Need and feasibility of telemedicine in non-urban day care centres

Abstract

There appear to have been no studies of telemedicine in rural day care centres. We have assessed the feasibility of using telemedicine in eight rural day care centres in Pennsylvania, from the day care centres' perspective. The average number of children in these centres was 76 (range 20–150). The centres sent an average of 4.7 children home each month because of illness. Using telephone and face-to-face interviews, we assessed their perceived need for and familiarity with telemedicine, as well as their openness and preparedness for implementing telemedicine. Most day care centres reported a need for telemedicine and were open to learning how to use it. Some centres were concerned about adequate space for the equipment, but overall, the centres felt that their resources were adequate. Telemedicine in rural day care centres appears to be feasible, and would have the potential to save time and money for parents, as well as perhaps improving health care for children in rural areas.

Introduction

Day care centres are facilities for supervising preschool-aged children while the parents work. In 2001, almost one-third of children below the age of six years were enrolled in day care centres.¹ Telemedicine has been used successfully in day care centres^2–6 where there are high rates of common acute illnesses among children. Childhood illnesses account for a large proportion of missed work for parents.^7,8

Past studies of telemedicine in day care centres have found it to be effective in improving health outcomes for children, reducing the burden on the health-care system, and offering favourable work schedules to parents.^2–6 One study found that telemedicine in day care centres led to a decrease in the number of childhood absences from day care due to illness.² Another study of the same programme found a 22% decrease in the number of emergency room visits for children with access to telemedicine compared to children without access to the technology.³ The programme was also able to replace 85% of illness visits to primary care paediatricians with the telemedicine encounters,⁴ and there were no differences in diagnosis made through telemedicine and in-person evaluation.⁶ The 2005 study also found that 91% of telemedicine visits allowed parents to stay at work and that 94% of problems managed by telemedicine would otherwise have led to a physician's office or emergency department visit.²

Although these studies have contributed to the understanding of how telemedicine in day care centres is beneficial, they have two significant limitations. First, the studies were focused on inner-city urban day care centres that were connected to a major children's hospital. Many areas in the USA are not near urban areas and do not have access to children's hospitals.

Second, the studies have assessed telemedicine in day care centres from the perspective of all key stakeholders except one – the day care centres themselves. More understanding is needed about day care centres' perceptions and acceptance of telemedicine.

The purpose of the present study was to assess the feasibility of a children's telemedicine programme in rural day care centres. The aim was to answer the following questions:

What is the current need for telemedicine in day care centres in rural areas?

Are the day care centres in these areas familiar with telemedicine?

How open are day care centres to the use of telemedicine?

How well are day care centres prepared to implement telemedicine?

Methods

Telephone and face-to-face surveys were administered to 13 day care centres in State College, a town in rural Pennsylvania. Each day care centre was asked to participate in a face-to-face interview. If the day care centre agreed, an appointment was made and a face-to-face interview was conducted. If a day care centre declined, they were then asked if they would participate in a telephone interview. Interviews were conducted by both authors, and interview responses were recorded on paper. Answers to open-ended questions were recorded by hand.

Eight out of 13 day care centres approached agreed to participate in the survey. Four centres failed to respond to our telephone calls, and one centre refused to participate in the study. The survey comprised a set of 15 questions designed to gather information regarding the day care centre and determine the need for telemedicine, the centres' knowledge of telemedicine, their receptiveness to implementing telemedicine in future, and their preparedness to implement the technology (see Appendix). The survey was administered to administrators of the centres. In order to confirm the face validity of the survey instrument, one of the day care centres was interviewed twice.

Sample composition

The characteristics of the participating day care centres are summarized in Table 1. The average number of children in these centres was 76 (range 20–150). The average age of the children in these centres was 4.0 years (range 2.2–8.0). There was an average of 18 childcare workers at each centre (range 4–30). There was an average of 4.6 children per worker (range 1.2–6.7). The average cost of a full-time childcare worker was $9.60/hour (range 5.75–15.00).

