Translating Value Across Telehealth Stakeholders: A Rapid Review of Telehealth Measurement Evidence and a New Policy Framework to Guide Telehealth Researchers.

Introduction: The surge in virtual care during the pandemic was accompanied by an increase in telehealth data of interest to policy stakeholders and other health care decision makers. However, these data often require substantial preprocessing and targeted analyses to be usable. By deliberately evaluating telehealth services with stakeholder perspectives in mind, telehealth researchers can more effectively inform clinical and policy decision making. Objective: To examine existing literature on telehealth measurement and evaluation and develop a new policy-oriented framework to guide telehealth researchers. Materials and Methods: A systematic rapid review of literature on telehealth measurement and evaluation was conducted by two independent reviewers in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The findings were analyzed and applied to the Supporting Pediatric Research on Outcomes and Utilization of Telehealth Evaluation and Measurement (STEM) Framework through the lens of key health care delivery decision makers to create a STEM Policy Framework Results: An initial search yielded 2,324 peer-reviewed articles and gray literatyre from 2012 to 2022, of which 56 met inclusion criteria. These measured and evaluated telehealth access (41.5%), quality (32.1%), cost (15.1%), experience (5.7%), and utilization (5.7%), consistent with the STEM Framework domains, but there was no universal approach. The STEM Policy Framework focuses this literature by describing data measures for each domain from the perspectives of five stakeholders. Conclusions: Literature describing measurement and evaluation approaches for telehealth is limited and not standardized, with few considering policy stakeholder perspectives. With this proposed STEM Policy Framework, we aim to improve this body of literature and support researchers seeking to inform telehealth policy through their work.

Hospitalists as Facilitators of Surge and Contingency Medical Operations and Planning.

Hospital medicine, a specialty encompassing physicians and advanced practice providers in internal medicine, pediatrics, and family medicine, has been a core and rapidly growing component of civilian health care for the past two decades. More recently, hospitalists have been taking on key roles during surge and contingency planning and operations, most notably during the COVID-19 pandemic which necessitated marked changes in inpatient care across the United States. The military health system has been slower to incorporate hospitalists into clinical care and planning than civilian organizations due to its unique features. However, an increasing focus on future distributed operations in contested environments, pandemic care, and humanitarian assistance/disaster response requires new consideration of their role in military medicine. This stems from hospitalists' value as clinicians who include triage, resource utilization stewardship, medical inpatient care, pre-/post-operative management of surgical patients, and high acuity patient stabilization and management within their scope, often working collaboratively with other specialists such as emergency medicine physicians, surgeons, and intensivists. Just as importantly, hospitalists are system-level facilitators and leaders of patient capacity expansion and/or clinical process changes when needed for response to incidents in a variety of acute care scenarios. With uniformed billets being increasingly targeted to military platform requirements, there is now an opportunity to revisit the value of hospitalists in military medicine. In this Commentary, we review the roles that hospitalists can fill in hospital and operational medical settings, with a focus on surge and contingency operations. To demonstrate this capability, we present here the experience of two operational units employing hospitalists for high acuity patient management and two civilian hospitals implementing surge operations during the 2022-2023 "tripledemic" of viral respiratory infections in the United States. Their innovations facilitated the care of higher acuity and higher volume during times when medical care requirements were limited by traditional staffing models. We end by reviewing opportunities and challenges related to expanding hospitalist use within the military health system and describing efforts that are underway to address the challenges.

Mixed methods evaluation of pediatric telehealth equity for patients/families who communicate in languages other than English.

