Potential of Telemedicine in Pediatric Primary Care - Pediatrics in ...

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Potential of Telemedicine in Pediatric Primary Care Kenneth M.

Introduction

McConnochie, MD, MPH*

Invalidating assumptions about space and time, telemedicine holds profound implications for health care. Much about the current structure and organization of health services reflects the assumption that patient and clinician must be in the same place at the same time. Yet telemedicine commonly eliminates geography as a barrier to access, and much exchange of information need not occur synchronously. The potential for specific telemedicine applications to enable quality health care has been demonstrated using commercially available technology. The opportunity for children, families, and primary care pediatricians to gain from the access and effectiveness proffered by telemedicine hinges on its acceptance and adoption in the health-care system. Adoption, in turn, depends on successful organizational innovation, especially reimbursement from insurance organizations. This discussion emphasizes the potential benefits of telemedicine in primary care pediatric practice and the challenge of integrating this tool into that setting. In our view, the greatest promise for benefiting children and families lies in integrating telemedicine into primary care. Telemedicine is defined by the American Telemedicine Association (ATA) as “the use of medical information exchanged from one site to another via electronic communications for the health and education of the patient or healthcare provider and for the purpose of improving patient care.” Although encompassing many applications beyond our purview (eg, teledermatology, telepathology, educational teleconferences, telecardiology, telemental health, virtual critical care units), (1) this broad definition is notable from the perspective of the primary care pediatrician because it rightfully includes practice via telephone. From a clinical perspective, telephone practice and more advanced forms of telemedicine are close kin because a required competency for both is the ability to judge whether available information is sufficient for diagnosis and management. As in telephone practice, the need to refer to a traditional, in-person care setting for hands-on, laboratory, or imaging evaluation is always a consideration. Experience with telephone practice provides valuable preparation for meeting the demands of other forms of telemedicine. Although the ATA definition seems sensible from a clinical perspective, other definitions may be needed for organizational, reimbursement, or regulatory purposes. Definitions may be central to specifying the services to be reimbursed by insurance, determining which services are included within existing grant and loan programs, and identifying services affected by state medical licensure laws. Telemedicine-related service and product vendors need definitions to identify the current and future market. Definitions may help medical centers determine which department(s) (eg, information services versus clinical departments) control and support telemedicine. Despite the need for operational definitions, with the exponential growth of digital sensing devices that enhance the quality of diagnostic information and the advent of remote intervention techniques, the only common thread remaining among the broad range of imaginable activities labeled telemedicine will soon be physical distance between the patient and the clinician. We expect that the geographic distance distinguishing telemedicine and other medical practice modalities eventually will become unimportant to patients and practitioners alike. Internet-based videoconferencing, already inexpensive and widely available for personal use, should hasten acceptance of this medium for patientpractitioner communication. Acquisition, storage, transmission, retrieval, and remote display of digital radiographic images already has become so commonplace that the distinction between radiology and teleradiology seems meaningless.

Author Disclosure Dr McConnochie holds an equity position in TeleAtrics, Inc, a vendor of telemedicine equipment, hosting, and support services. Readers are encouraged to view the many images that accompany this article (see links in the Table of Contents).

*Professor of Pediatrics and Director, Health-e-Access Telemedicine Program, The University of Rochester School of Medicine & Dentistry, Rochester, NY. e58 Pediatrics in Review Vol.27 No.9 September 2006

