Paediatric tele-emergency care: A study of two delivery models

Abstract

Introduction

Tele-emergency models have been utilized for decades, with growing evidence of their effectiveness. Due to the variety of tele-emergency department (tele-ED) models used in practice, however, it is challenging to build standardized metrics for ongoing evaluation. This study describes two tele-ED programs, one specialized and one general, that provide care to paediatric populations. Through an examination of model structures and patient populations, we gain insight into how evaluative measures should reflect tele-ED model design and purpose.

Methods

Qualitative descriptions of the two tele-ED models are presented. We show a retrospective cohort analysis describing paediatric patients’ key characteristics, reasons for visit, and disposition status by case/control status. Case/control patient encounter data were collected October 2015 through December 2017, from 15 spoke hospitals within each tele-ED program.

Results

The two tele-ED models serve distinct paediatric populations, and measures of tele-ED utilization and disposition reflect those differences. In the specialized University of California (UC) Davis Health program, tele-ED was utilized in 36% of paediatric critical care encounters and 78% of those were transferred. In the Avera eCARE program, tele-ED was activated in 1.7% of paediatric encounters and 50.6% of those were transferred. When Avera eCARE paediatric encounters were stratified by severity, measures of tele-ED use and disposition status among high-severity encounters were more similar to UC Davis Health.

Discussion

This study describes how design choices of tele-ED models have implications for evaluative measures. Measures of tele-ED model success need to reflect model purpose, populations served, and for whom tele-ED service use is appropriate.

Keywords

Telemedicine paediatric population disposition tele-emergency rural telepaediatrics pediatrics

Introduction

There is limited but growing evidence of the effectiveness of tele-emergency department (tele-ED) programs in extending specialized emergency care in rural hospitals, where the provision of specialty care can be challenging.^1,2 Tele-ED, utilized since the mid-1990s, is a specific application of telemedicine defined as an electronic, two-way audio/visual communication between a central emergency care centre and a remote ED designed to provide real-time emergency care consultation.^3,4 Early tele-ED applications focused on tele-radiology or specific conditions such as stroke, cardiac, or trauma care, and have predominantly been hospital-based models that enable rural hospital EDs to consult medical specialists on demand. Studies of tele-ED models characterized by connections between a large ED “hub” and smaller, more remote hospital EDs referred to as “spokes” have shown that providers on both ends of telemedicine exchanges feel consultations improve patient care, and that care is comparable to traditional care in patient outcomes.^5–7 Tele-ED applications focused specifically on critically ill children evolved in the 2000s, with two of the earliest programs developing in Northern California and Vermont.⁸ Studies of paediatric tele-ED programs have shown that rural and community-based hospital EDs connected to hubs with paediatric subspecialty expertise are associated with improved access to care, higher quality and timeliness of care, greater parent and provider satisfaction, fewer medication errors, improved appropriate disposition, and a reduction in costs related to transfer and inpatient care.^9–18

Nationally, there has been interest in evaluating the effectiveness of telemedicine programs and building standardized metrics and tools for ongoing evaluation.^19,20 These efforts have been challenged by the great variety of clinical and operational models because the purpose for which tele-ED models exist have implications for the measures used to judge their success. For example, if a tele-ED model is designed to facilitate, or conversely avert, patient transfers, then the rate of patient transfers would change, either increasing or decreasing according to the design and intent of the tele-ED program. Likewise, if the purpose of a tele-ED model was to provide additional decision support or extend local provider resources, measures of timely access to specialized medical care or quality of care (i.e. improved diagnostic accuracy, improved communication with patients and families) should reflect program impact. How models are designed and implemented at the system level have significant ramifications for process development and outcome measures, and few studies have researched telemedicine at the system level compared to the clinical level. Thus, the primary purpose of this study is to describe two distinct and longstanding tele-ED programs, one specialized and one general, that provide care to paediatric populations in order to inform others about how different tele-ED paediatric models work in the real world. The secondary purpose is to provide a detailed picture of the paediatric patient populations accessing these system’s tele-ED services and discuss how they differ given the designs of the two programs. Through an examination of model structures and patient populations, we gain insight into how measures reflect the design and purpose of different tele-ED models used in practice.