Background: Emerging research demonstrates telehealth disparities for patients who communicate in languages other than English. A better understanding of pediatric telehealth use with families who communicate in languages other than English is needed to inform interventions to promote telehealth equity. Methods: We conducted a mixed methods study of telehealth care in a children's hospital health system using electronic health record data for outpatient video telehealth encounters from April 2020 to July 2021 and qualitative interviews with clinical staff and Spanish-speaking parents of telehealth patients. Results: The 16-month study period included 102,387 telehealth encounters; 5% of which were encounters in languages other than English. 83% of languages other than English encounters were with patients/families with a preferred healthcare language of Spanish. 11% of providers conducted ≥10 languages other than English telehealth encounters. This subset of providers conducted 71% of all languages other than English encounters. We conducted 25 interviews with clinical staff (n=13) and parents (n=12). Common themes identified across interviews were: (I) technology barriers affect access to and quality of telehealth; (II) clinical staff and parents are uncertain about the future role of telehealth for patients/families who communicate in languages other than English; (III) the well-known impact of language barriers on in-person healthcare access and quality for patients who communicate in languages other than English is also evident in telehealth. Conclusions: Patients who communicate in languages other than English were underrepresented among telehealth encounters and encounters were concentrated among few providers. Promoting equitable telehealth care requires investment to address technology barriers, increase the readiness of providers and clinics to provide telehealth care in languages other than English, and continued attention to reducing the healthcare impact of language barriers.

Retrospective chart review of patient socioeconomic status and language preference associated with live video telehealth in a pediatric dermatology practice.

Pediatric teledermatology rapidly expanded with the COVID-19 pandemic, and the impacts of this expansion on patients' access to care have not yet been entirely defined. In this retrospective study of 3027 patients in an academic pediatric dermatology practice, patients who identified as having a primary language other than English were less likely to access pediatric dermatology care during the COVID lockdown. This study did not identify a significant or meaningful difference in age, geography, socioeconomic status, ethnicity, or race between patients who were offered pediatric dermatology care that was either in-person or via synchronous telehealth. These findings are overall reassuring that there were not major disparities in telehealth utilization during the COVID shelter-in-place mandate, although highlight the need for institutions to ensure systems are in place to enhance telehealth access for patients with non-English primary language.

The Use of Telehealth to Improve Handoffs Between Neonatologists and Primary Care Providers for Medically Complex Infants.

As part of the Supporting Pediatric Research Outcomes Utilizing Telehealth (SPROUT) collaboration, three institutions (University of California, Davis, Children's Hospital Colorado, and Children's Hospital of Philadelphia) sought to improve communication with primary care providers (PCPs) using telehealth. This project connected families of neonatal intensive care unit (NICU) patients, their PCPs, and their NICU team through telehealth to provide an enhanced hospital handoff. This case series reports four cases that exemplify the benefits of these enhanced hospital handoffs: Case 1: assisting with changing care plans after NICU discharge, Case 2: demonstrating physical findings, Case 3: incorporation of additional subspecialties through telehealth, Case 4: arranging care for remote patients. Although these cases demonstrate some of the potential benefits of these handoffs, further study is needed to determine acceptability of these handoffs and to see whether they impact patient outcomes.

Telehealth Coverage for a Pediatric Gastroenterology Consult Service at a Regional Hospital: An Accepted, Useful, and Sustainable Model of Care.

OBJECTIVE: To evaluate a novel telehealth inpatient pediatric gastroenterology (GI) consult service at a regional children's hospital in regard to acceptance, utility, quality, sustainability, and provider resiliency. STUDY DESIGN: Patients requiring GI care at a regional children's hospital between July 2020 and June 2021 were treated by an in-person or telehealth physician with physician assistant support, randomly assigned based on a weekly preset staffing schedule. A retrospective, multidomain program evaluation was performed based on the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) and STEM (SPROUT Telehealth Evaluation and Management) frameworks, using statistical analysis to compare the patient cohorts and anonymous surveys to assess provider perceptions. RESULTS: In total, 1051 patient-days of GI care were provided for 348 patients, 17% by telehealth and 83% in-person. There were no significant differences in diagnosis, transfer, or readmission rates between the cohorts. No transfers occurred for reasons other than need to access specialized services not available at the regional hospital. Daily consult workload was slightly greater for telehealth physicians. Primary and consult team providers accepted the practice. The model continued beyond the first year. In total, 75% of local GI physicians reported greater Brief Resilience Scores in the context of shifting 20% of their inpatient call weeks to another campus's physicians. CONCLUSION: Episodic pediatric GI consult service coverage via telehealth at a regional hospital was well accepted, useful, and sustainable, with improved physician resilience and no adverse outcomes seen. Telehealth holds promise for leveraging pediatric subspecialty physicians across hospitals, allowing complex patients to be admitted closer to home while reducing inpatient coverage requirements for smaller physician groups.

When is synchronous telehealth acceptable for pediatric dermatology?

