Abstract
The regionalization of pediatric services has resulted in differential access to care, sometimes creating barriers to those living in underserved, rural communities. These disparities in access contribute to inferior healthcare outcomes among infants and children. We review the medical literature on telemedicine and its use to improve access and the quality of care provided to pediatric patients with otherwise limited access to pediatric subspecialty care. We review the use of telemedicine for the provision of pediatric subspecialty consultations in the settings of ambulatory care, acute and inpatient care, and perinatal and newborn care. Studies demonstrate the feasibility and efficiencies gained with models of care that use telemedicine. By providing pediatric subspecialty care in more convenient settings such as local primary care offices and community hospitals, pediatric patients are more likely to receive care that adheres to evidence-based guidelines. In many cases, telemedicine can significantly improve provider, patient, and family satisfaction, increase measures of quality of care and patient safety, and reduce overall costs of care. Models of care that use telemedicine have the potential to address pediatric specialists’ geographic misdistribution and address disparities in the quality of care delivered to children in underserved communities.
Similar content being viewed by others
Log in or create a free account to read this content
Gain free access to this article, as well as selected content from this journal and more on nature.com
or
References
Randolph GD, Pathman DE. Trends in the rural-urban distribution of general pediatricians. Pediatrics 2001;107:E18.
Basco WT, Rimsza ME ; Committee on Pediatric Workforce; American Academy of Pediatrics. Pediatrician workforce policy statement. Pediatrics 2013;132:390–7.
Pletcher BA, Rimsza ME, Cull WL, Shipman SA, Shugerman RP, O’Connor KG. Primary care pediatricians’ satisfaction with subspecialty care, perceived supply, and barriers to care. J Pediatr 2010;156:1011–5, 1015.e1.
Skinner AC, Slifkin RT. Rural/urban differences in barriers to and burden of care for children with special health care needs. J Rural Health 2007;23:150–7.
Johnson WG, Rimsza ME. The effects of access to pediatric care and insurance coverage on emergency department utilization. Pediatrics 2004;113:483–7.
Ray KN, Bogen DL, Bertolet M, Forrest CB, Mehrotra A. Supply and utilization of pediatric subspecialists in the United States. Pediatrics 2014;133:1061–9.
Marcin JP, Ellis J, Mawis R, Nagrampa E, Nesbitt TS, Dimand RJ. Using telemedicine to provide pediatric subspecialty care to children with special health care needs in an underserved rural community. Pediatrics 2004;113:1–6.
Herendeen N, Deshpande P. Telemedicine and the patient-centered medical home. Pediatr Ann 2014;43:e28–32.
McConnochie KM, Conners GP, Brayer AF, et al. Effectiveness of telemedicine in replacing in-person evaluation for acute childhood illness in office settings. Telemed J E Health 2006;12:308–16.
Uscher-Pines L, Mehrotra A. Analysis of Teladoc use seems to indicate expanded access to care for patients without prior connection to a provider. Health Aff (Millwood) 2014;33:258–64.
McConnochie KM. Potential of telemedicine in pediatric primary care. Pediatr Rev 2006;27:e58–65.
McConnochie KM, Wood NE, Herendeen NE, ten Hoopen CB, Roghmann KJ. Telemedicine in urban and suburban childcare and elementary schools lightens family burdens. Telemed J E Health 2010;16:533–42.
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;115:1273–82.
Institute of Medicine. Telemedicine: A Guide to Assessing Telecommunications for Health Care. Washington, D.C.: Natinoal Academy Press, 1996.
Marcin J, Ellis J, Mawis R, Nagrampa E, Nesbitt T, Dimand R. Telemedicine and the medical home: providing pediatric subspecialty care to children with special health care needs in an underserved rural community. Pediatrics 2003;113:1–6.
Marcin JP, Trujano J, Sadorra C, Dharmar M. Telemedicine in rural pediatric care: the fundamentals. Pediatr Ann 2009;38:224–6.
Farmer JE, Muhlenbruck L. Telehealth for children with special health care needs: promoting comprehensive systems of care. Clin Pediatr (Phila) 2001;40:93–8.
Karp WB, Grigsby RK, McSwiggan-Hardin M, et al. Use of telemedicine for children with special health care needs. Pediatrics 2000;105:843–7.