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Telemedicine Stories Consider the dilemma confronting Lakeisha, a 26-yearold single mother busy at her welfare-to-work assembly line job, when she receives a call from child care to pick up her 14-month-old son Roberto. He has been coughing for 2 weeks. His child care teacher has brought the cough to Lakeisha’s attention before, but this afternoon the boy has been fussy, and his temperature is 100.4°F (38°C). She tells Lakeisha that she must pick him up from school and that he cannot return without a physician’s documented approval. The mother has already missed 5 days of work this winter because of Roberto’s illnesses. Each hour off the assembly line means an hour’s less pay. After her last lost work day, Lakeisha’s supervisor told her that he could not keep her if she missed another day, regardless of the reason. The only way to have Roberto seen today is via an emergency department (ED) visit, which requires taking two buses in both directions and a total of at least 6 hours. She knows that it is not an emergency, that to ED staff she’ll just be “the overanxious young mom who has the cute baby,” and that her other two children need her at home this evening. However, the ED is her only choice if she is to keep the job she desperately needs to improve her family’s circumstances. Consider also the dilemma confronting John and Ellen when Sally, their 3-year-old, appears in their bedroom at 5:00 AM, grimacing and holding her ear. Sally has had three ear infections already this winter, a cold these past 3 days, and a restless night, but no fever. John has a 7:00 AM flight to New York City, and Ellen has a career-defining presentation scheduled at 9:00 AM. Does a parent bring Sally to her pediatrician this morning? If so, which one? Or, do both parents forge ahead in their careers, struggle with their guilt, and “take their chances” that ibuprofen will at least delay the dreaded call from child care until after Ellen has finished her presentation? Now consider how these stories might play out with child care centers participating in a telemedicine network that enables Roberto and Sally to be evaluated in child care by their own primary care physicians. At Roberto’s child care center, the telehealth assistant does not hesitate to call Lakeisha about her concern, knowing that the telemedicine link to Roberto’s doctor allows both quick access to care and peace of mind to mother and staff. Telemedicine allows the pediatrician in the office to see Roberto in child care as an alert, vigorous toddler, who is coughing frequently but in no distress, has normal tympanic membranes, and low-pitched, expiratory wheezes in all lung fields. The pediatrician can reassure the child

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care staff that the boy’s low-grade fever is due to a respiratory virus that poses no more threat to staff and other children than any cold virus. The physician can call in a prescription for albuterol and a “spacer” to be delivered to child care and instruct the telehealth assistant to administer the medication and to record lung sounds again 30 minutes thereafter. About 90 minutes later, the physician notes in passing the computer monitor in his office that Roberto’s lung sounds are in the telemedicine “waiting room.” In 2 minutes, he determines that the boy’s lungs are now clear. A call to the telehealth assistant confirms that his cough has just about disappeared, and Roberto is back at play. Lakeisha, the telehealth assistant, and the pediatrician are gratified in sharing the news. With telemedicine, the near-panic of Sally’s parents is allayed by the realization that Sally can be checked out by her pediatrician from the office when Ellen drops her off at child care at 8:00 AM as usual. If Sally has an ear infection, as expected, the antibiotic can be called in to a pharmacy for delivery to child care. Treatment will begin as quickly as if they had an office appointment that morning. Child care staff should be comfortable keeping Sally, once they know her mild fussiness is due to an ear infection that is being treated. If later in the day, despite antibiotic and ibuprofen, Sally feels miserable and requires more care than child care staff can provide or she simply needs a parent, Ellen can pick her up, knowing her daughter already has been seen by her pediatrician and treatment was started as soon as possible.

Working Telemedicine Models Substantial experience supports the feasibility of telemedicine services providing care for acute illness in child care and school settings. (2)(3)(4) Service in these settings may be most relevant to primary care pediatric practice because these sites represent a “home away from home” for almost all children, and common acute illness constitutes such a large proportion of general pediatrics. Children younger than 15 years of age in the United States make an estimated 71 million office visits annually for acute problems. (5) These visits account for 48.8% of all office visits for children and 30.0% of office visits for individuals of any age. (5) Our experience has involved more than 3,500 telemedicine visits, predominantly in urban child care, but now including both urban and suburban elementary schools and suburban child care. Through this experience, we have developed a model to allow physicians and nurse practitioners to make the decisions needed to manage most acute illnesses arising in these settings. Pediatrics in Review Vol.27 No.9 September 2006 e59