Methods

This study provides an in-depth look at two unique tele-ED models that serve paediatric populations: the University of California (UC) Davis Children’s Hospital paediatric critical care telemedicine program in Sacramento, California, and Avera Health’s eCARE Emergency located in Sioux Falls, South Dakota. Both organizations received Health Resources and Services Administration (HRSA) grant funding in late 2014 under the Evidence-Based Tele-Emergency Network Grant Program in order to “support implementation and evaluation of broad telehealth networks to deliver ED consultation services via telehealth to rural and community providers without emergency care specialists.”²¹ The funding opportunity served two policy objectives: 1) expanding access to needed services for rural patients; and 2) establishing an evidence-base assessing the effectiveness of tele-emergency care for patients, providers, and payers through systematic data collection and analysis. Grant funding was provided to the UC Davis Children’s Hospital paediatric critical care telemedicine program to determine the impact of their existing tele-emergency care network on care quality, appropriateness of care utilization, patient safety, and cost-effectiveness compared to telephone consultations. Funding was provided to Avera Health to enhance rural access to emergency services through telemedicine, and research its impact on access, care quality, and costs in the Midwest service area.

The first part of this study presents a descriptive summary of the two models. The paediatric critical care telemedicine program at UC Davis Health was initiated in 2000,⁹ though UC Davis Health has offered telemedicine services since the mid-1990s.²² Under the umbrella of the Center for Health and Technology (CHT), the paediatric critical care telemedicine program is one of several telehealth service lines fulfilling CHT’s clinical outreach mission to support medically underserved communities throughout California and the surrounding states. This particular program is focused on tele-ED services provided by paediatric critical care physicians based in the UC Davis Children’s Hospital (the hub) to a network of remote hospital-based ED providers (the spokes) for seriously or critically ill children presenting to those EDs. The remote hospitals using tele-ED services for paediatric populations are independent of UC Davis Health and all are located in the state of California.

Avera Health is an integrated health system offering a variety of telemedicine services to rural, frontier, and community hospitals throughout the US via its eCARE business model. Though Avera Health launched eCARE Emergency in 2009, it has had specialty telemedicine clinical programs since 1993. Avera’s eCARE Emergency service providers, working in a virtual hospital (“e-hub”), provide on-demand tele-ED consultations by emergency physicians as well as nursing, and transfer support to hospital EDs across the country for all patient populations. Less than 15% of the network hospitals are owned by Avera Health.

The two programs in this study differ in how they work by intention. In general, UC Davis Health takes calls from remote EDs through a call centre, where a transfer centre nurse triages patients by telephone. If a call concerns a neonate, the process flows through the Neonatal Intensive Care Unit service; if a call is about a very sick paediatric case, the process flows through the Paediatric Intensive Care Unit service. For calls about issues requiring surgical interventions, traumas, or paediatric patients who are stable but warrant transfer, the process flows through either paediatric surgery, the acute care/trauma service, or hospitalists. Telemedicine may be used to facilitate transfers in a portion of the surgical, acute care, or hospitalist cases; however, these paediatric consultations are not counted in the paediatric critical care telemedicine model. As a result, measures of paediatric tele-ED utilization in this particular model reflect only the paediatric population that warrant paediatric or neonatal intensivist care. In the Avera eCARE model, the tele-ED program serves the general population, including paediatrics. When nurses or family practice providers at spoke sites desire help with a paediatric patient, they push the call button and are directly connected to the eCARE emergency physician and nurse team. On occasion, the eCARE team may consult with paediatric specialists.

