The use of digital health care models is exploding across all populations. In response to this, the World Health Organization released its first ever guidelines on digital health interventions earlier this month. These guidelines simultaneously recognize the value-add of digital health technologies for health systems AND caution against substituting digital health interventions for components of health systems based on the evidence to-date. Similarly, research on different models of telemedicine within the field of pediatrics is limited. Earlier this week, the Centers for Medicare and Medicaid Services (CMS) announced a new initiative, CMS Primary Cares, in an effort to more strongly implement value-based care. It is hypothesized that this initiative will further increase the utilization and availability of digital health and telemedicine. Our blog post today will highlight examples of how digital health technology is being used and what we are learning from its use in pediatrics in three areas of digital health: Direct-to-consumer telemedicine, mobile-health communication, and neighborhood telemedicine.
Direct-to- consumer telemedicine refers to models where patients (or caregivers) can access health care providers through "virtual" means rather than making an in-person office visit. A study of direct-to-consumer use of telemedicine among a commercially insured pediatric population showed in a five-year period, use of this modality increased from 38 annual visits in 2011 to 24,409 annual visits in 2016. The most common diagnoses for these visits matched those of the most common diagnoses for in-person primary care visits; that is, acute upper respiratory infections. At the same time, another study out this year showed a differential pattern of prescribing antibiotics when comparing visits done via telemedicine compared to in-person visits. Children who had direct-to-consumer telemedicine visits for an acute respiratory infection were more likely to receive antibiotics and were less likely to receive guideline-concordant antibiotic management compared to the children who had in-person visits and urgent care visits. The author of this study noted that a similar analysis among adults showed that antibiotic prescribing did not differ by modality of visit, indicating this finding may potentially be unique to pediatric populations.
Thinking about the context of child sickness, it is worth noting that several factors are at play with children's illnesses. Of course, caregivers want their children to be well and many are aware of antibiotic resistance. However, at the time of sickness, parents are also concerned with having to decide if they are able to take time off of work. In addition, parents are often challenged by well-intended daycare or school policies which state children are not able to return until they are well or, as is often the case with conjunctivitis, have had a certain number of doses of antibiotic eye drops. “Letting viruses run their course” may be the evidence-based approach, yet modern workplace, daycare and education policies may not be consistent with that approach. The convenience factor of direct-to-consumer telemedicine for patients and families cannot be ignored; however, we must not compromise high quality care for convenience.
This area of digital health includes text message reminders for appointments or other preventive health reminders, in addition to medication adherence and behavior change communication. This mode of communication has been used for vaccine reminders for children and is expanding to include development of apps to support children with various chronic health conditions. As with any patient-facing communication, health literacy is a large factor to take into consideration. A recent study examined how health literacy may affect uptake of mobile health information and found that while differences in the type of modality used (e.g., text, app, Internet) existed by health literacy level, the desire to have access to these technologies to assist with communicating with their child’s provider did not. Apps were preferred by persons with higher health literacy levels. It is worth considering generational differences in health literacy with technology, particularly in the area of adolescent health. Tools for parents may differ than the tools used to engage adolescent patients. One example is the ADAPT tool for adolescents with asthma. The app designed for this study had several different functionalities, including symptom tracker, medication management, ability to connect with a care provider, and peer connection. Adolescents engaged with different components of the app, leading authors to recommend having multi-functional apps for this population. A systematic review of adolescent-focused asthma management apps indicated a positive effect on asthma control, self-efficacy and medication adherence, although sample sizes of included studies were small and there was a noted lack of control trials included in the review.
Neighborhood Telemedicine Model
In these models, digital health technologies are used to connect community-based services. One example of such a model was conducted in inner-city areas of Rochester, NY where telemedicine sites were set up in childcare settings, schools and neighborhoods (via health workers with portable telemedicine units) to more effectively connect families to primary care instead of the emergency department. Again, the most common diagnoses were acute upper respiratory infections and again, parents were highly satisfied with the models, primarily for the convenience the model afforded. We can imagine using portable telemedicine units in a different iteration of the Kitchen Table Clinic model we co-designed, described in a previous blog post.
Digital health technologies show promise in pediatric health care delivery, although the field would benefit from a stronger evidence base. Additionally, as the WHO guidelines state, considerations regarding implementation including strategy, investment and resourcing, policies around standards and interoperability, infrastructure assessment, compliance, services and application, and workforce need to be well defined and operationalized. The American Academy of Pediatrics provides a variety of resources to assist providers and systems in thinking through many of these issues.
Learn more about how Genesis Health Consulting can help your health system think through implementation context by emailing us at firstname.lastname@example.org