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Both real-time interactive and store-and-forward telemedicine are practiced. After a problem is identified by parents or school or child care staff, trained on-site personnel (telehealth assistants) collect information about the present illness and past medical history. The assistants complete electronic medical history forms that are tailored to evaluate illness in school-age and preschool-age children and acquire still images, video clips, and audio files. Saved via secure Internet connection on a central server, these data become accessible to clinicians in remote locations. Storeand-forward “feeds” include digitized input from an electronic stethoscope and an all-purpose digital camera that captures ear canal, tympanic membrane, nose, throat, eye, and skin images. Store-and-forward material is supplemented by the clinician with real-time close-up video and additional history obtained through video conference interaction or telephone conversations with telehealth assistants, child care or school staff, or parents. When indicated, clinicians call in prescriptions to a pharmacy that frequently delivers to the child care site. The telehealth assistant receives 2 weeks of didactic instruction and hands-on training, followed by an 8-week, on-the-job internship, in which proficiency must be demonstrated. The value of real-time observation and interaction warrants emphasis. The ability to observe the child’s behavior directly offers numerous clinical advantages. Observations of activity level, social interactions, and respiratory patterns may be vital in assessing illness severity. Sometimes, clinicians use real-time interaction to guide telehealth assistants in obtaining more useful images or video clips. Moreover, real-time interaction promotes acceptance by clinicians, parents, and staff by making the telehealth process feel similar to an in-person office visit. Real-time video interaction adds facial expression and body language to the communication process, enhancing the potential for effective exchange beyond voice communication. Considerations of availability, function, security, quality, and cost led us to use an integrated, Internetbased telemedicine system that does not require “bandwidth” beyond that available through consumer-class digital subscriber line or cable modem. A fully integrated system, in which a single Internet-based software application handles videoconferencing and capture, storage, and retrieval of text, image, video, and audio files, seems essential for integrating this new technology into a busy primary care office. Use of the Internet ensures widespread availability at relatively low cost. Technical details e60 Pediatrics in Review Vol.27 No.9 September 2006

of a system that meets these specifications are beyond the scope of this article but are available. (6) The purpose of this model is to allow health care when and where patients/parents feel they need it by people they know and trust. Services are available in a child’s “home away from home” whenever health problems arise. People providing services include staff known well by children and trusted primary care clinicians.

Value of Telemedicine to Children and Families Fewer than 50% of working women in the United States believe that they can avoid conflict between family and work responsibilities the next time one of their children is sick. (7) Consistent with these findings, 40% of work absences among parents who have preschool-age children is attributed to a child’s illness. (8) Clearly, the social and economic burden associated with each child’s absence from child care or school may be substantial. Stories similar to those of Roberto and Sally play out daily for many families. Many child care and school absences resulting from illness are unnecessary. In the view of the American Academy of Pediatrics (AAP), “Exclusion [from school] is necessary when a student’s illness requires a greater degree of observation or care than school staff can safely provide, precludes any benefit of attending class because of inability to focus and learn, or poses a threat to the health or safety of others. Relatively few illnesses mandate exclusion from school.” (9) The level of observation that staff can provide safely and the ability of the child to benefit from attending class represent judgments that seem most appropriately left to parents and staff. Training, experience, and professional stature require the physician, however, to determine whether the illness poses a threat to the health and safety of others. Much absence due to illness occurs because the child must leave school or child care to enable the physician to provide safety certification, that is, to provide credible professional judgment that the incremental threat posed to others by the continued participation of an ill child is minimal. Our experience with telemedicine in child care strongly supports the AAP opinion that many absences due to illness are unnecessary and suggests that telemedicine plays a powerful role in reducing these absences. We studied absence due to illness (ADI) in Rochester, NY, for an 18-month period beginning January 1, 2001, by using a before-and-after design, with historical and concurrent controls, (3) in five inner-city child care centers that had an average enrollment of 138 children. ADI during weeks with telemedicine (4.07 absences/100

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child-days) was less than half that during weeks without telemedicine (8.78 absences/100 child-days). After adjusting for potentially confounding variables in multivariate analysis, telemedicine remained the strongest predictor of ADI. A 63% reduction in ADI was attributable to telemedicine, an effect similar to the 59% variation in ADI with season of the year. For the 940 telemedicine encounters that occurred during this study, clinicians recommended exclusion from child care for 7.0% and in-person visits for 2.8%. In surveys, parents indicated that 91.2% of telemedicine contacts allowed them to stay at work and that 93.8% of problems managed by telemedicine would otherwise have led to an office or ED visit. Plausible mechanisms for the large impact of this telemedicine program on ADI include the capacity of the system to: 1) provide information that enabled the telemedicine clinician to be confident of diagnosis and management decisions in all but 2.8% of visits, 2) enable on-the-spot safety certification, 3) facilitate early diagnosis and treatment, and 4) promote collaboration and trust among parents and staff. On-site telemedicine promotes collaboration and trust because it enables child care staff and parents to work together to find solutions to the problems posed by illness. Child care staff report that parents bring health problems to their attention rather than hiding them with antipyretics, turtleneck shirts, and long sleeves. Consistent with these reports, 55% of telemedicine contacts have been initiated because of concerns raised by parents.

