Impact of critical care telemedicine consultations on children in rural emergency departments.

OBJECTIVES: To compare the quality of care delivered to critically ill and injured children receiving telemedicine, telephone, or no consultation in rural emergency departments. DESIGN: Retrospective chart review with concurrent surveys. SETTING AND PARTICIPANTS: Three hundred twenty patients presenting in the highest triage category to five rural emergency departments with access to pediatric critical care consultations from an academic children's hospital. MEASUREMENTS AND MAIN RESULTS: Quality of care was independently rated by two pediatric emergency medicine physicians applying a previously validated 7-point implicit quality review tool to the medical records. Quality was compared using multivariable linear regression adjusting for age, severity of illness, and temporal trend. Referring physicians were surveyed to evaluate consultation-related changes in their care. Parents were also surveyed to evaluate their satisfaction and perceived quality of care. In the multivariable analysis, with the no-consultation cohort as the reference, overall quality was highest among patients who received telemedicine consultations (n=58; ß=0.50 [95% CI, 0.17-0.84]), intermediate among patients receiving telephone consultation (n=63; ß=0.12 [95% CI, -0.14 to 0.39]), and lowest among patients receiving no consultation (n=199). Referring emergency department physicians reported changing their diagnosis (47.8% vs 13.3%; p<0.01) and therapeutic interventions (55.2% vs 7.1%; p<0.01) more frequently when consultations were provided using telemedicine than telephone. Parent satisfaction and perceived quality were significantly higher when telemedicine was used, compared with telephone, for six of the seven measures. CONCLUSIONS: Physician-rated quality of care was higher for patients who received consultations with telemedicine than for patients who received either telephone or no consultation. Telemedicine consultations were associated with more frequent changes in diagnostic and therapeutic interventions, and higher parent satisfaction, than telephone consultations.

Rural inpatient telepharmacy consultation demonstration for after-hours medication review.

OBJECTIVE: Medication errors contribute to a significant number of fatal and nonfatal adverse medical events each year. Many actions, from both a policy and innovation standpoint, have been taken to reduce medication errors in the inpatient setting; yet, these actions often target larger urban hospitals. Rural hospitals face many more challenges in implementing these changes due to fewer resources and lower patient volumes. Our article discusses the implementation and results of a telepharmacy demonstration implemented between the University of California Davis Health System and six rural hospitals. MATERIALS AND METHODS: A retrospective chart review obtained baseline medication errors for comparison with the prospective review of medication orders through telepharmacy. Medication orders from rural hospitals were transmitted via fax to the University of California Davis Pharmacy for after-hours review. If a medication required after-hours removal from the pharmacy, it was requested that video verification by a telepharmacist be used to verify that the correct medication was removed from the pharmacy. RESULTS: Baseline findings from the retrospective chart review indicated that 30.0% of patients had one or more medication errors and that these errors occurred in 7.2% of the medication orders. None of these errors were found to have resulted in harm to the patients. During the telepharmacy demonstration, 2,378 medication orders were screened from 504 independent order review requests. In total, 58 (19.2%) patients had one or more medication errors. The errors from the telepharmacy demonstration represented potential errors that were identified through telepharmacy medication review. CONCLUSIONS: Telepharmacy represents a potential alternative to around-the-clock on-site pharmacist medication review for rural hospitals.

Quality of care of children in the emergency department: association with hospital setting and physician training.

OBJECTIVE: To investigate differences in the quality of emergency care for children related to differences in hospital setting, physician training, and demographic factors. STUDY DESIGN: This was a retrospective cohort study of a consecutive sample of children presenting with high-acuity illnesses or injuries at 4 rural non-children's hospitals (RNCHs) and 1 academic urban children's hospital (UCH). Two of 4 study physicians independently rated quality of care using a validated implicit review instrument. Hierarchical modeling was used to estimate quality of care (scored from 5 to 35) across hospital settings and by physician training. RESULTS: A total of 304 patients presenting to the RNCHs and the UCH were studied. Quality was lower (difference = -3.23; 95% confidence interval [CI] = -4.48 to -1.98) at the RNCHs compared with the UCH. Pediatric emergency medicine (PEM) physicians provided better care than family medicine (FM) physicians and those in the "other" category (difference = -3.34, 95% CI = -5.40 to -1.27 and -3.12, 95% CI = -5.25 to -0.99, respectively). Quality of care did not differ significantly between PEM and general emergency medicine (GEM) physicians in general, or between GEM and PEM physicians at the UCH; however, GEM physicians at the RNCHs provided care of lesser quality than PEM physicians at the UCH (difference = -2.75; 95% CI = -5.40 to -0.05). Older children received better care. CONCLUSIONS: The quality of care provided to children is associated with age, hospital setting, and physician training.

Clinical management and patient outcomes among children and adolescents receiving telemedicine consultations for obesity.