Hilt RJ, Barclay RP, Bush J, Stout B, Anderson N, Wignall JR. A statewide child telepsychiatry consult system yields desired health system changes and savings. Telemed J E Health 2015;21:533–7.
Webb CL, Waugh CL, Grigsby J, et al.; American Society of Echocardiography Telemedicine Collaborators’ Group. Impact of telemedicine on hospital transport, length of stay, and medical outcomes in infants with suspected heart disease: a multicenter study. J Am Soc Echocardiogr 2013;26:1090–8.
Sable C. Telemedicine applications in pediatric cardiology. Minerva Pediatr 2003;55:1–13.
Sable C. Digital echocardiography and telemedicine applications in pediatric cardiology. Pediatr Cardiol 2002;23:358–69.
Philp JC, Frieden IJ, Cordoro KM. Pediatric teledermatology consultations: relationship between provided data and diagnosis. Pediatr Dermatol 2013;30:561–7.
Fogel AL, Teng JM. Pediatric teledermatology: a survey of usage, perspectives, and practice. Pediatr Dermatol 2015;32:363–8.
Fierson WM, Capone A Jr ; American Academy of Pediatrics Section on Ophthalmology; American Academy of Ophthalmology, American Association of Certified Orthoptists. Telemedicine for evaluation of retinopathy of prematurity. Pediatrics 2015;135:e238–54.
Chan DS, Callahan CW, Hatch-Pigott VB, et al. Internet-based home monitoring and education of children with asthma is comparable to ideal office-based care: results of a 1-year asthma in-home monitoring trial. Pediatrics 2007;119:569–78.
Recupero A, Mahnke B, Pinsker JE. Emerging technology in diabetes care: the real-time diabetes monitoring system. Mil Med 2013;178:218–21.
Shaikh U, Cole SL, Marcin JP, Nesbitt TS. Clinical management and patient outcomes among children and adolescents receiving telemedicine consultations for obesity. Telemed J E Health 2008;14:434–40.
Herendeen NE, Schaefer GB. Practical applications of telemedicine for pediatricians. Pediatr Ann 2009;38:567–9.
McSwain SD, Marcin JP. Telemedicine for the care of children in the hospital setting. Pediatr Ann 2014;43:e44–9.
North SW, McElligot J, Douglas G, Martin A. Improving access to care through the patient-centered medical home. Pediatr Ann 2014;43:e33–8.
Dower C, McRee T, Grumbach K, et al. The Practice of Medicine in California: A Profile of the Physician Workforce. San Francisco, CA: California Workforce Initiative at the UCSF Center for the Health Professions, 2001.
Merwin E, Snyder A, Katz E. Differential access to quality rural healthcare: professional and policy challenges. Fam Community Health 2006;29:186–94.
Cull WL, Chang CH, Goodman DC. Where do graduating pediatric residents seek practice positions? Ambul Pediatr 2005;5:228–34.
Hartley D. Rural health disparities, population health, and rural culture. Am J Public Health 2004;94:1675–8.
Eberhardt M, Ingram D, Makuc D. Health, United States, 2001. Urban and Rural Health Chartbook. Hyattsville, MD: National Center for Health Statistics, 2001.
Eberhardt MS, Pamuk ER. The importance of place of residence: examining health in rural and nonrural areas. Am J Public Health 2004;94:1682–6.
US Department of Health and Human Services - Health Resources and Services Administration - Maternal and Child Health Bureau. The Health and Well-Being of Children in Rural Areas: A Portrait of the Nation. Rockville, MD: US Department of Health and Human Services, 2005.
Levey LM, Curry JP, Levey S. Rural-urban differences in access to Iowa child health services. J Rural Health 1988;4:59–72.
Saywell RM Jr, Zollinger TW, Schafer ME, Schmit TM, Ladd JK. Children with special health care needs program: urban/rural comparisons. J Rural Health 1993;9:314–25.
Bolin JN, Bellamy GR, Ferdinand AO, et al. Rural healthy people 2020: new decade, same challenges. J Rural Health 2015;31:326–33.
U.S. Department of Health and Human Services. Detailed Health Professional Shortage Area (HPSA) Report for Primary Medical Care, 2015. (http://datawarehouse.hrsa.gov/HGDWReports/RT_App.aspx?rpt=H1).
