Analysis of a Pediatric Telemedicine Program

Introduction and Objective

Telemedicine serves millions of patients and is transforming healthcare delivery worldwide. ¹ Telemedicine may improve access without limiting the quality of care provided. ² It has also shown to benefit families by reducing time lost from work and school. ³ Many acute nonurgent illnesses can be treated using simple telemedicine models. ⁴ Direct-to-Consumer (DTC) care is offered by many telemedicine companies to provide services for nonemergent conditions. According to an 2017 American Academy of Pediatrics (AAP) Policy Statement of “Nonemergency Acute Care: When It's Not the Medical Home,” key areas of focus should include benchmark data on clinical parameters, research on patient satisfaction and quality metrics and outcomes. ⁵ Currently, there are no descriptive data on pediatric-specific 24/7 DTC synchronous programs. This is the first article to our knowledge to provide such data.

In October 2015, Nemours Children's Health System, a pediatric nonprofit health system of hospitals and clinics, launched Nemours CareConnect (NCC), a telemedicine initiative. NCC provides DTC synchronous care 24 h per day, 7 days per week, to families with children from birth to 20 years of age via the Internet or a mobile application. NCC uses board-certified pediatricians to provide telemedicine care in Florida, Pennsylvania, and Maryland; and nights and weekends in Delaware. Although a variety of telemedicine models exist, the NCC DTC platform uses a secure, simple, audiovisual model to provide care for the families. We describe an evaluation of how NCC has functioned since its launch. Our objective was to evaluate the first 1,000 visits for patient demographics, chief complaints, visit experience, and parent satisfaction. A postvisit survey identified where parents would have gone if NCC were not available. This information was used to demonstrate potential cost savings.

Materials and Methods

To begin a telemedicine visit on the NCC platform, a parent downloads the free NCC application onto his or her device such as computer, laptop, tablet or cell phone. The parent enters his or her child's demographic, pharmacy, and insurance information. NCC provides real-time eligibility checks for insurance. The visit is $49 without insurance. If the parent's insurance is accepted, a copay is charged. All charges are made via credit card through the intake platform. The parent requests a visit by clicking on the available pediatrician on the screen. Real-time care is provided through interactive, high-definition video and audio communication. NCC's equipment meets the recommended criteria and complies with the current organizational and technological requirements. Specifically, NCC equipment is H.323 compliant with live video resolution of 4 × Common Intermediate Format (4CIF), and has bidirectional connection at a minimum of 384 kilobits per second running 4CIF at 30 frames per second. ⁶ Our technology supports H.264 video compression standard and G.711 audio compression standard. To ensure secure data transmission and to protect patient information, all the video, audio, and electronic medical record components have encryption from beginning to end.

From his or her home setting, a parent selects a provider and the patient enters a virtual waiting room. The provider is notified and accepts the connection. While the parent provides the history, the provider assesses whether the visit is appropriate for telehealth. The NCC model is an audiovisual model without the use of peripheral devices or further laboratory testing. Patients with complaints that warrant an in-person medical evaluation are referred to their pediatrician or the local emergency room (ER). For example, patients with chief complaints of dysuria, suspected strep throat, or ear pain are referred. Once the provider deems the visit appropriate, the provider guides the patient, with the parent's assistance, through a virtual physical examination, the physician observes the child, assesses the general state of health, and notes patterns of behavior. The physician visually assesses the eyes, nose, throat, skin, work of breathing, and respiratory rate. If tactile sensation is needed, the physician guides the parent to assist. If the physician decides the physical examination requires an in-person evaluation or the patient is not cooperative, the physician refers the patient. Once the history and physical are complete, the provider discusses the assessment and treatment options with the family. Before disconnecting, the provider confirms understanding. After the visit, the parent rates the provider and the platform using a 5-star rating system where five reflects the best patient experience. Parents are then surveyed about their alternative choice of care, whether they would have gone to the ER, urgent care, retail clinic, doctor's office, or done nothing, if NCC were not available.

Once the provider disconnects from the NCC platform, he or she logs into the Epic System (Epic Systems Corporation, Verona, WI), which is an electronic medical database. In Epic, the provider documents the telehealth visit, electronically sends medication to the pharmacy, and creates an after visit summary. NCC uses a secure and encrypted communication portal called MyNemours. Parents are e-mailed an activation code to enroll in the MyNemours program. Through MyNemours, parents have secure access to their child's electronic medical record. Pediatricians are sent a copy of the after visit summary through the Epic database. This ensures the integrity of the medical home.

Data were obtained from the NCC database (patient age and gender, day of call, time of call, wait time, treatment time, and 5-star rating for provider and platform) and from the Epic database (chief complaint). All data were organized using Microsoft Excel 2016 spreadsheets. Statistical analyses were conducted using R ⁷ , descriptive statistical data such as age, wait time, and encounter time were reported as medians and interquartile ranges as they were non-normally distributed. Sample size and percentages were reported for categorical variables such as gender, chief complaints, day of call, time of call, satisfaction rating, and survey results. This study was approved by the Nemours Institutional Review Board.

