allergy/immunology CMS clinics from the Augusta CMS site to the Waycross CMS site. Physicians who staffed telemedicine clinics continued to provide on-site services in Waycross as they had before the project began, but on-site subspecialty care clinics included in the project were now held quarterly instead of monthly. Pediatric cardiology was not included in this project because most of those patients were acute patients requiring transfer to MCG and/or most of the community needs were already being met through a network of statewide subspecialty cardiology clinics.

MCG physician attitudes toward the use of telemedicine changed during the course of the project. Initially, many physicians believed they could see only established patients via telemedicine and were unable to accept the idea of seeing a wider range of patients by telemedicine. As the physicians became more experienced with telemedicine, they became more comfortable with seeing new patients.

We interpret the success of this project as being related, in part, to the health care delivery design that allowed physician subspecialists to continue to see patients at the local, on-site CMS clinics. The physician subspecialists continued to travel periodically to the remote site, but relied on telemedicine for ongoing care. On-site clinics were held quarterly, and telemedicine clinics were either held monthly or twice monthly, thus increasing the patient's access to subspecialty care. The physician subspecialists described this delivery model as "enhanced continuity of subspecialty care for CMS patients." The most successful model of clinical care used the identical team of physician subspecialists and CMS personnel, both on-site and via telemedicine. This experience leads to the preliminary suggestion that telemedicine may have a greater potential for success when it is a part of an integrated health delivery model rather than when it is used as the sole mode for delivery of care.

Although we thought that some patients and their caregivers would be awed or intimidated by the technologies, this proved not to be the case. We believe that several factors played a role in the patient's comfort with the technologies, including the presence of the CMS nurse case manager throughout the consultation, patient orientation to the system before the consultation, increasing general comfort with high-tech experiences, and the high quality audio and video of the GSTP system.

Two critical issues in using telemedicine to provide services include the efficiency with which the consultation can be accomplished and the effectiveness of the consultation itself. Although this project was not specifically designed to measure consultation efficiency, as personnel gained more experience with telemedicine, they became more facile in the use of the telemedicine equipment. In addition, staff learned to expeditiously prepare patients for the consultation. These factors contributed to a reduction in the duration of a telemedicine consultation and improved efficiency.

We did not document changes in faculty attitude with regard to the type of patients seen via telemedicine. However, at the initiation of the project, many faculty memebers believed that only follow-up visits should be conducted via telemedicine. After experience with telemedicine, several faculty members began to conduct their initial encounters with patients over the telemedicine network.

The effectiveness of the consultation was often a reflection of the professional's ability at the remote site to manipulate the equipment. As their experience increased, so did equipment proficiency. Still, some subspecialists believed that there were inherent limitations in the use of the available equipment. For example, pulmonologists were concerned about the ability to adequately ascultate the chest of patients <2 years old or with patients presenting with severely compromised pulmonary status. Similarly, the inability to palpate or feel is a known significant limitation.

The expense of providing pediatric subspecialists for a telemedicine clinic is difficult to calculate. The telemedicine consult requires a little more time than the traditional face-to-face consultation. The time of the telemedicine consult was televised time and does not include time for review of records and documentation of the visit. That makes the entire visit of the patient slightly longer. The overall cost-effectiveness of the telemedicine consult will vary depending on the distance the physician has to travel to satellite clinics. Most likely, in order for a telemedicine consultation to have cost benefits over on-site visits, the site must be at least an hour's travel time each way for a half-day (4-hour) clinic. The reader is referred to Adams and Grigsby² for a discussion of the costs in settting up the GSTP and the way in which the GSTP was funded.

In this study, 5 encounters were billed using Current Procedural Terminology (CPT) code 99241; 7 using CPT code 99242; and 5 using CPT code 99243. All the rest of the encounters were billed using CPT code 99212, 99213, 99214, or 99215. These CPT codes were used for most initial or follow-up consultations whether live or via telemedicine. Bills were submitted to insurance companies including Medicaid. Medicare has created specially designated CPT codes that are prefaced by QQ. The process is not very different from live consults.

To address some of the liability issues raised during telemedicine consults in this study, the institutional legal office required the use of a separate consent form for telemedicine encounters. In addition, each telemedicine encounter was videotaped and kept as part of the permanent medical record for that patient.

Based on the data in this study, we hypothesize that a statewide telemedicine system would reduce the cost of delivering medical care to children with special health care needs by improving access to subspecialty pediatric care and by decreasing the time and cost incurred with transportation. Since the completion of this project, we have continued the telemedicine clinics at this site and have initiated clinics at 2 other sites using telemedicine.

	ACKNOWLEDGMENTS

This work was supported, in part, by Contract 427-93-52160 from the Department of Human Resources, the State of Georgia.

We thank the parents, caregivers, and children in Waycross, Georgia who participated in the project.

We also thank all Children's Medical Services personnel involved in this project including Laura Symmes (Georgia Department of Human Resources, Division of Public Health, Children's Medical Services), Barbara Miller (Director of Children with Special Health Care Needs, Southeast Health District), Connie Barfield (Children's Medical Services Coordinator, Waycross), Angie Jenkins-Jacobs (Children's Medical Services nurse, Waycross), Jackie Woodard (Coordinator of Telemedicine Services, Southeast Health District), and Angela Smith (Children's Medical Services Telemedicine Coordinator, Waycross).

We also thank all the following physicians: Dr Ted Holloway (Southeast Health District Medical Director, Waycross), and Drs Ned Rupp, Margaret Guill, James Carroll, and David Flannery (the subspecialist physicians at the Medical College of Georgia).

Finally, we thank Jamie Porterfield, the project manager for the Children's Medical Services Telemedicine Project; Bibek Mohanty, the project research assistant; Suzanne Moon, the Children's Medical Services Telemedicine Coordinator; and Peggy Salter, the Medical College of Georgia Telemedicine Consult Coordinator. Without their help in the collection and analysis of this data, this work would not have been possible. This was a very complex project that required contributions from all the many people mentioned above.

	FOOTNOTES

Dr Bell is currently in private practice.

Received for publication May 17, 1999; accepted Jul 29, 1999.

Reprint requests to (W.B.K.) Medical College of Georgia, CK295, Augusta, GA 30912. E-mail: wkarp{at}mail.mcg.edu

	ABBREVIATIONS

CMS, Children's Medical Services; MCG, Medical College of Georgia; GSTP, Georgia Statewide Telemedicine Program; CPT, Current Procedural Terminology.

	REFERENCES

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1. Division of Public Health, Family Health Branch, Georgia Department of Human Resources. FY1996 Maternal and Child Health Block Grant Application, Section II. Atlanta, GA: Georgia Department of Human Resources; 1995:9-10
2. Adams LN, Grigsby RK The Georgia state telemedicine program: initiation, design, and plans. Telemedine J 1995; 1:227-235
3. Grigsby RK University outreach through telemedicine. J Public Serv Outreach 1997; 2:38-44
4. Attkisson CC, Zwick R The client satisfaction questionnaire. Eval Program Plann 1982; 5:233-237 [CrossRef][Medline]
5. Field MJ, ed. Telemedicine: A Guide to Assessing Telecommunications in Health Care. Washington, DC: Institute of Medicine, National Academy Press; 1996