BACKGROUND/OBJECTIVES: We evaluated the acceptance of synchronous (live video) telehealth for pediatric dermatology. METHODS: This was a prospective, single-center study of patient and dermatologist surveys paired at the encounter level for telehealth encounters with Children's Hospital Colorado Pediatric Dermatology Clinic between 21 April 2020 and 22 May 2020. RESULTS: Dermatologists were most receptive to a telehealth encounter for isotretinoin monitoring (96.6%) and non-isotretinoin acne (89.5%). In contrast, 71.8% and 58.8% of patients surveyed were open to telehealth for isotretinoin encounters and non-isotretinoin acne encounters, respectively. There was no significant correlation between patient and dermatologist satisfaction regarding a telehealth encounter (r = 0.09, CI [-0.09, 0.26], p = .34) or between patient and dermatologist preference for telehealth encounter (r = 0.07, CI [-0.11, 0.25] p = .46). Dermatologists reported needing a photo to aid their physical examination in 38/363 (10.7%) of encounters and preferred in-person examinations when an encounter would have benefitted from laboratories, procedures, dermatoscopic examination, examination by palpation, and accurate weights in infants. CONCLUSIONS: Synchronous, live-video telehealth is an effective method of healthcare delivery in certain situations for pediatric dermatology, but it does not replace in-person encounters. Families and dermatologists have different perceptions about its acceptance.

Case report: Cystic fibrosis with kwashiorkor: A rare presentation in the era of universal newborn screening.

Background: Universal newborn screening changed the way medical providers think about the presentation of cystic fibrosis (CF). Before implementation of universal screening, it was common for children with CF to present with failure to thrive, nutritional deficiencies, and recurrent infections. Now, nearly all cases of CF are diagnosed by newborn screening shortly after birth before significant symptoms develop. Therefore, providers often do not consider this illness in the setting of a normal newborn screen. Newborn screening significantly decreases the risk of complications in early childhood, yet definitive testing should be pursued if a patient with negative newborn screening presents with symptoms consistent with CF, including severe failure to thrive, metabolic alkalosis due to significant salt losses, or recurrent respiratory infections. Case presentation: We present a case of a 6-month-old infant male with kwashiorkor, severe edema, multiple vitamin deficiencies, hematemesis secondary to coagulopathy, and diffuse erythematous rash, all secondary to severe pancreatic insufficiency. His first newborn screen had an immunoreactive trypsinogen (IRT) value below the state cut-off value, so additional testing was not performed, and his growth trajectory appeared reassuring. He was ultimately diagnosed with CF by genetic testing and confirmatory sweat chloride testing, in the setting of his parents being known CF carriers and his severe presentation being clinically consistent with CF. Acutely, management with supplemental albumin, furosemide, potassium, and vitamin K was initiated to correct the presenting hypoalbuminemia, edema, and coagulopathy. Later, pancreatic enzyme supplementation and additional vitamins and minerals were added to manage ongoing deficiencies from pancreatic insufficiency. With appropriate treatment, his vitamin deficiencies and edema resolved, and his growth improved. Conclusion: Due to universal newborn screening, symptomatic presentation of CF is rare and presentation with kwashiorkor is extremely rare in resource-rich communities. The diagnosis of CF was delayed in our patient because of a normal newborn screen and falsely reassuring growth, which after diagnosis was determined to be secondary to severe edematous malnutrition. This case highlights that newborn screening is a useful but imperfect tool. Clinicians should continue to have suspicion for CF in the right clinical context, even in the setting of normal newborn screen results.

Pediatric Telehealth in the COVID-19 Pandemic Era and Beyond.