Value of Telemedicine to Clinicians Beyond the satisfaction of providing more accessible care, telemedicine offers many benefits to primary care clinicians. We use the term optimized telemedicine for information technology designed to meet the needs of a busy primary care clinician. This term represents an ideal that is easier to conceptualize than achieve. Telemedicine is a new field in the “information age,” and information technology evolves rapidly. An essential feature of optimized telemedicine is full integration into the electronic medical record (EMR). The information already gathered in digital format for telemedicine can be stored and retrieved easily in the patient’s EMR. From the perspective of clinicians already using EMRs, distinction between telemedicine and EMR technology seems arbitrary. Telemedicine, arguably, is an EMR that has enhanced information capture, exchange, distribution, and retrieval capacity. Clinical and administrative benefits of EMRs, as well as many of the pitfalls and barriers to implementation of EMRs, (10)(11)(12)

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apply to optimized telemedicine, as well. Quality assurance initiatives, which gain a powerful tool in EMRs through aggregating information, could be enhanced further through retrieval of actual observations. Examples of diagnostic-quality visual and auditory information included in the data supplement that accompanies this article demonstrates the potential of telemedicine records for this use. Optimized telemedicine might improve the efficiency of primary care office operations. It has been said that the dimension of time was invented to prevent everything from happening at once, but clinicians in a busy office practice may wonder whether time really works this way; sometimes, everything does happen at once. As with e-mail, some of the value of telemedicine in primary care may be increased flexibility and control by the clinician over the timing of encounters because asynchronous information exchange (as opposed to real-time, or synchronous, exchange) often is acceptable. For the clinician, there is less pressure to complete a telemedicine visit at a specific time than an in-person encounter. Usually, this also benefits the child’s caretakers. Child care programs and schools expect to care for the child for a period of several hours, and although the presence of a health problem may influence staff attitudes, no great sense of urgency usually exists. The telemedicine clinician is notified of a request for a telemedicine visit. Information regarding the child and problem is placed in the child’s record by the telehealth assistant. The clinician can access this information from a personal computer when time permits. Perusal of information accessed through the virtual waiting room, which usually requires less than 2 minutes of the clinician’s time, allows him or her to determine whether text, image, audio clips, and video clips already obtained will allow completion of the visit or whether additional information is desired. The clinician may obtain additional information through a real-time videoconference that includes the child or through additional store-and-forward files. Some clinicians prefer to include the real-time videoconference as a standard component of the telemedicine visit, although this practice diminishes flexibility and the opportunity for the clinician to fit the telemedicine visit into a “free moment.” When the child’s problem is straightforward, and the telehealth assistant can provide high-quality information, evaluation time usually is less than 5 minutes. Efficiency also is enhanced by the opportunity to move on to other activities while waiting for information needed to complete a visit. The clinician can move from one telemedicine patient to another with the click of a mouse. Pediatrics in Review Vol.27 No.9 September 2006 e61

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The ease of next-day follow-up is especially satisfying. To enable next-day assessment of an ear problem or a rash, for example, the family simply follows regular routines for transport to child care or school. The “watchful waiting” approach to management of acute otitis media that is not severe seems more acceptable to both parents and clinicians when telemedicine is available. Finally, substituting telemedicine for in-person office visits conserves office resources. Office staff time, parking facilities, waiting area, and examination rooms are not involved. Patient check-in and preparation are eliminated. Time-consuming procedures, such as cerumen removal or fever reduction, have no impact on scarce office resources. Telemedicine may offer another advantage over inperson care because fixed images or video clips provide higher quality clinical observations than those obtained in person. Change over time is assessed readily by comparing images from different times. Tympanic membrane examination using video clips may be more informative than fixed images because the value of fixed images depends on field of view, lighting, and focus at one instant. A 10-second video clip includes a large number of frames, much improving the odds that optimal field of view, lighting, and focus will be achieved despite obstacles introduced by cerumen, narrow or tortuous ear canals, or movement of a struggling child. Ear images and video clips in the data supplement especially illustrate these points. It also is possible that in-office care some day might incorporate some of the technology used in telemedicine to improve performance.