The second part of this study is a retrospective cohort analysis that relies on case/control patient encounter data collected from the spoke hospitals starting in October 2015 through December 2017. There are 15 spoke hospitals from each tele-ED model contributing data to this study. We used HRSA’s Health Professional Shortage Area lookup tool²³ to find the rural/non-rural status of a hospital’s county, and found that 10 of the 15 UC Davis Health spoke hospitals are in rural-designated counties. Of the 15 Avera eCARE spoke hospitals, 14 are in rural communities.

Patients from the UC Davis Health model were included in the study if they were less than or equal to 14 years of age and had contact with the hub, either by tele-ED (cases) or telephone (controls). Paediatric cases with no contact to the hub were excluded because the UC Davis paediatric critical care telemedicine program would not be utilized for general paediatric ED encounters. Avera eCARE patients were included in the study if they were less than or equal to 14 years of age, and contact with the hub was made via tele-ED or not at all (cases and controls, respectively).

Patient encounters were deemed “case” if tele-ED was activated and audio-visual technology was employed during the consultation. Patient encounters were deemed “control” differently under each model because the populations each tele-ED program was designed to serve are different: UC Davis Health controls were paediatric critical care encounters with telephone-only contact between remote EDs and specialists at UC Davis Children’s Hospital; and Avera eCARE controls were all paediatric encounters with emergency room billing codes between 99282 and 99285 and for whom tele-ED was not activated. Emergency room billing codes 99282 through 99285 are used in control identification because they are evaluation and management codes for patients with increasing complexity and problem severity and, thus, would have a higher likelihood of having tele-ED activated. Avera eCARE controls did not include patient encounters with emergency room billing code 99281 because this code is used for self-limited problems or minor conditions with no medications or home treatment required (i.e. suture removal).

Results

Both the UC Davis Children’s Hospital paediatric critical care telemedicine program and Avera eCARE emergency service are “consultative models,” meaning they function as need-based consultations from medical specialists provided only when requested by providers or nurses in the EDs of participating rural and community hospitals.¹⁷ Table 1 highlights key features of both tele-ED service models.

Table 1.

Tele-emergency model features.

