'Telemedicine' may be good Rx for schools

by Paul Heiser

On Board Online • August 14, 2017

By Paul Heiser
Senior Research Analyst

Picture this: A fifth-grader tells her teacher she feels sick and it hurts to swallow. She visits the nurse's office in her school. The nurse establishes a video connection with the girl's family physician 10 miles away, allowing him to assess the girl's health and communicate with the child, the nurse and her mother. Digital images of her throat are taken and sent electronically to her doctor, who reviews the images and confirms the girl has strep throat. The doctor then calls in a prescription to the local pharmacy.

Welcome to the world of telemedicine, which uses telecommunication and information technology (e.g., computing imagery) to provide clinical health care from a remote location. Because the doctor and the patient don't have to be in the same physical location together, some schools are using this model to overcome distance barriers, improve access to medical services, and decrease the time spent away from school.

"It really cuts down on the amount of instructional time students miss," said Jane Hamilton, RN manager of school-based health for the Bassett Healthcare Network. "A traditional on-site doctor visit takes typically half a day due to travel to and from the appointment, waiting time, the actual appointment, etc. With the telemedicine model, the whole process takes only 20 to 30 minutes."

The Bassett Healthcare Network, which operates 20 school-based health centers across four counties (Chenango, Delaware, Otsego and Schoharie), has been offering telemedicine services in schools since New York enacted a law in 2011 requiring students who sustain concussions during athletic activities to be evaluated by, and receive written and signed authorization to return to activities from, a licensed physician.

"Since a physician visits each site typically only one day per month, if a student got a concussion the day after the visit by the physician, he would have to wait a full month to be cleared by a physician under the concussion protocol," Hamilton told On Board.

To address that challenge, Bassett purchased videophones for three pediatricians that would allow doctors to see and evaluate students remotely. Relatively low- tech, the system was a "proof of concept" for telemedicine in rural areas.

In September 2016, Bassett Healthcare Network was awarded a four-year grant of $297,419 by the U.S. Department of Health and Human Services to bring telehealth services to the school-based health care setting. The grant benefits students enrolled in 18 of Bassett's school-based health centers in rural Delaware, Otsego and Chenango counties. All three counties are federally-designated health professional shortage areas with significant unmet needs for high quality, accessible, comprehensive primary and preventive care.

Bassett's telehealth initiative includes nutritional counseling that will allow its staff dietitian to increase the number of students served; psychiatric services, including psychotherapy and medication management; and "teledentistry" for procedures that can be done remotely, such as checking X-rays and reviewing treatment options.

In addition, Bassett will soon be partnering with the University of Rochester to provide services that the network doesn't have the capacity to provide, such as pediatric endocrinology (primarily for the care and treatment of diabetes) and pediatric pulmonology (mostly to serve students with severe asthma). Care is available to students even during summer months and holidays.

Once equipment for remote access is in place and the program established, nearly 200 telepsychiatry visits can be completed annually, as well as several hundred asthma self-management activities and at least 280 preventive and specialty oral telehealth visits.

The Rochester City School District has partnered with the University of Rochester Medical Center's Health-e-Access program, which has been available in every Rochester city school as of September 2010. Health-e-Access allows students in pre-K through grade 12 to see a doctor without leaving school.

According to Erin Graupman, the district's coordinator of student health services, if a student arrives at the nurse's office complaining of health conditions such as an ear infection, skin problem, sore throat, respiratory illness or fungal infection, the nurse can arrange to have a technician from the University of Rochester come to the school and take digital images. The technician carries a portable laptop, which features such attachments as a stethoscope and ear and throat scopes. Images are then sent either to the student's own family doctor (if he or she is involved in the program) or to a doctor at the University of Rochester for diagnosis and treatment. The district typically receives 500 to 600 such visits each school year, with charter schools experiencing another 100 or so visits.

"The benefit is that we have found kids spend more time in school," Graupman told On Board.

The program has gotten high marks from all of its stakeholder groups, according to Neil Herendeen, as associate professor of pediatrics at the University of Rochester Medical Center.

"Feedback from parents has been extremely positive, feedback from the school nurses is that this is very helpful in keeping kids in school and in collaborating closely with primary care pediatricians on some of their more complex students, and feedback from teachers is they appreciate being able to give input for their students with ADHD directly to their provider," Herendeen told On Board.

Herendeen said that 96 percent of acute care illness visits can be successfully diagnosed and treated by this model of telemedicine without the need for inpatient care. This holds true for complex developmentally disabled patient populations as well.

Even if telemedicine increases access to care and minimizes the amount of time spent out of the classroom, is the quality of care up to par with that of a traditional office visit?

Kenneth M. McConnochie, a physician in the Department of Pediatrics at the University of Rochester Medical Center, was the lead author on a study that was published in the June 2016 issue of the journal Telemedicine and e-Health. The study analyzed 13,812 Health-e-Access telemedicine visits that were initiated between the program's inception in 2001 through June 30, 2013. Over that 12-year period, there were 13,812 Health-E-Access consultations. In more than 95 percent of cases, the telehealth conference led to primary diagnoses that were later supported. Similarly, in 95 percent of cases, the consultation was able to rule out more serious diagnoses.

McConnochie has conducted other studies pointing to the benefits of the Health-e-Access program. One such study found a 63 percent reduction in absences from childcare for those that had telemedicine access, compared to matched centers/children that did not yet have telemedicine access.

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