Challenges to the Adoption of Telemedicine by Primary Care Pediatricians Although substantial challenges confront efforts to adopt and integrate telemedicine into primary care practice, we believe these challenges are worthy of attack. It makes sense for the same practice providing well child and illness care for a family through office visits and telephone consultation to care for illness via telemedicine. Advantages of care in the primary care medical home are discussed elsewhere in depth. (13)(14) Resolve to address challenges may be fortified by recognition that technical barriers to health care from great distances via telemedicine are minor. Threats to the primary care medical home posed by urgent care centers might prove trivial when compared with those of out-of-state or international telemedicine clinicians. The telehealth assistant plays an essential role in the successful telemedicine visit. Much or all of the information about the child’s condition is elicited by the assise62 Pediatrics in Review Vol.27 No.9 September 2006

tant. Information provided to parents by the clinician about the child may be imparted by the assistant. Although telephone contact between parent and clinician generally is possible for the 80% of telemedicine visits in which the parent is not present, usually neither parent nor clinician has felt this contact to be necessary. Thus, telemedicine visits may reduce demands not just on office resources but on the parent’s and the clinician’s time. Change also presents challenges. The clinician loses direct control over processes and resources critical to completion of a visit. Telehealth assistants represent an essential resource that must be shared among multiple practices because children served by a specific child site often are served by many different clinicians. Sharing critical resources raises issues. First, because the telehealth assistant is essential to providing the service and replaces office resources, should some reimbursement for the service, presently going entirely to the physician’s office, be allocated toward the telehealth assistant’s salary? Second, how do independent office practices share this vital resource? Can the telehealth assistant be expected to vary procedures to meet different preferences of different practices? Finally, how does visit volume figure in determining payment for services of the telehealth assistant? The telehealth assistant is positioned to influence demand for visits, which might be considered in plans to pay for services of the assistant. Dependence on the telehealth assistant also may present psychological challenges. Clinicians in primary care customarily acquire most clinical information directly. Relying on the telehealth assistant for acquisition of important information adds an unfamiliar source of uncertainty to practice. The clinician may wonder whether a better tympanic membrane image might be obtained, what a rash might look or feel like in person, or whether in-office cerumen removal is important. Although forced to wrestle with such new questions, solace may be gained from knowing that even the simple telemedicine model we have described allows the clinician to acquire much more information than usual telephone practice. Managing uncertainty is fundamental to all medical practice, whether information is acquired in person, by telephone, or via telemedicine. In assessing uncertainty, clinicians should consider the quality and completeness of available information as well as their ability to synthesize data and the current state of medical knowledge. When clinicians settle on a diagnosis, they decide implicitly that the likelihood of an alternative diagnosis is either too small or that alternatives are sufficiently unimportant to justify additional diagnostic evaluation. Although

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managing uncertainty initially may feel different when practicing telemedicine, the challenge is fundamentally the same. Technical challenges also exist. The clinician’s requirement for a dependable system that can be integrated efficiently into office routines demands specifications and technical support with the authority and capability to trouble-shoot throughout the system, that is, with knowledge and access to hardware, software, firewalls, and connectivity solutions.