	UC Davis Children’s Hospital paediatric critical care telemedicine program	Avera eCARE Emergency
Hub home	Sacramento, CA, USAUC Davis Children’s Hospital Paediatric Intensive Care Unit (PICU) and Neonatal Intensive Care Unit (NICU)	Sioux Falls, SD, USADedicated 30,000 sq. ft. telemedicine centre, Avera eHelm
Number and characteristics of spoke hospitals in study*	For all study hospitals (N = 15): Five are designated Critical Access Hospitals. 10 are in rural communities. Average number of general beds is 96. Average annual hospital admissions is 5958. Average annual ED visits is 21,675.	For all study hospitals (N = 15): 14 are designated Critical Access Hospitals. 14 are in rural communities. Average number of general beds is 23. Average annual hospital admissions is 434. Average annual ED visits is 2947.
Population served	Acutely or critically ill paediatric patients.All critically ill neonates (<30 days of age) are directed to the neonatologists and all critically ill infants or children >30 days of age are directed to the paediatric critical care physician.	Acutely ill or critically injured patients of all ages.
24/7 physician staffing	Paediatric intensivist: one primary on-call physician in the PICU, plus one designated back-up physician with remote telemedicine capabilities.Neonatologist: one primary on-call physician in the NICU, plus one designated back-up physician with remote telemedicine capabilities.	Emergency medicine: one or two emergency medicine physicians staffed to take telemedicine calls.Paediatric specialists: Paediatric specialists from Avera McKennan Hospital are also available 24/7 and utilized on an as-needed, on-call basis.
The tele-ED process	When remote ED physicians desire a consultation, they call a toll-free number and make a request for critical care telemedicine consultation. Call centre pages the paediatric or neonatal critical care physician at UC Davis Children’s Hospital (median time, 2.5 min). Physician at hub connects by telephone first to remote hospital provider, and a joint determination is made to use telemedicine or not. If telemedicine is to be used, the UC Davis paediatric critical care specialist calls into the rural ED hospital unit and the unit automatically answers; time between initial phone call and telemedicine consult is approximately 10 min. Consultation involves the UC Davis physician and any of the following: referring ED physician or nurse practitioner, bedside ED nurse, respiratory therapist, and/or parents/guardians.	When remote site staff desire a consultation, they press the eEmergency call button on an emergency speakerphone that autodials the hub and starts a two-way speaker phone conversation. Board-certified emergency physicians and critical care nurses at the hub respond and assess immediate request. Hub clinicians activate the two-way high-definition video system within approximately 30 seconds of the call. Hub staff assess needs and services desired by the rural clinician. If specialty support is required, eEmergency can call paediatric specialists at one of the rural hospital’s regional referral centres. Specialists are consulted by telephone and do not appear on the telemedicine consult. Hub staff are also available to facilitate nursing documentation and patient transfers.
Equipment used in tele-ED consultation	Cart-based telemedicine system. Turnkey videoconferencing unit and a flat-screen, high-resolution monitor, which allow bi-directional audio and video using high-definition cameras capable of pan, tilt, and zoom functions.	Wall-mounted telemedicine system. Turnkey videoconferencing unit and a flat-screen, high-resolution monitor, which allow bi-directional audio and video using high-definition cameras capable of pan, tilt, and zoom functions. eEmergency call button/speaker phone. Audio content captured by ceiling microphone.
Information that is captured and/or shared in tele-ED consultation	Patient history, vital signs, laboratory results, any therapeutic devices, and collaborative physical examination. At conclusion of consultation, a summary is written by the UC Davis critical care physician in the UC Davis electronic medical record, which is securely and electronically shared/faxed to the originating site for inclusion in patient’s medical record. Paediatric neonatologist or critical care physician’s consultation notes are then submitted to the patient’s insurance for payment.	• Patient examination, vital signs, laboratory results and history, and ability to remotely assist with procedures such as chest tube, intubations, and central venous access placement. At end of consultation, hub staff document their work, sign any verbal orders, and securely fax to remote site for inclusion in the patient’s medical record. Hub staff are available to facilitate debriefing with site staff on difficult cases.
Payment structure for hub consultation services	Varies among sites. Structures include: Contract for tele-ED services with a flat monthly fee-for-service payment. Per consult fee-for-service for professional services. Grant funding.	Hospitals pay a subscription fee to Avera Health for the tele-ED service.

*Critical Access Hospital designation, number of general medical/surgical beds, annual emergency department visits, and annual hospital admissions data are sourced from the 2017 American Hospital Association Annual Survey of Hospitals. Rural status is determined by HRSA’s Healthcare Professional Shortage Area lookup tool.²³

Both programs encountered challenges during the initial deployment and provision of clinical telemedicine services. For the UC Davis Health model, the primary challenge was related to changing the culture and processes of care to involve an “external” physician. Physicians working in remote EDs did not want tele-ED consultations to slow or significantly change their workflow. However, as the program matured, and paediatric telemedicine consultations became part of the care routine, this issue subsided. While there were some technical challenges initially, after the implementation of weekly test calls, the frequency of connectivity problems dramatically reduced.

Avera Health cited rural provider comfort using telemedicine as a challenge. Over time, Avera eCARE providers have learned to adjust their approach in communicating with rural providers on tele-ED calls. Avera eCARE providers have built rapport by attending medical staff meetings, and work jointly with rural providers on quality initiatives when there are challenges in the capability, training, and resources of the sites. To monitor video call quality and troubleshoot connectivity challenges, they use HD video codecs and a dedicated network for their tele-ED service.

Patient-level characteristics for each program stratified by case/control status are shown in Table 2. Tables 3 and 4 describe “reason for visit” in UC Davis Children’s Hospital paediatric critical care telemedicine program and Avera eCARE Emergency, respectively, and Figure 1 shows the distribution of discharge disposition for each model by case/control status.

