Telehealth and Medicine Today

Telehealth in a Pediatric Patient with Nevoid Basal Cell Carcinoma Syndrome

Allison M. Jay, MD, Anthony Hamame, MD, M. Susan Jay, MD — Thu, 31 Oct 2024 00:00:00 -0700

During COVID19, telemedicine was adapted by many practices to serve patients with a variety of health conditions including those affected by cancer. Here we report an 11-year-old patient who went to her dentist where a routine panorama x-ray showed multiple jaw keratocysts. Because jaw keratocysts can be identified with a hereditary predisposition to basal cell cancer and other tumors, she was referred for genetics.

She was seen in 2021 where telehealth was the primary modality for visits. The hospital’s secure video platform was used to gather medical history and counsel the mother on genetic testing for nevoid basal cell carcinoma syndrome(NBCCS). While in the past genetic testing was often thousands of dollars, the genetic testing company offered a patient pay option of $250.

Two days later, the patient presented to the cancer center to have her blood drawn and a fifteen-minute physical exam was performed which identified macrocephaly, and palmar pits. Of note the mother asked about numerous pinpoint lesions around the patient’s ocular region.

Genetic testing was positive for a pathogenic variant in PTCH1 c.454_455del. The patient was referred to pediatric dermatology where over fifty basal cells were diagnosed and started treatment with imiquimod and efudex. She also was referred to cardiology and gynecology given reports of individuals with cardiac fibromas and gynecologic ovarian tumors. The patient is now 14 going into her freshman year of high school and is doing well. This case highlights how telehealth offers a holistic approach to patient care.

Development and Implementation of a Value-Based Care Telehealth Emergency Medicine Program: Triage and Care Alignment in an Integrated Health System

Thu, 31 Oct 2024 00:00:00 -0700

Background: Acute unscheduled episodic care is an area of potential cost savings, given the high frequency and cost of unnecessary emergency department (ED) utilization.

Methods: We developed a provider-assisted patient navigation program using a telehealth platform designed to decrease ED utilization and reduce costs while providing exceptional patient satisfaction.

Results: Urgent care (UC) visits were analyzed from July 1, 2022, to June 30, 2023. The “ED comparison” group (n = 68,320) consisted of patients discharged to home after receiving care in the ED. The “avoided ED visits” group included patients (n = 7,430) who received care in a lower-acuity setting and did not require emergency services within 48 hours. The calculated overall medical expense savings comparing the costs between the ED vs. lower-acuity settings revealed that 50% (n = 450) of consultations were managed as outpatients, avoiding ED visits. Evaluation of distribution by source revealed that 67% of ConnectCare consults resulted in admission, 48% for UC, while 36% of patients were service center consults. Conversely, 31% of consultations resulted in recommendations to go to the ED, and 16% of these were assisted transfers where the Telehealth Emergency Medicine (TeleEM) clinician communicated with the receiving ED. Among the 280 patients directed to the ED, 243 were sent because of immediate clinical acuity, 28 were because of logistical or scheduling issues, three for non-qualifying insurance for outpatient workup, and six were redirected to the ED following diagnostic results. Our analysis suggests an estimated average avoided medical expense of $1,701 per case to insurers and patients if an ED visit was avoided.

Conclusion: Implementing a TeleEM program to assist with triage and resource alignment, as well as identification and outpatient management of patients while avoiding an ED visit, is feasible within an integrated health system. Our TeleEM program may be a model for other integrated health systems.

Reduction of Preoperative Anxiety Using Virtual Reality vs Midazolam: A Randomized Controlled Trial

Thu, 31 Oct 2024 00:00:00 -0700

More than 50% of pediatric patients experience significant stress and anxiety prior to surgery.¹ High anxiety can result in increased postoperative pain, analgesic consumption, and delayed recovery.² To reduce this preoperative anxiety, multiple therapeutic modalities have been developed, including the use of distraction, such as playing video games, watching movies, and listening to music. In severe cases of anxiety, anxiolytic and sedative medications like midazolam are used. However, given the acknowledged drawbacks of medications, including the risk of paradoxical reactions to the drug, alternatives to medication for reducing preoperative anxiety in patients may be useful. We aim to compare the use of virtual reality (VR) to midazolam in reducing preoperative anxiety in surgical patients and assess differences in induction compliance, emergence delirium, pain scores, and opioid use in VR vs. midazolam-treated patients.

Methods

This study was approved by the Phoenix Children’s Hospital Institutional Review Board. First-time surgical patients (N = 36) between the ages of 5 and 11 years undergoing tonsillectomy or tonsillectomy/adenoidectomy procedures were randomly assigned to either receive midazolam (0.5 mg/kg up to 25 mg) or play an interactive underwater-themed game using VR. The Modified Yale Preoperative Anxiety Scale (mYPAS) was administered by a single child life specialist preoperatively, and only patients who reached a threshold of >40 on mYPAS scoring were enrolled (scale range: 23 - 100).