Challenges for the Health-care System in the Adoption of Telemedicine The concept of disruptive innovation provides a framework for understanding system-wide challenges to adoption. Disruptive innovations, defined as “cheaper, simpler, more convenient products and services that start by meeting the needs of less demanding customers,” have been recommended by Christensen and colleagues (15) as a “cure” for the ailing United States health-care system. The telemedicine model fits this definition well. The “less demanding customers” it serves are the many children who have relatively minor, common, acute problems and do not need an ED, after-hours urgent care center, or even in-person office visit, where they are seen currently. They do not need the capacity of the ED to intervene in crises, and they usually do not need the hands-on care, laboratory testing, and advanced imaging available in the office or urgent care center. Telemedicine is simpler and more convenient for the family because costs of transportation and time are markedly reduced. In part because of reduced absence due to illness, it appears that the model should reduce costs from a societal perspective. No definitive study addresses the more narrow question of impact on health-care costs, although the capacity to replace nonurgent ED visits, costing about seven times more than telemedicine visits, suggests that health-care cost reduction also may be anticipated. Considering the far-reaching implications of telemedicine for distribution of health-care resources, it is hard to imagine that cost savings will not accrue simply from reduced costs to supply professional expertise and reduced costs for patients to access care. In adopting this process, challenges posed by disruption counter the allure of cheaper, simpler, and more convenient. Pivotal requirements for the development of telemedicine in primary care include the following: new skills and roles among physicians, nurses, and other health-care workers; new organizational relationships among educational and care organizations for children (schools, child care, developmental centers, group

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homes), health-care providers, and technology support organizations; reassurance of clinicians and participating organizations about liability concerns; and appropriate reimbursement for telemedicine service and mechanisms for distributing revenue for these services that reasonably reflect the value added by all who contribute to their supply. These requirements for adopting telemedicine disrupt existing, expected, and even entrenched operational procedures. As with any tool, there is a potential for misuse of telemedicine. The most commonly raised concerns are that communication might be deficient and that parents might abuse the service by sending ill children to child care who should not be there. This potential for misuse can be addressed through intelligent design and thoughtful application of telemedicine models. Rather than imposing a cold, impersonal process, telemedicine might enhance communication and continuity of care through ready access to the child’s primary care clinician via real-time videoconference. Telemedicine can enable care when and where children need it by clinicians whom families know and trust. Whether it does depends on how physicians decide to use this tool. With telemedicine enabling professional safety certification and reduced absence due to illness, parents can conserve workplace sick days for times that a child really needs to be home with a parent. With telemedicine available, they may feel less pressure to send children to school inappropriately. For children and families to gain the potential benefits of telemedicine, clinicians also must meet psychological and organizational challenges, such as by negotiating agreements to share essential telemedicine resources. As well-intentioned, influential, creative problem-solving professionals, we expect that most clinicians will adopt telemedicine systems that are optimized to fit office workflow if demand exists and reimbursement is appropriate. Sufficient demand requires deployment of a sufficient number of telemedicine units to child care sites, schools, and similar sites. Because of their “power of the purse,” public and private insurance organizations dominate decisions enabling major health system innovations, determining whether appropriate reimbursement will be provided. Although their influence is prodigious, insurance organizations ultimately work for those who pay premiums and taxes. Sustainability and expansion, the decisive challenges to telemedicine services, can be met if the industries and individuals who ultimately pay for health care recognize telemedicine’s potential and require reimbursement. Reimbursement for services delivered via telemedicine Pediatrics in Review Vol.27 No.9 September 2006 e63

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is evolving rapidly and varies widely among geographic areas and insurance organizations. In 2005, Medicaid reimbursed for some form of telemedicine in 23 states, and four more states were planning to reimburse. (16) State-to-state coverage varies with diagnoses and procedures, clinician type (physician, nurse practitioners, physician’s assistant, occupational or physical therapist), site (patient, physician, consultant), and interaction (realtime versus store-and-forward). Billing and coding conventions and licensure issues also vary. Several commercial health insurance organizations reimburse telemedicine nationwide. In some states (eg, California, Texas, Oklahoma), legislatures have mandated reimbursement for a broad range of telemedicine activities. (17) The AAP resolved in 2004 that “the Academy encourage private and government third-party reimbursement for telemedicine.” (18) Organizations such as the Center for Telehealth and E-Health Law play an important role in promoting the adoption of telemedicine by the health-care system.

Summary and Conclusions Telemedicine virtually eliminates geography as a barrier to access to health care because it does not require patient and clinician to be in the same place at the same time. Telemedicine models using commercially available technology have enabled high-quality illness care in pediatric primary care settings and markedly improved access. More equitable distribution of health services is a likely result. Potential for children, families, and primary care pediatricians to gain from the access and effectiveness proffered by telemedicine hinges on acceptance by physicians and adoption in the health-care system. Significant organizational and psychological barriers to physician acceptance exist. Health system adoption, in turn, depends on successful organizational innovation and reimbursement from insurance organizations.