Figure 1.

Disposition status in tele-ED models by cases/control status.

Table 2.

Patient characteristics.

	UC Davis Children’s Hospital paediatric critical care telemedicine program^a				Avera eCARE Emergency^b
	N		%		N		%
Patient characteristics	Case	Control	Case	Control	Case	Control	Case	Control
Paediatric patients	232	406	36%	64%	162	9235	2%	98%
Age
<1	67	113	29%	29%	21	220	13%	2%
1–14	165	284	71%	72%	141	9015	87%	98%
Male	134	223	58%	55%	84	5097	52%	55%
Race
White	146	261	63%	64%	108	5432	67%	59%
African-American	14	46	6%	11%	*	217	*	2%
Asian	*	22	*	5%	*	31	*	*
American Indian/Native Alaskan/ Pacific Islander	*	*	*	*	32	2030	20%	22%
Unknown	*	*	*	*	22	1525	14%	17%
Ethnicity
Hispanic/Latino	47	75	20%	19%	11	933	7%	10%
Not Hispanic/Latino	172	321	74%	79%	138	7590	85%	82%
Payer status
Medicaid	181	311	78%	77%	92	5571	57%	60%
Private insurance	45	85	19%	21%	51	3013	32%	33%
Emergency billing codes†
99282	*	*	*	*	18	3872	11%	42%
99283	15	17	7%	5%	41	4211	26%	46%
99284	44	62	19%	17%	45	963	29%	10%
99285	128	230	55%	64%	39	181	25%	2%
99291	36	47	16%	13%	*	*	*	*
99292	*	*	*	*	*	*	*	*

*Cells with N < 10 suppressed.

†Emergency billing codes are Current Procedural Terminology (CPT) codes for emergency department visits. Codes 99282–99285 reflect evaluation and management of a patient during emergency department visits, with increasing medical complexity and severity of presenting problems as codes increase. Code 99282 indicates presenting problems that are low to moderate severity, while Code 99285 indicates problems that are of high severity and pose immediate significant threat to life or physiologic function. Codes 99291 and 99292 indicate “Critical care, evaluation and management of the critically ill or critically injured patient; first 30–74 minutes” and “Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes,” respectively.

^aControls in the UC Davis Children’s Hospital paediatric critical care telemedicine program are paediatric critical care patients who received a telephone (vs. tele-ED) consultation from the hub.

^bControls in the Avera eCARE program are all paediatric patients presenting to remote emergency departments in the study hospitals using the eCARE service and for whom no contact with the hub was made.

Table 3.

Reason for visit UC Davis Children’s Hospital paediatric critical care telemedicine program.

	N		%
	Case	Control^a	Case	Control^a
Shortness of breath	55	*	24%	*
Cough	36	39	16%	10%
Fever or suspected infection	32	30	14%	7%
Other	20	109	9%	27%
Seizure	18	41	8%	10%
Nausea or vomiting	15	35	7%	9%
Rash	12	*	5%	*
Overdose/substance abuse	10	*	4%	*
Other respiratory	*	47	*	12%
Neurological/altered mental status	*	37	*	9%
Accidental ingestion	*	17	*	4%
Abdominal pain	*	11	*	3%

*Cells with N < 10 suppressed. Remaining reason for visit categories not shown due to N < 10.

^aControls in the UC Davis Children’s Hospital paediatric critical care telemedicine program are paediatric critical care patients who received a telephone (vs. tele-ED) consultation from the hub.

Table 4.

Reason for visit Avera eCARE Emergency.

	N		%
	Case	Control^a	Case	Control^a
Mental/behavioural health	38	118	24%	1%
Injury or trauma	34	2512	21%	27%
Shortness of breath	27	57	17%	1%
Fever or suspected infection	10	1061	6%	12%
Neurological/altered mental state	10	*	6%	*
Other	*	2676	*	30%
Cough	*	797	*	9%
Abdominal pain	*	365	*	4%
Rash	*	236	*	3%
Other respiratory	*	227	*	3%
Nausea or vomiting	*	226	*	3%
Sore throat	*	177	*	2%
Earache/otitis	*	155	*	2%
Allergic reaction	*	118	*	1%

^*Cells with N < 10 suppressed. Remaining reason for visit categories not shown due to N < 10.