Rural residents report lower likelihood of exercising, and higher rates of obesity, heart disease, and diabetes compared to their urban counterparts. Our goals were to (1) investigate the outcomes of telemedicine consultations for pediatric obesity on changes/additions to diagnoses, diagnostic evaluation or treatment, and (2) determine whether changes in diagnostic and management recommendations made by the consultant were associated with improvements in patient nutrition, activity level, and weight. We conducted a retrospective medical record review of patients referred to a University-affiliated Children's Hospital Pediatric Telemedicine Weight Management Clinic for a diagnosis of obesity. Of the 139 children and adolescents who received pediatric weight management consultations during the study period, 99 patients met inclusion criteria. Weight management consultations resulted in changes/additions to diagnoses in 77.8% of patients and changes/additions to diagnostic evaluation in 79.8% of patients. Of patients seen more than once, 80.7% showed improvement in clinical outcomes. Of patients seen more than once, 80.6% improved their diet, 69.4% increased activity levels, 21.0% showed slowing of weight gain or weight maintenance, and 22.6% showed weight reduction. Improvements in clinical outcomes were not associated with changes/additions to diagnoses (Odds Ratio [OR] = 0.98; 95% Confidence Interval [CI] = 0.25-3.98) and were weakly associated with changes/additions to diagnostic evaluations (OR = 2.23; 95% CI = 0.58-8.73). However, changes/additions to treatment were associated with improvement in weight status (OR = 9.0; 95% CI = 1.34-76.21). Obesity consultations were associated with changes/additions to diagnoses, diagnostic evaluation, and treatment. Treatment changes were associated with improvement in weight status. Telemedicine weight management consultations have the potential to result in modifications in patient care plans and outcomes.

Medication errors among acutely ill and injured children treated in rural emergency departments.

STUDY OBJECTIVE: We identify the incidence, nature, and consequences of medication errors among acutely ill and injured children receiving care in a sample of rural emergency departments (EDs). METHODS: Two pediatric pharmacists applied a medication error data collection instrument to the medical records of all critically ill children (highest triage category) treated in 4 northern California rural EDs between January 2000 and June 2003. Physician-related medication errors were defined as those involving wrong dose, wrong or inappropriate medication for condition, wrong route, or wrong dosage form. Wrong dose was determined by preset criteria, with doses above or below 10% to 25% of correct dose considered errors, depending on class of medication. Medication errors were classified into categories A through I under 3 broader categories, including errors having the potential to cause harm (A), errors that cause no harm (B to D), and errors that cause harm to the patient (E to I). RESULTS: Complete data were available from 177 (97.3%) of the 182 patients identified as having been triaged in the highest category during the study period. A total of 84 medication errors were identified among 69 patients, resulting in a medication error incidence of 39.0%. Twenty-four physician-related medication errors were identified among 21 patients, resulting in a physician-related medication error incidence of 11.9%. Among the 69 patients with medication errors, 11 had errors categorized as having the potential to cause harm (15.9%), and 58 had errors categorized as causing no harm (85.5%). CONCLUSION: We found a high incidence of medication errors and physician-related medication errors among the acutely ill and injured children presenting to rural EDs in northern California. None of the medication errors identified caused harm to the patients included in this study.

Perceptions of local health care quality in 7 rural communities with telemedicine.

CONTEXT: Rural health services are difficult to maintain because of low patient volumes, limited numbers of providers, and unfavorable economies of scale. Rural patients may perceive poor quality in local health care, directly impacting the sustainability of local health care services. PURPOSE: This study examines perceptions of local health care quality in 7 rural, underserved communities where telemedicine was implemented. This study also assesses factors associated with travel outside of local communities for health care services. METHODS: Community-based pretelemedicine and posttelemedicine random telephone surveys were conducted in 7 northern California rural communities assessing local residents' perceptions of health care quality and the frequency of travel outside their community for health care services. Five-hundred rural residents were interviewed in each of the pretelemedicine and posttelemedicine surveys. Between surveys, telemedicine services were made available in each of the communities. FINDINGS: Residents aware of telemedicine services in their community had a significantly higher opinion of local health care quality (P =.002). Satisfaction with telemedicine was rated high by both rural providers and patients. Residents with lower opinions of local health care quality were more likely to have traveled out of their community for medical care services (P =.014). CONCLUSIONS: The introduction of telemedicine into rural communities is associated with increases in the local communities' perception of local health care quality. Therefore, is it possible that telemedicine may result in a decrease in the desire and need for local patients to travel outside of their community for health care services.

WiFi RFID demonstration for resource tracking in a statewide disaster drill.