Anderson EA, Bergeron D, Crouse BJ. Recruitment of family physicians in rural practice. Minn Med 1994;77:29–32.
Conte SJ, Imershein AW, Magill MK. Rural community and physician perspectives on resource factors affecting physician retention. J Rural Health 1992;8:185–96.
Callahan EJ, Hilty DM, Nesbitt TS. Patient satisfaction with telemedicine consultation in primary care: comparison of ratings of medical and mental health applications. Telemed J 1998;4:363–9.
Pacht ER, Turner JW, Gailiun M, et al. Effectiveness of telemedicine in the outpatient pulmonary clinic. Telemed J 1998;4:287–92.
Marcin JP, Nesbitt TS, Cole SL, et al. Changes in diagnosis, treatment, and clinical improvement among patients receiving telemedicine consultations. Telemed J E Health 2005;11:36–43.
Pesämaa L, Ebeling H, Kuusimäki ML, Winblad I, Isohanni M, Moilanen I. Videoconferencing in child and adolescent telepsychiatry: a systematic review of the literature. J Telemed Telecare 2004;10:187–92.
Kumar S, Tay-Kearney ML, Chaves F, Constable IJ, Yogesan K. Remote ophthalmology services: cost comparison of telemedicine and alternative service delivery options. J Telemed Telecare 2006;12:19–22.
Samii A, Ryan-Dykes P, Tsukuda RA, Zink C, Franks R, Nichol WP. Telemedicine for delivery of health care in Parkinson’s disease. J Telemed Telecare 2006;12:16–8.
Malasanos TH, Burlingame JB, Youngblade L, Patel BD, Muir AB. Improved access to subspecialist diabetes care by telemedicine: cost savings and care measures in the first two years of the FITE diabetes project. J Telemed Telecare 2005;11:Suppl 1:74–6.
McConnochie KM, Wood NE, Herendeen NE, et al. Acute illness care patterns change with use of telemedicine. Pediatrics 2009;123:e989–95.
Lamel S, Chambers CJ, Ratnarathorn M, Armstrong AW. Impact of live interactive teledermatology on diagnosis, disease management, and clinical outcomes. Arch Dermatol 2012;148:61–5.
Xu CQ, Smith AC, Scuffham PA, Wootton R. A cost minimisation analysis of a telepaediatric otolaryngology service. BMC Health Serv Res 2008;8:30.
Arora S, Thornton K, Murata G, et al. Outcomes of treatment for hepatitis C virus infection by primary care providers. N Engl J Med 2011;364:2199–207.
Arora S, Kalishman S, Dion D, et al. Partnering urban academic medical centers and rural primary care clinicians to provide complex chronic disease care. Health Aff (Millwood) 2011;30:1176–84.
Romano MJ, Hernandez J, Gaylor A, Howard S, Knox R. Improvement in asthma symptoms and quality of life in pediatric patients through specialty care delivered via telemedicine. Telemed J E Health 2001;7:281–6.
Izquierdo R, Morin PC, Bratt K, et al. School-centered telemedicine for children with type 1 diabetes mellitus. J Pediatr 2009;155:374–9.
Burrows E, Suh R, Hamann D. Health Care Workforce Distribution and Shortage Issues in Rural America 2012. (http://www.ruralhealthweb.org/index.cfm?objectid=3D776162-3048-651A-FEA70F1F09670B0D).
Shaikh U, Nettiksimmons J, Romano P. Pediatric obesity management in rural clinics in California and the role of telehealth in distance education. J Rural Health 2011;27:263–9.
Gagnon MP, Duplantie J, Fortin JP, Landry R. Implementing telehealth to support medical practice in rural/remote regions: what are the conditions for success? Implement Sci 2006;1:18.
US Institute of Medicine. Preventing Childhood Obesity - Health in the Balance. Washington, D.C.: US Institute of Medicine, 2005.
Shaikh U, Nettiksimmons J, Joseph JG, Tancredi D, Romano PS. Collaborative practice improvement for childhood obesity in rural clinics: the Healthy Eating Active Living Telehealth Community of Practice (HEALTH COP). Am J Med Qual 2014;29:467–75.
Brennan JA, Kealy JA, Gerardi LH, et al. Telemedicine in the emergency department: a randomized controlled trial. J Telemed Telecare 1999;5:18–22.