^aControls in the Avera eCARE program are all paediatric patients presenting to remote emergency departments in the study hospitals using the eCARE service and for whom no contact with the hub was made.

In the specialized paediatric critical care telemedicine program at UC Davis Health, tele-ED was utilized in 36% of the 638 study patients. The top eight reasons for visit among the tele-ED activated cases accounted for 85% of the case volume, and included shortness of breath, cough, fever or suspected infection, other, seizure, nausea or vomiting, rash, and overdose/substance abuse. Among controls, the non-discriminate reason for visit category of “other” accounted for more than 25% of patients, followed by other respiratory, seizure, cough, neurological/altered mental status (AMS), nausea or vomiting, and fever or suspected infection.

The distribution of emergency billing codes, or Current Procedural Terminology (CPT) codes, which indicate the level of severity of emergency visit, are relatively comparable among cases and controls in the UC Davis Health data. Just over 74% of cases are higher-severity ED evaluation and management codes (99284 and 99285), while nearly 81% of controls fit this category. Lower-severity visits (99281 through 99283) are under 10% of cases and controls.

While the majority of discharges for both cases and controls in the UC Davis Health model were transfers to another inpatient facility, the percentage of routine discharge among cases was more than double controls, and the percentage of cases admitted locally was four times controls.

In the Avera eCARE general emergency model, over 9000 paediatric patients presented to the 15 study hospitals, of which 2% had tele-ED activated. Among cases, the top five reasons for visit accounted for nearly 74% of the distribution, and included mental/behavioural health, injury or trauma, shortness of breath, fever or suspected infection, and neurological/AMS. Among controls, the top five reasons for visit accounted for 82% of the distribution, with “other” comprising 30% of the distribution, followed by injury or trauma, fever or suspected infection, cough, and abdominal pain.

The distribution of emergency billing codes in the Avera eCARE data is noticeably different between cases and controls. While over 37% of cases are lower severity (99282 and 99283), among controls more than 87% are low-severity encounters. Cases that are higher severity (99284 and 99285) account for 53% of the case data but just over 12% of controls.

Discharge dispositions diverged for cases and controls in the Avera eCARE model. Nearly 35% of cases had routine discharge versus 93% of controls, and almost 10% of cases were admitted locally compared to 4% of controls. The rate of transfer to another inpatient facility in the Avera eCARE program was 51% for cases versus 3% for controls.

Discussion

This study describes system-level model characteristics and patient-level data from two unique tele-ED programs that serve paediatric populations. UC Davis Health’s highly specialized paediatric critical care telemedicine program focuses on children with critical care needs, including neonates, while Avera eCARE Emergency focuses on the general population. The differences in populations served by the tele-ED models have implications for the tele-ED measures used to evaluate models of care, such as incidence of tele-ED use, access to care, and disposition status.

Distributions of reason for visit among cases and controls within the UC Davis Health model are very similar because in this model, all paediatric patients have a critical care need that drives contact with the paediatric critical care team at the UC Davis Children’s Hospital hub. Thus, the comparison groups are relatively homogeneous in terms of clinical need. The distribution differences in reason for visit among cases and controls in the Avera eCARE model reflect the diversity and volume of paediatric patient populations presenting to remote EDs. In particular, the distribution among tele-ED cases may reflect rural hospital ED’s need for support with particular types of emergency paediatric presentations (i.e. mental and behavioural health, trauma) due to a lack of local providers with the expertise to care for those types of emergencies.