Additional anxiety measurement was tested using the adult and child State-Trait Anxiety Inventory (STAI). Midazolam or VR was administered prior to transport to the OR, and mYPAS was scored again at the time of separation from the family. The Induction Compliance Checklist (ICC) was utilized for assessment at the time of anesthesia induction. The VR-treated patients continued use of the VR headset through mask induction. A standardized anesthesia induction protocol was used for all patients. The Pediatric Anesthesia Emergence Delirium (PAED) scale was administered at emergence, postoperatively. Postoperative nurses scored pain and administered IV pain medication as needed. Group means and standard deviations were reported and compared with two-sided t tests.

Results

Interim results show the mYPAS anxiety scores dropped 20.1 ± 11.7 points following midazolam treatment (p<0.001) and dropped 28.3 ± 7.3 points following VR treatment (p < 0.001). There was a significant difference in mYPAS scores between groups following treatment (midazolam = 32.0 ± 4.9; VR = 25.4 ± 4.7; p = 0.04). There were no significant differences between midazolam- and VR-treated groups in the Induction Compliance Checklist, PAED scale, peak postoperative pain scores, and medication use for pain control postoperatively. This study is currently ongoing.

Conclusion

VR appears to reduce preoperative anxiety similarly to midazolam in anxious first-time surgical pediatric patients. Limitations include patient population. Further studies should be conducted for greater generalizability.

The Use of Telehealth Technology in the Medical Management of Adults with Intellectual Disability: A Scoping Review.

Thu, 31 Oct 2024 00:00:00 -0700

Background: Individuals with intellectual disability (ID) experience substantial inequalities and barriers accessing health care despite requiring constant accessibility to healthcare providers as they are more likely to die from avoidable causes of death than those without ID. Telehealth technologies have the capacity to improve access to health providers and health information and could greatly reduce morbidity and mortality rates in people with ID. This study aims to explore the use of mobile health technology in the medical management of adults with intellectual disability.

Methodology: PubMed, IEEE Explore, ACM, and Scopus databases were examined to extract peer-reviewed articles published from January 2000 to January 2022. Original research, published in English and focused on the use of telehealth technologies in the medical management of intellectual disability were deemed eligible. A narrative synthesis of the results was completed, structured around the characteristics of telehealth technologies used and the outcomes of the studies.

Results: Thirteen of 1008 reviewed articles were considered eligible for inclusion. Most of the studies used videoconferencing platforms for real-time telehealth, while others focused on symptom or medication monitoring applications. The evidence supports the feasibility, potential effectiveness and satisfaction of using telehealth to manage intellectual disability among adults despite accessibility issues including poor internet connectivity and poor knowledge of technology which may limit its use.

Conclusion: The use of telehealth was feasible, acceptable and potentially effective for the management of ID among adults though the varied methodology of included studies maybe inadequate. A more structured methodology will be useful in future studies.

Telemedicine: Bridging the Gap in Providing Primary Care to Rural Area Patients Across India

Aswini Ashokan Naidu, MD — Thu, 31 Oct 2024 00:00:00 -0700

Telemedicine has emerged as a transformative solution to address the significant healthcare disparities faced by rural India, where over 70% of the population resides. In this article, the evolution of telemedicine in India, its current landscape, and its potential to revolutionize primary healthcare delivery in rural areas are reviewed. Despite progress in establishing Primary Health Centers, rural healthcare infrastructure remains underutilized due to staffing shortages and other challenges. Telemedicine offers a lifeline by bridging critical gaps in primary care, with government initiatives such as E-Sanjeevni and private entities such as M-Swasth and Apollo TeleHealth expanding access to healthcare services.

The COVID-19 pandemic accelerated the adoption of more advanced, patient-centric telemedicine models incorporating artificial intelligence, machine learning, and Internet of Things technologies. These innovations aim to provide rural communities with healthcare standards comparable to urban areas. However, challenges persist, including technological barriers, digital literacy gaps, and concerns about data security and privacy.

To fully realize telemedicine’s potential, a multifaceted approach is necessary. This includes culturally adapting platforms for rural populations, strengthening data protection legislation, enhancing digital infrastructure, and increasing digital literacy. The collaborative efforts of government bodies, private enterprises, healthcare professionals, and non-profit private organizations are crucial in overcoming these challenges. By embracing telemedicine and addressing its implementation barriers, India can bridge the healthcare gap, improve the quality of life for millions of rural residents, and potentially catalyze economic development in rural areas.