The coronavirus disease 2019 (COVID-19) pandemic led to an unprecedented demand for health care at a distance, and telehealth (the delivery of patient care using telecommunications technology) became more widespread. Since our 2018 state-of-the-art review assessing the pediatric telehealth landscape, there have been many changes in technology, policy, payment, and physician and patient acceptance of this care model. Clinical best practices in telehealth, on the other hand, have remained unchanged during this time, with the primary difference being the need to implement them at scale.Because of the pandemic, underlying health system weaknesses that have previously challenged telehealth adoption (including inequitable access to care, unsustainable costs in a fee-for-service system, and a lack of quality metrics for novel care delivery modalities) were simultaneously exacerbated. Higher volume use has provided a new appreciation of how patients from underrepresented backgrounds can benefit from or be disadvantaged by the shift toward virtual care. Moving forward, it will be critical to assess which COVID-19 telehealth changes should remain in place or be developed further to ensure children have equitable access to high-quality care.With this review, we aim to (1) depict today's pediatric telehealth practice in an era of digital disruption; (2) describe the people, training, processes, and tools needed for its successful implementation and sustainability; (3) examine health equity implications; and (4) critically review current telehealth policy as well as future policy needs. The American Academy of Pediatrics (AAP) is continuing to develop policy, specific practice tips, training modules, checklists, and other detailed resources, which will be available later in 2021.

Quality and Safety Analysis of 2,999 Telemedicine Encounters During the COVID-19 Pandemic.

OBJECTIVE: To examine whether telemedicine remains safe and of high quality despite rapid expansion of services by comparing telemedicine encounters before and during the COVID-19 pandemic. METHODS: Pre-post study investigating 2,999 telemedicine encounters: February 1, 2020-May 15, 2020, was performed. A total of 2,919 completed visits before and after strict social distancing implementation were analyzed for patient and provider characteristics, encounter characteristics (e.g., history and physical examination), and quality and safety metrics (phone calls ≤ 7 days postvisit, visit-cause-specific hospital admission or mortality ≤ 30 days after visit). Stratified analysis of 3 groups for outcomes (young age, neuromuscular diagnosis, and new encounters) was performed. RESULTS: Patients ranging from 1 month to 33 years of age were seen. Rural patients were less likely to be seen during the pandemic compared with urban patients (8% vs 90%; p < 0.0001); teaching clinic and specialty clinic encounters increased significantly during the pandemic (8% vs 3%; p = 0.005), and documentation of at least 2 systems on examination was noted significantly more frequently during the pandemic (13% vs 7%; p = 0.009). No deaths were reported. There were no differences before/during the pandemic in safety or telemedicine failure metrics within the entire group and high-risk subgroups. CONCLUSIONS: Despite a markedly and rapidly expanded scope of ambulatory telemedicine care during the COVID-19 pandemic, telemedicine remained a safe and high-quality option for pediatric neurology patients. In addition, populations perceived as high risk for telemedicine (the very young, new patients, and those with neuromuscular diagnoses) can benefit from telemedicine visits, particularly when access to in-person care is limited.

An Economic Framework to Measure Value of Pediatric Telehealth.

Background: Health care is experiencing significant disruptive innovation with the use of technology, including telemedicine and virtual modalities to deliver care. These new models can dramatically improve access to care and reduce health care disparities for patients, especially in underserved and vulnerable populations like children. Problem: To assure diffusions and retention of new approaches they must be assessed for economic value. However, measuring telehealth programs using only an institutional financial viewpoint fails to convey all the societal value of such interventions, so economic studies of telehealth are needed but complex to design. Methods: We reviewed economic study guidelines, details from telehealth study research protocols, IRB submission questions, and telehealth study design literature. We then used an iterative consensus process to develop a framework for measuring value of virtual care at the societal level. Results: The work produced a set of tools that are useful for designing studies for measuring value of virtual care at the societal level. The framework and tools are presented in this report. Conclusions: The conceptual framework for economic evaluation was feasible for use when applied to measure pediatric telehealth value.

Exploring Online RN-to-BSN Student Perceptions of Learner Presence.

AIM: The aim of this study was to describe how RN-to-BSN student and program-specific characteristics influence student perceptions of learner presence (LP) in the online learning environment. BACKGROUND: Online RN-to-BSN students represent a diverse group of practicing nurses who must balance multiple obligations and challenging learner requirements. LP represents the student's perceptions of being close to and interacting with faculty and peers within the online learning environment. METHOD: A descriptive, exploratory design was used to examine the relationship between participant perceptions of LP and student and program characteristics. RESULTS: Findings describe student and program characteristics and perceptions of LP. Significant findings revealed that more collaborative assignments were associated with higher perceptions of LP; individual assignments resulted in lower perceptions. CONCLUSION: This study may enhance faculty understanding of this population of students and the extent to which course activities impact students' communication and collaboration to meet online learner requirements.