Table 1

Characteristics of the day care centres participating in the survey

	Mean	Minimum	Maximum
Number of children attending the day care	76	20	150
Average age of children in day care (years)	4.0	2.2	8.1
Total number of childcare workers at the centre	17.6	4	30
Number of childcare workers per child	4.6	1.2	6.7
Cost of a full-time childcare worker (US dollars)*	9.60	5.75	15.00

*Response rate for the item was 75%

Data analysis

Survey responses from each day care centre were transcribed into a worksheet and converted into a data file for the statistical package used (Stata).

To assess if the responses varied by subgroups of centres based on number of children attending the day care centre, number of children per worker, and whether the centre had a consulting physician, statistical comparison of subgroups were conducted on these survey items using t-tests. The subgroups based on number of children and children-worker ratio were defined based on whether the centre was above or below the average for all centres. The two subgroups based on the number of children were ‘greater than or equal to 76’ and ‘less than 76’ children on average, with each subgroup having equal number of centres. For the children-worker ratio the two subgroups were – ‘ratio of greater than or equal to five’ and ‘ratio of less than five,’ with 63% of the centres in former group and 38% in the latter. About 60% of the centres were in the subgroup with consulting physician and the rest in the group with no consulting physician.

Results

Need for telemedicine

Seven survey items in the instrument were relevant to the need for telemedicine use at participating day care centres. An average of five children were sent home every month due to illness. All centres reported that they sent the highest number of sick children home during the winter months and during the flu season, at which times the number rose to 10 per month.

The criteria used by the staff to send a child home included one or more of the following: a fever of 100/101°F; diarrhoea or vomiting; unexplained rashes; any infectious or contagious disease, including coughing or signs of pink eye. A few centres also considered a child's eating behaviour and how the child behaved generally. All day care centres used parents as the first point of contact to inform of a child's sickness, and about 22% of the centres also contacted the child's physician. About one third (38%) of the day care centres had a consulting physician associated with the centre, and 25% also knew the primary physician of each child in the day care centre. A summary of the results is provided in Table 2.

Table 2

Assessment of the need for telemedicine at day care centres

	Response
Number of children sent home sick each month*	On average 4.7
Period when the rate is highest*	Winter/flu season
Highest number	Up to 10 per month
Criteria to send child home when ill	High fever (above 100/101°F), vomiting/diarrhoea, contagious disease, flu symptoms, unexplained rash
Have a consulting physician	38% responded yes
Call parent/physician when child sick	75% contact only parents, 25% contact both parent and physician
Do know which paediatrician most children use	75% do not know, 25% do

*Response rate for the item was 88%

Feasibility of telemedicine implementation

The seven survey items assessing the feasibility of telemedicine implementation were divided into three categories – familiarity with telemedicine, openness to implementing telemedicine and preparedness for telemedicine. The items on familiarity showed that slightly more than one-third (38%) of the participating day care centres had heard about telemedicine before. However, after a brief introduction to telemedicine by the interviewer, all respondents became familiar with the technology. Given the scenario that telemedicine would be cost neutral, 88% of the respondents were open to the idea of implementing it at their centre.

The centres that were open to implementation of telemedicine were then assessed for their preparedness with respect to staffing and space resources. While all centres confirmed that they would not need extra staffing resources, almost one-third (29%) reported lack of adequate space to evaluate children using telemedicine equipment. All centres agreed that someone on their staff would be willing to learn how to use the equipment if the centre was to implement telemedicine. Three respondents added comments further explaining that they did not need additional staffing for telemedicine because their staff already spent a great deal of time consulting with parents regarding sick children. They felt that telemedicine could streamline the process and reduce the time, or at least not add to it. A summary of the results is provided in Table 3.