Kofos D, Pitetti R, Orr R, Thompson A. Telemedicine in pediatric transport: a feasibility study. Pediatrics 1998;102:E58.
Heath B, Salerno R, Hopkins A, Hertzig J, Caputo M. Pediatric critical care telemedicine in rural underserved emergency departments. Pediatr Crit Care Med 2009;10:588–91.
Meyer BC, Raman R, Hemmen T, et al. Efficacy of site-independent telemedicine in the STRokE DOC trial: a randomised, blinded, prospective study. Lancet Neurol 2008;7:787–95.
Demaerschalk BM, Raman R, Ernstrom K, Meyer BC. Efficacy of telemedicine for stroke: pooled analysis of the Stroke Team Remote Evaluation Using a Digital Observation Camera (STRokE DOC) and STRokE DOC Arizona telestroke trials. Telemed J E Health 2012;18:230–7.
Ellenby MS, Marcin JP. The role of telemedicine in pediatric critical care. Crit Care Clin 2015;31:275–90.
Uscher-Pines L, Kahn JM. Barriers and facilitators to pediatric emergency telemedicine in the United States. Telemed J E Health 2014;20:990–6.
Dharmar M, Marcin JP, Kuppermann N, et al. A new implicit review instrument for measuring quality of care delivered to pediatric patients in the emergency department. BMC Emerg Med 2007;7:13.
Dharmar M, Romano PS, Kuppermann N, et al. Impact of critical care telemedicine consultations on children in rural emergency departments. Crit Care Med 2013;41:2388–95.
Dharmar M, Kuppermann N, Romano PS, et al. Telemedicine consultations and medication errors in rural emergency departments. Pediatrics 2013;132:1090–7.
Yang NH, Dharmar M, Kuppermann N, et al. Appropriateness of disposition following telemedicine consultations in rural emergency departments. Pediatr Crit Care Med 2015;16:e59–64.
Wakefield DS, Ward M, Miller T, et al. Intensive care unit utilization and interhospital transfers as potential indicators of rural hospital quality. J Rural Health 2004;20:394–400.
Rosenberg DI, Moss MM ; American College of Critical Care Medicine of the Society of Critical Care Medicine. Guidelines and levels of care for pediatric intensive care units. Crit Care Med 2004;32:2117–27.
Walls TA, Chamberlain JM, Klein BL. Factors associated with emergency department discharge after pediatric interhospital transport: a role for outreach education? Pediatr Emerg Care 2015;31:10–4.
Merenstein D, Egleston B, Diener-West M. Lengths of stay and costs associated with children’s hospitals. Pediatrics 2005;115:839–44.
Odetola FO, Gebremariam A, Freed GL. Patient and hospital correlates of clinical outcomes and resource utilization in severe pediatric sepsis. Pediatrics 2007;119:487–94.
Gupta RS, Bewtra M, Prosser LA, Finkelstein JA. Predictors of hospital charges for children admitted with asthma. Ambul Pediatr 2006;6:15–20.
Dharmar M, Smith AC, Armfield NR, Trujano J, Sadorra C, Marcin JP. Telemedicine for children in need of intensive care. Pediatr Ann 2009;38:562–6.
Labarbera JM, Ellenby MS, Bouressa P, Burrell J, Flori HR, Marcin JP. The impact of telemedicine intensivist support and a pediatric hospitalist program on a community hospital. Telemed J E Health 2013;19:760–6.
Marcin JP. Telemedicine in the pediatric intensive care unit. Pediatr Clin North Am 2013;60:581–92.
Marcin JP, Schepps DE, Page KA, Struve SN, Nagrampa E, Dimand RJ. The use of telemedicine to provide pediatric critical care consultations to pediatric trauma patients admitted to a remote trauma intensive care unit: a preliminary report. Pediatr Crit Care Med 2004;5:251–6.
Marcin JP, Nesbitt TS, Kallas HJ, Struve SN, Traugott CA, Dimand RJ. Use of telemedicine to provide pediatric critical care inpatient consultations to underserved rural Northern California. J Pediatr 2004;144:375–80.
Reynolds HN, Rogove H, Bander J, McCambridge M, Cowboy E, Niemeier M. A working lexicon for the tele-intensive care unit: we need to define tele-intensive care unit to grow and understand it. Telemed J E Health 2011;17:773–83.