Risk Stratification of Fetal Cardiac Anomalies in an Underserved Population Using Telecardiology.

OBJECTIVE: To evaluate a fetal telecardiology program in a medically underserved area. METHODS: We conducted a prospective case series of pregnant women at 18-38 weeks of gestation with risk factors for fetal congenital heart disease. Obstetric ultrasonographers performed fetal echocardiograms (local site) that were read in real time. The results were given to the mother by a fetal cardiologist at a children's hospital 243 miles and two mountain passes away (distant site). We evaluated the fetal telecardiology program in five domains: 1) education of obstetric ultrasonographers before initiation of telecardiology services, 2) process and efficiency, 3) patient satisfaction, 4) economic effects, and 5) accuracy of cardiac diagnosis and success of risk stratification. RESULTS: The program was initiated on November 12, 2015, and here we describe its first 37 months. Over the initial training period of 3 months and about 70 examinations, obstetric ultrasonographers improved their identification of fetal congenital heart disease. Telecardiology was performed once a week and also for suspected fetal congenital heart disease or arrhythmia outside clinic hours, for a total of 455 examinations. All mothers preferred having their fetal cardiac evaluations performed locally as opposed to traveling to the distant center. The estimated cost to parents for fetal cardiac evaluation at the distant center was nine times greater than that of telecardiology ($581 vs $61). Congenital heart disease or arrhythmia was diagnosed in 28 and 15 fetuses, respectively; there was one false-negative result. All fetuses were correctly risk-stratified with respect to delivery location. CONCLUSIONS: Neither diagnostic quality nor patient satisfaction were sacrificed with telecardiology. The program was feasible, empowered the local health care providers and ultrasonographers, offered strong economic advantages to families, and offered the benefit of timely standard-of-care, face-to-face consultation without travel. Based on the success of this program, further studies are warranted to assess its replicability.

Gastroenteritis, Hepatitis, Encephalopathy, and Human Herpesvirus 6 Detection in an Immunocompetent Child: Benefits and Risks of Syndromic Multiplex Molecular Panel Testing.

An immunocompetent toddler came to medication attention with gastroenteritis, complicated by encephalopathy and hepatitis. Multiplexed testing using a polymerase chain reaction meningitis panel was positive for human herpesvirus 6 (HHV-6). Clinical correlation, quantitative HHV-6 polymerase chain reaction, and metagenomic next-generation sequencing supported a likely diagnosis of primary HHV-6B infection.

Teaching Helping Babies Breathe via Telehealth: A New Application in Rural Guatemala.

BACKGROUND: Helping Babies Breathe (HBB) is a neonatal resuscitation curriculum that teaches life-saving interventions utilized in the first minutes after birth, reducing morbidity and mortality. Traditionally, it requires in-person facilitators for didactic and hands-on training. OBJECTIVES: The aim of this study was to offer HBB to nurses and nursing students in Guatemala, with the lead facilitator presenting concepts via telehealth and in-person facilitators providing hands-on demonstration. METHODS: Learners completed pre- and post-tests that included the standard HBB knowledge check, as well as an assessment of the course teaching model. Learners also completed the standard Objective Structured Clinical Evaluations (OSCEs). RESULTS: Eighteen learners were included in the analysis. All but one learner (94%) passed the course, and the average percent improvement from the pre- to post-test was 12%. All learners achieved passing scores on the OSCEs. Learners responded positively to questions regarding the technology, connection with the instructor, and ability to ask questions. Ninety-four percent of the learners agreed with the statement "this lecture was as good via telehealth as in person." A cost analysis demonstrated approximately USD 3,979.00 in savings using telehealth compared to a standard in-person course. CONCLUSIONS: The telehealth model was successful in delivering course material to the learners and was well received. This model represents a cost-effective way to improve access to HBB. This study may not be generalizable to other populations, and the ability to use telehealth requires reliable internet connectivity, which may not be available in all settings. Further study and expansion of this pilot are needed to assess success in other settings.

The Current Pediatric Telehealth Landscape.