Table 3

Familiarity with, openness to, and preparedness for telemedicine by the day care centres. Values shown are percentages of centres that responded to the survey item

	Yes	No
Familiarity with telemedicine
Have you heard of telemedicine before?	38	63
If no, are you familiar with telemedicine after an explanation*	100	0
Openness to implementing telemedicine
If telemedicine technology were cost neutral, would you consider using it?	88	13
Preparedness for telemedicine (if you were to implement telemedicine)
Would you have adequate space to evaluate children?	71	29
Would you have someone on the staff who would be willing to learn how to use the equipment and interact with health-care providers?	100	0
Would extra staffing resources be needed to use telemedicine?^†	0	100

*Response rate for the item was 80%

^†Response rate for the item was 57%

The results of the subgroup analysis (Table 4) indicated that the day care centres differed in their familiarity and preparedness for telemedicine based on the number of children attending the centre and the number of children per staff member. The smaller centres were less familiar with telemedicine to start with but there was no difference between the subgroups after an explanation. In terms of the preparedness for telemedicine, fewer small centres reported having adequate space if they were to implement telemedicine. The subgroups were not significantly different in their response to any other survey item. There were no differences between providers with or without consulting physician on any survey item.

Table 4

Subgroup differences in familiarity, openness, and preparedness for telemedicine at the day care centres. Values shown are percentages of centres that responded to each survey item. Similar subgroup differences were conducted on centres with and without a consulting physician but no difference were found for any survey item

	No. of children at the centre			No. of children/worker
	≥76	<76	t value	≥5	<5	t value
Familiarity with telemedicine
Have you heard of telemedicine before?	0	75	3.0*	0	60	1.8
If no, are you familiar with telemedicine after an explanation?	100	100	–	100	100	–
Openness to implementing telemedicine
If telemedicine was cost neutral, would you consider using it?	75	100	1.0	100	80	0.8
Preparedness for telemedicine (If were to implement telemedicine)
Do you have adequate space to evaluate children	33	100	2.4*	33	100	2.4*
Do you have someone on the staff who would be willing to learn how to use the equipment and interact with health-care providers?	100	100	–	100	100	–
Would extra staffing resources be needed to use telemedicine?	0	0	–	0	0	–

*P < 0.05

Discussion

The findings of the present study indicate a reasonable need for telemedicine in rural day care centres, since many centres do not have a consulting physician associated with them and often lack knowledge about a child's paediatrician. In addition, day care workers are not trained clinicians, but must often use their judgement to decide when a child is sick and needs to go home.

An initial unfamiliarity with telemedicine by many of the centres would not be a deterrent to implementation, since most of them (85%) were open to the idea after being familiarized with the concept. However, the high level of acceptance of telemedicine does not mean that they were adequately prepared. Most centres acknowledged the lack of adequate space to set up telemedicine equipment, although they claimed that sufficient human resources would be available to manage the equipment.

Past research has identified various problems associated with the implementation of telemedicine, including the availability of broadband communication,⁹ ways of reimbursement for care provided through telemedicine,¹⁰ legal concerns about personal health-care data transmission,¹¹ the costs associated with operating telemedicine,^9,11,12 and the efforts needed to educate physicians and telemedicine coordinators for multiple functions and uses of the new technology.^10,11

Limitations

The present study had a number of limitations. First, because the survey instrument contained several open-ended questions, there is the possibility that they were interpreted with bias by the researchers. However, every effort was made to include the exact words of the survey respondents, including repeating the answers to the respondents and asking for verification of correctness and clarification to attenuate this bias. Second, it is unclear if day care centres would have accepted a simple telephone consultation with a clinician, or whether a more sophisticated telemedicine system would have produced additional benefits. Finally, the study focused on a small region of the USA and a relatively small number of day care centres, so it may be difficult to generalize the results.

Conclusion

The present study demonstrates that some rural day care centres in the state of Pennsylvania are willing to use telemedicine. If supportive state policies were in place, telemedicine in rural day care centres would have the potential to save time and money for parents, as well as perhaps improving health care for children in rural areas.

Footnotes

Acknowledgements

We thank Kathryn Dansky and Marianne Hillemeier (Pennsylvania State University) for their comments. Funding was provided by a grant from the Children, Youth and Families Consortium at Pennsylvania State University.

Appendix

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