References 1. Office for the Advancement of Telemedicine. Dramatic Consultations Using Telemedicine. Washington, DC: Health Resources and Services Administration; December 2003. Available at: http:// telehealth.hrsa.gov/grants/success.htm#reach

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2. Whitten P, Cook DJ, Shaw P, Ermer D, Goodwin J. TelekidCare: bringing health care into schools. Telemed J. 1998;4:335–343

3. Young TL, Ireson C. Effectiveness of school-based telehealth care in urban and rural elementary schools. Pediatrics. 2003;112: 1088 –1094 4. McConnochie KM, Wood NE, Kitzman HJ, Herendeen NE, Roy J, Roghmann KJ. Telemedicine reduces absence resulting from illness in urban child care: evaluation of an innovation. Pediatrics. 2005;115:1273–1282 5. Cherry DK, Burt CW, Woodwell DA. National Ambulatory Medical Care Survey: 2001 summary. Advance Data From Vital and Health Statistics. No. 337. Hyattsville, Md: United States Department of Health and Human Services; 2003. Available at: http://www.cdc.gov/nchs/data/ad/ad337.pdf 6. TeleActrics Web page. Available at: http://www.teleatrics. com/index.html 7. Wyn R, Ojeda V, Ranji U, Salganicoff A. Women, work and family health: a balancing act. Issue Brief. Menlo Park, Calif: Kaiser Family Foundation; 2003 8. Bell DM, Gleiber DW, Mercer AA, et al. Illness associated with child day care: a study of incidence and cost. Comparison with day care homes and households. Am J Public Health. 1989;79: 479 – 484 9. American Academy of Pediatrics. School Health Policy and Practice. 6th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2004:34 10. Hillestad R, Bigelow J, Bower A, et al. Can electronic medical record systems transform health care? Potential health benefits, savings, and costs. Health Affairs. 2005;24:1104 –1117 11. Himmelstein DU, Woolhandler S. Hope and hype: predicting the impact of electronic medical records. Health Affairs. 2005;24: 1121–1123 12. Bates D. Physicians and ambulatory electronic health records. Health Affairs. 2005;24:1180 –1189 13. Starfield B. Effectiveness of Medical Care: Validating Clinical Wisdom. Baltimore, Md: Johns Hopkins University Press; 1985 14. Shi L, Starfield B, Politzer R, Regan J. Primary care, self-rated health, and reductions in social disparities in health. Health Serv Res. 2002;37:529 –550 15. Christensen CM, Bohmer R, Kenagy J. Will disruptive innovations cure health care? Harv Bus Rev. 2000;78:102–112 16. Youngblade L, Malasanos T, Shenkman EA, et al. Telemedicine for CSHCN: A State-by-State Comparison of Medicaid Reimbursement Policies and Title V Activities. Technical Report. Gainesville, Fla: Institute for Child Health Policy, University of Florida; 2005 17. National Conference of State Legislatures. Telemedicine Legislation. Updated September 2005. Available at: http://www.ncsl. org/programs/health/teleleg.htm 18. American Academy of Pediatrics. Resolution #21, (04)-2004 Annual Leadership Forum. Telemedicine in Pediatric Primary Care. 2004

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Updated References Following are updated references for the In Brief on The Female Athlete Triad that appeared online in the January 2006 issue of PIR on page e12. Medical Concerns in the Female Athlete. American Academy of Pediatrics Committee on Sports Medicine and Fitness. Pediatrics. 2000;106:610 – 613 Female Athlete Triad. Birch K. BMJ. 2005;330:244 –246 The Female Athlete Triad. Otis CL, Drinkwater B, Johnson M, et al. American College of Sports Medicine position stand. Med Sci Sports Exerc. 1997;29:i–ix Preparticipation Physical Examination: Selected Issues for the Female Athlete. Rumball JS, Lebrun CM. Clin J Sport Med. 2004;14:153–160

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