Results

Of the 1,000 patient visits from October 2015 to June 2017, 44.6% were male and 55.4% were female. Ages ranged from 2 weeks to 20 years, with the median age of 4 years (interquartile range [IQR] = 6.8). The most common chief complaints were skin-related issues (18.7%), followed by upper respiratory symptoms (17.5%), fever (15.2%), gastrointestinal issues (9.7%), hospital follow-ups (9.1%), and eye-related problems (7.9%) (Table 1). The “other” category in Table 1 consisted of chief complaints that were not duplicated. Some examples of these complaints were dizziness, lice, pinworms, anal pain, penile pain, tracheostomy concern, and nosebleed. The higher volume of calls occurred on the weekends. Calls on Saturdays (18.5%) and Sundays (18.6%) were higher than any other day of the week (Table 2). The peak time of call was between 4:00 PM and 8:00 PM followed by 8:00 PM and 12:00 AM (Table 3). The average wait time for patients to see a provider was 2 min 11 s (IQR = 1 min 53 s). The average treatment time for all visits was 12 min 10 s (IQR = 3 min 20 s). A postvisit satisfaction survey was given to parents. Of the 686 parents who responded, 93.6% rated the providers five out of 5 stars. Of the 684 parents who responded, 86.0% rated the platform five out of 5 stars (Table 4). A follow-up survey asked parents where they would have sought care if NCC were not available ⁸ Of the 587 parents who responded, 36.6% stated they would have gone to an urgent care center and 27.9% would have gone to the ER. Only 6.0% of the parents stated they would have “done nothing” if NCC were not available (Table 5).

Discussion

NCC patient demographics were consistent with those from Florida's ER Utilization Report. ⁹ However, wait times and encounter times were much less than those documented by the Centers for Disease Control and Prevention (CDC). ¹⁰ NCC telemedicine data demonstrated an efficient system with an encounter time of approximately 14 min. The CDC reported an average encounter time in the ER of approximately 2 h. Patient satisfaction is directly linked to excessive delays in a patient's healthcare experience. In a study published in the Journal of Medical Practice Management, 96% of low patient satisfaction ratings were due to poor communication, disorganization, and excessive delays in seeing the physician. ¹¹ Besides efficient service, pediatric telemedicine offers redirection away from more expensive care. Of our surveyed families, 27.9% stated they would have gone to the ER if NCC were not available. According to the Florida ER Utilization Report, there were 528,380 low-acuity pediatric emergency department visits with an average charge of $909/patient. ⁹ Therefore, the total pediatric ER cost was approximately $480.3 million. If 27.9% of our families used NCC instead of the ER, as the survey suggested, then the Florida healthcare system would have potentially saved $113.9 million.

Not all telemedicine studies demonstrate cost savings. One adult study suggested that DTC telemedicine may actually increase healthcare spending instead of decrease through “induced” utilization. ¹² It suggested some adult patients use telemedicine, when normally they may not have sought any services. Our post-treatment survey had a low “do nothing” utilization rate of 6.0%. Our study suggested “induced” utilization in pediatric telemedicine might differ from that of the adult population. More studies are needed to evaluate how induced utilization in pediatric DTC telemedicine impacts cost.

There are several limitations to the data presented. Diagnostic data were not collected, and there were no clinical outcome measures. Data on objective medical outcomes will be important in the future for the development of quality metrics. When categorizing chief complaints, there was a large “other” category. A larger sample size would help assess the lesser reported chief complaints. Because our audiovisual model does not use peripheral devices or laboratory testing, illnesses suggestive of a urinary tract infection, ear infection, or strep throat infection were referred to a primary care provider, an urgent care center, or the ER. The final diagnoses treated via the platform, and the referral process used when unable to treat, need further investigation. Parent surveys suggested that families would have sought more expensive services if NCC were not available. However, the actual impact with respect to either more expensive or less expensive options needs further investigation. The surveys are an initial step in examining redirection of services. We plan to conduct more rigorous studies to determine actual redirection and how this may affect costs. Despite these limitations, these data provided important information from a standardizing-care perspective in pediatric on-demand telemedicine, especially for commonly reported chief complaints.

Conclusion

Our analysis provided data on demographics, platform use, and patient satisfaction consistent with the needs identified by the AAP's 2017 Policy Statement on Nonemergency Acute Care. ⁵ Parents received care for their child in the privacy of their home and at the time of their choice. Patient wait times and treatment times were minimal compared with wait times reported by emergency departments, even more so when factoring in travel time. NCC increases access, provides timely care, and parents are satisfied with the service. More importantly, parents reported using NCC instead of more costly options such as the ER or an urgent care.

With increasing healthcare costs, the future of medicine is moving toward consumerism. Telemedicine is growing and the medical neighborhood is expanding beyond the conventional pediatric office. ¹³ We believe pediatric DTC telemedicine is complementary to a child's medical neighborhood and is important to the creation of a full-service health system that aligns with our primary directive, which is written from our patients' perspective: “Help me receive exactly the care I need and want, how and when I need and want it.” It is the responsibility of pediatric telemedicine providers to present data, support key stakeholders such as the AAP in creating clinical guidelines, and ensure the safe evolution of pediatric DTC telemedicine into the expanding medical neighborhood. Our goal is to continue analyzing the NCC platform and partner with key stakeholders in the development of pediatric telemedicine clinical guidelines and quality metrics.