Lopez-Magallon AJ, Otero AV, Welchering N, et al. Patient outcomes of an international telepediatric cardiac critical care program. Telemed J E Health 2015;21:601–10.
Munoz RA, Burbano NH, Motoa MV, Santiago G, Klevemann M, Casilli J. Telemedicine in pediatric cardiac critical care. Telemed J E Health 2012;18:132–6.
Otero AV, Lopez-Magallon AJ, Jaimes D, et al. International telemedicine in pediatric cardiac critical care: a multicenter experience. Telemed J E Health 2014;20:619–25.
Ivey TL, Hughes D, Dajani NK, Magann EF. Antenatal management of at-risk pregnancies from a distance. Aust N Z J Obstet Gynaecol 2015;55:87–9.
Magann EF, Bronstein J, McKelvey SS, Wendel P, Smith DM, Lowery CL. Evolving trends in maternal fetal medicine referrals in a rural state using telemedicine. Arch Gynecol Obstet 2012;286:1383–92.
Krishnan A, Fuska M, Dixon R, Sable CA. The evolution of pediatric tele-echocardiography: 15-year experience of over 10,000 transmissions. Telemed J E Health 2014;20:681–6.
Hall-Barrow J, Hall RW, Burke BL Jr . Telemedicine and neonatal regionalization of care - ensuring that the right baby gets to the right nursery. Pediatr Ann 2009;38:557–61.
Kim EW, Teague-Ross TJ, Greenfield WW, Keith Williams D, Kuo D, Hall RW. Telemedicine collaboration improves perinatal regionalization and lowers statewide infant mortality. J Perinatol 2013;33:725–30.
McCrossan BA, Sands AJ, Kileen T, Doherty NN, Casey FA. A fetal telecardiology service: patient preference and socio-economic factors. Prenat Diagn 2012;32:883–7.
Adriaanse BM, Tromp CH, Simpson JM, et al. Interobserver agreement in detailed prenatal diagnosis of congenital heart disease by telemedicine using four-dimensional ultrasound with spatiotemporal image correlation. Ultrasound Obstet Gynecol 2012;39:203–9.
McCrossan BA, Sands AJ, Kileen T, Cardwell CR, Casey FA. Fetal diagnosis of congenital heart disease by telemedicine. Arch Dis Child Fetal Neonatal Ed 2011;96:F394–7.
Scheans P. Telemedicine for neonatal resuscitation. Neonatal Netw 2014;33:283–7.
Jain A, Agarwal R, Chawla D, Paul V, Deorari A. Tele-education vs classroom training of neonatal resuscitation: a randomized trial. J Perinatol 2010;30:773–9.
Trevisanuto D, Ferrarese P, Cavicchioli P, Fasson A, Zanardo V, Zacchello F. Knowledge gained by pediatric residents after neonatal resuscitation program courses. Paediatr Anaesth 2005;15:944–7.
Peterson C, Ailes E, Riehle-Colarusso T, et al. Late detection of critical congenital heart disease among US infants: estimation of the potential impact of proposed universal screening using pulse oximetry. JAMA Pediatr 2014;168:361–70.
Lorch SA, Baiocchi M, Ahlberg CE, Small DS. The differential impact of delivery hospital on the outcomes of premature infants. Pediatrics 2012;130:270–8.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Marcin, J., Shaikh, U. & Steinhorn, R. Addressing health disparities in rural communities using telehealth. Pediatr Res 79, 169–176 (2016). https://doi.org/10.1038/pr.2015.192
Received:
Accepted:
Published:
Issue date:
DOI: https://doi.org/10.1038/pr.2015.192
This article is cited by
-
Addressing the Spectrum of Opioid Misuse Prevention, Treatment, and Recovery in Rural Washington State Communities: Provider Identified Barriers and Needs
Community Mental Health Journal (2024)
-
Measuring Developmental Delays: Comparison of Parent Report and Direct Testing
Journal of Autism and Developmental Disorders (2024)
-
Telemedicine in an adolescent and young adult medicine clinic: a mixed methods study
BMC Health Services Research (2023)
-
Present and future of telemedicine for pediatric care: an Italian regional experience
Italian Journal of Pediatrics (2023)
-
Scheduled and attended pediatric primary care telemedicine appointments during COVID-19
Pediatric Research (2023)