OBJECTIVE: To investigate the capabilities of Radio Frequency Identification (RFID) tracking of patients and medical equipment during a simulated disaster response scenario. DESIGN: RFID infrastructure was deployed at two small rural hospitals, in one large academic medical center and in two vehicles. Several item types from the mutual aid equipment list were selected for tracking during the demonstration. A central database server was installed at the UC Davis Medical Center (UCDMC) that collected RFID information from all constituent sites. The system was tested during a statewide disaster drill. During the drill, volunteers at UCDMC were selected to locate assets using the traditional method of locating resources and then using the RFID system. RESULTS: This study demonstrated the effectiveness of RFID infrastructure in real-time resource identification and tracking. Volunteers at UCDMC were able to locate assets substantially faster using RFID, demonstrating that real-time geolocation can be substantially more efficient and accurate than traditional manual methods. A mobile, Global Positioning System (GPS)-enabled RFID system was installed in a pediatric ambulance and connected to the central RFID database via secure cellular communication. This system is unique in that it provides for seamless region-wide tracking that adaptively uses and seamlessly integrates both outdoor cellular-based mobile tracking and indoor WiFi-based tracking. CONCLUSIONS: RFID tracking can provide a real-time picture of the medical situation across medical facilities and other critical locations, leading to a more coordinated deployment of resources. The RFID system deployed during this study demonstrated the potential to improve the ability to locate and track victims, healthcare professionals, and medical equipment during a region-wide disaster.

Hepatitis C videoconferencing: the impact on continuing medical education for rural healthcare providers.

This study compared the impact of multipoint videoconferencing (VC) versus standard lecturing (ST) on primary care providers' (MDs, NPs/PAs, and RNs) education regarding hepatitis C virus (HCV). The hypothesis was that the educational impact of teaching through telemedicine is comparable to the traditional method. The aim was to provide participants clinically relevant information and knowledge about the natural history, diagnosis, and management of HCV. Improved knowledge was scored from a 10-item quiz administered before and after the educational intervention. Comparison of the pretest knowledge scores within provider groups showed no statistically significant difference in baseline knowledge for the ST versus VC method. However, for all practitioners combined, the VC group scored significantly lower on the pretest than the ST group (p < 0.05). All three types of learners improved their knowledge scores following intervention. On average, MDs and NP/PAs correctly answered two to 3.5 more questions in the posttest. RNs showed the greatest improvements, correctly answering an average of four to five more questions following intervention. Improvement in knowledge scores between the two methods was statistically significant in favor of VC for the MDs (VC = 3.56 +/- 1.92 vs. ST = 2.13 +/- 1.89, p < 0.001) and all groups combined (VC 4.37 +/- 1.92 vs ST 3.06 +/- 1.89, p < 0.001). The results of this study indicate that VC is equivalent, if not better, than standard continuing medical education (CME). VC can potentially improve clinician education regarding the history, diagnosis, and management of HCV, thereby making a substantial impact on the clinical course of patients with this condition. In addition, VC has the potential to eliminate the financial and geographic barriers to professional education for rural practitioners.

Rural outreach in home telehealth: assessing challenges and reviewing successes.

Most home health agencies that adopt home telehealth tend to be located in urban or metropolitan areas. This paper discusses a 3-year pilot of home telehealth in four rural areas. Several challenges related to the rural nature of the home health agencies were recognized. These challenges are discussed with recommendations for assessing rural home health agencies for home telehealth. Our findings suggest ways to improve the implementation of home telehealth for rural home health agencies. In addition to the challenges, successes were realized as well. Approximately 145 travel hours and 7500 miles of nurse travel were avoided through the use of home telehealth during the program. Patient examples show improvements in their medical conditions, which the nursing staff thought would not have been accomplished without the more frequent monitoring that home telehealth allowed the agencies to provide.

Changes in diagnosis, treatment, and clinical improvement among patients receiving telemedicine consultations.

The aim of this study was to determine whether outpatient telemedicine specialty consultations to primary care clinicians result in changes in a patient's diagnosis, treatment management, and clinical outcomes. Medical records of patients who received two or more clinical telemedicine consultations in dermatology, psychiatry, and endocrinology were evaluated in a nonconcurrent retrospective analysis. Three indicators were used to measure changes in the processes of care and clinical outcomes: change in diagnosis, change in treatment, and patient clinical improvement. A retrospective review of 223 individual telemedicine patient medical records was conducted. Specialty telemedicine consultations were found to result in changes in diagnoses in 48% of the cases, changes in treatment therapy in 81.6% of the cases, and clinical improvement in 60.1%. These results are consistent with previous literature that has assessed changes in processes of care and outcomes from face-to-face specialty consultations in outpatient clinics. Changes in diagnosis and treatment therapy were found to be associated with clinical improvement with odds ratios (ORs) of 2.66 (95% confidence interval [CI]: 1.47-4.83) and 11.22 (95% CI: 4.49-31.48), respectively. This study found that telemedicine consultations resulted in changes in diagnosis and treatment regimens and also are associated with clinical improvements.