The growth and evolution of telehealth are opening new avenues for efficient, effective, and affordable pediatric health care services in the United States and around the world. However, there remain several barriers to the integration of telehealth into current practice. Establishing the necessary technical, administrative, and operational infrastructure can be challenging, and there is a relative lack of rigorous research data to demonstrate that telehealth is indeed delivering on its promise. That being said, a knowledge of the current state of pediatric telehealth can overcome many of these barriers, and programs are beginning to collaborate through a new pediatric telehealth research network called Supporting Pediatric Research on Outcomes and Utilization of Telehealth (SPROUT). In this report, we provide an update on the landscape of pediatric telehealth and summarize the findings of a recent SPROUT study in which researchers assessed pediatric telehealth programs across the United States. There were >50 programs representing 30 states that provided data on their implementation barriers, staffing resources, operational processes, technology, and funding sources to establish a base understanding of pediatric telehealth infrastructure on a national level. Moving forward, the database created from the SPROUT study will also serve as a foundation on which multicenter studies will be developed and facilitated in an ongoing effort to firmly establish the value of telehealth in pediatric health care.

The Use of Telepsychiatry to Provide Cost-Efficient Care During Pediatric Mental Health Emergencies.

OBJECTIVE: This study evaluated a videoconference-based psychiatric emergency consultation program (telepsychiatry) at geographically dispersed emergency department (ED) sites that are part of the network of care of an academic children's hospital system. The study compared program outcomes with those of usual care involving ambulance transport to the hospital for in-person psychiatric emergency consultation prior to disposition to inpatient care or discharge home. METHODS: This study compared process outcomes in a cross-sectional, pre-post design at five network-of-care sites before and after systemwide implementation of telepsychiatry consultation in 2015. Clinical records on 494 pediatric psychiatric emergencies included ED length of stay, disposition/discharge, and hospital system charges. Satisfaction surveys regarding telepsychiatry consultations were completed by providers and parents or guardians. RESULTS: Compared with children who received usual care, children who received telepsychiatry consultations had significantly shorter median ED lengths of stay (5.5 hours and 8.3 hours, respectively, p<.001) and lower total patient charges ($3,493 and $8,611, p<.001). Providers and patient caregivers reported high satisfaction with overall acceptability, effectiveness, and efficiency of telepsychiatry. No safety concerns were indicated based on readmissions within 72 hours in either treatment condition. CONCLUSIONS: Measured by charges and time, telepsychiatry consultations for pediatric psychiatric emergencies were cost-efficient from a hospital system perspective compared with usual care consisting of ambulance transport for in-person consultation at a children's hospital main campus. Telepsychiatry also improved clinical and operational efficiency and patient and family experience, and it showed promise for increasing access to other specialized health care needs.

Who is behind the stocking of energy-dense foods and beverages in small stores? The importance of food and beverage distributors.

OBJECTIVE: The present study examined food and beverage distributors' sourcing, placement and promotion of obesogenic (energy-dense, nutrient-poor) product categories from the perspective of small food store owners/managers. The obesogenic product categories of interest were savoury snacks, sugary beverages, sweet snacks, confectionery and frozen treats. Specifically, we examined how frequently distributors sourced these products, and the types of agreements and expectations they had for their placement and promotion. Differences were explored by store size and ethnicity. Fresh produce was used as a comparison when examining differences in frequency of sourcing only, with implications for healthy food access. DESIGN: Survey research involving in-person interviews. SETTING: Four urban areas in the USA: Baltimore, MD; Durham, NC; Minneapolis/St. Paul, MN; and San Diego, CA. SUBJECTS: Seventy-two small food store owners/managers, 65 % consent rate. RESULTS: Most distributors sourced obesogenic products weekly. Agreements to place products were predominantly informal (e.g. handshake) with sweet snack, confectionery and frozen treat distributors, and formal (e.g. contract) with savoury snack and sugary beverage distributors. Free-standing displays were the most common incentive provided by distributors and they expected some control over their placement and pricing. Free/discounted products and signage were also common incentives but slotting fees were not. Smaller stores and ethnic stores were less likely to receive various incentives, but among sweet snack distributors, they were more likely to control the price in ethnic v. non-ethnic stores. CONCLUSIONS: Obesogenic products are ubiquitous. Influencing what is made available to consumers in the retail food environment needs to consider the distributor.