Discharge disposition distributions vary between models, another reflection of the different populations served by each program. Within the UC Davis Health program, a higher proportion of cases than controls were discharged routinely and admitted to local inpatient facilities, and fewer cases transferred. This suggests that the tele-ED model is affecting resource use and disposition outcomes, perhaps because care in the UC Davis Health telemedicine program is being directed to the most appropriate hospital setting. If patients do not need to be transferred because they can be safely cared for in the community (determined via tele-ED consultation), then transfer rates in the case group are potentially reflecting the change in decision-making as a result of the tele-ED service.

Differences in disposition status between cases and controls within the Avera eCARE program are likely a reflection of the differences in groups’ severity of ED visit. In subsequent analysis, cases and controls were stratified by visit severity, with “low”-severity encounters containing codes 99282 and 99283 and “high”-severity encounters containing codes 99284 and 99285. The percentage of cases that were high severity was 53% (vs. 12% of controls) while the percentage of cases that were low severity was 37% (vs. 87% of controls), suggesting that tele-ED is appropriately being activated for higher-severity emergency encounters. Furthermore, when stratified this way, the distribution of disposition within groups changes dramatically, as shown in Table 5. High severity cases had a 10% routine discharge rate (vs. 35% for all cases shown in Figure 1), a 14% local inpatient admission rate (vs. 10% for all cases), and a transfer rate of nearly 68% (vs. 51% for all cases). For controls, nearly 56% of high-severity cases were routine discharge (vs. 93% for all controls), 25% were admitted locally (vs. 4% for all controls), and 18% were transferred (vs. 3% for all controls shown in Figure 1). When stratified by emergency visit severity, Avera eCARE disposition rates for high-severity paediatric encounters approach those of UC Davis Health for paediatric and neonatal critical care cases, suggesting also that it is having an effect on resource use and efficiency in terms of directing care to the most appropriate setting.

Table 5.

Disposition status by “high”- and “low”-severity visits for Avera eCARE, by case and control status.

	“High” severity visits		“Low” severity visits
	Case	Control^a	Case	Control^a
Routine discharge	10%	56%	75%	98%
Admitted to local inpatient facility	14%	25%	3%	1%
Transferred to another inpatient facility	68%	18%	20%	1%

Note: “high”-severity visits defined by CPT codes 99284 and 99285. “Low”-severity visits defined by CPT codes 99282 and 99283. Totals do not add up to 100% because other disposition categories are not included. Other dispositions are “Died in ED,” “Left Against Medical Advice,” “Transferred to Psychiatric Inpatient Facility,” “Observation,” and “Other”.

Limitations

There are several limitations to this descriptive study. First, because data were not collected under randomized control trial conditions, we cannot make any statistical inferences about either program’s ability to improve access, resource use and efficiency, or care outcomes for paediatric populations using tele-ED services. Discretionary decision-making on the part of remote ED providers likely increases the influence of unobserved patient-level factors when tele-ED activation did occur.

Second, case/control data from each model could not be pooled because the tele-ED models are different by design. While this is a limitation for quantitative analysis, the contrast in model designs show how paediatric tele-ED applications can develop and evolve in unique and impactful ways for the populations and healthcare providers that they are designed to serve.

Conclusion

This study describes how the design choices of tele-ED models have implications for measures of access, use, and outcomes. Measures of tele-ED model success need to reflect model purpose, the population intended to be served, for whom tele-ED service use is appropriate and for whom it is not, and what the expected changes on resource use and efficiency are, given the scope and scale of the tele-ED program.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by the Federal Office of Rural Health Policy (FORHP), Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services (HHS) to the Rural Telehealth Research Center under cooperative agreement #UICRH29074. The Evidence-Based Tele-Emergency Network Grant Program provided funding for delivering teleED services to grantees – Avera Health (PI – Amanda Bell, Grant No. GO1RH27868) and University of California – Davis (PI – James Marcin, Grant No. G01RH27872). The information, conclusions, and opinions expressed are those of the authors and no endorsement by FORHP, HRSA, or HHS is intended or should be inferred.

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