Telemedicine Integrated into Pediatric Primary Care & Child Outcomes

在2021年夏天，80%的儿科医生报告说，他们在之前使用了现场音视频远程医疗。 4个月前，只有16%的儿科医生有远程医疗经验。支持 有利的联邦和州政策开始支持2019年冠状病毒病期间的物理距离 （COVID-19）大流行，儿童卫生工作者现在积极使用远程医疗来照顾儿童，但缺乏 为儿科初级保健使用远程医疗的最佳做法提供指导的证据。我们的研究团队此前 发现商业直接面向消费者的远程医疗提供的护理质量存在差距， 常见急性儿科问题（急性呼吸道感染）。我们还证明了在以下方面的改进： 常见慢性病的管理（例如，哮喘、注意力缺陷/多动障碍）使用 远程医疗在研究中的应用。然而，儿童健康社区缺乏关于使用 远程医疗在不断发展的“现实世界”初级保健实践中的作用，包括远程医疗就诊与 远程医疗的使用如何影响纵向结果和公平性， 初级保健患者。此外，我们缺乏对支持主要业务的结构和流程的理解， 以最佳方式加强儿童健康和健康公平的远程医疗护理做法。的 该提案的总体目标是确定促进远程医疗使用的可行战略 利用初级保健实践的数据， 2018-25在目标1中，我们将比较通过以下方式提供的儿童初级保健就诊的就诊水平质量： 远程医疗与面对面使用来自1，000多个实践的电子健康记录数据， 实践，卫生系统附属实践和社区卫生中心。在目标2中，我们将比较儿童 在远程医疗使用率较高与较低的初级保健实践中接受护理的儿童的健康结果 通过对与预防、急性和慢性护理相关的指标进行比较性中断时间序列分析。 在这两个目标中，我们将通过评估远程医疗对健康公平性的影响， 远程医疗对儿童的影响及临床特点最后，在目标3中，我们将确定实践结构 促进或阻碍以改善儿童健康的方式在初级保健中使用远程医疗 通过一个定性的多案例研究。通过这种严格的混合方法， 患者安全系统工程倡议（SEIPS）2.0模型和结构能力框架， 我们将确定远程医疗在儿童初级保健中的就诊水平和儿童水平的影响， 以及支持利用远程医疗促进健康的程序。因此，本研究 远程医疗跨预防，急性和慢性护理活动的整体，亚群，并在 范例实践将提供关键知识，为研究、实践和政策提供信息，以优化正在进行的 在初级保健中使用远程医疗，以促进儿童健康和健康公平。

During the summer of 2021, 80% of pediatricians reported using live audio-video telemedicine in the prior month, up from 16% of pediatricians with telemedicine experience just four years before. Supported by favorable federal and state policies begun to support physical distancing during the Coronavirus Disease 2019 (COVID-19) pandemic, the child health workforce now actively uses telemedicine to care for children, but lacks evidence to guide best practices for telemedicine use in pediatric primary care. Our research team previously found gaps in the quality of care delivered by commercial direct-to-consumer telemedicine for the most common acute pediatric concerns (acute respiratory tract infections). We also demonstrated improvement in management of common chronic conditions (e.g., asthma, attention-deficit/hyperactivity disorder) using telemedicine in research settings. However, the child health community lacks data regarding the use of telemedicine in evolving “real-world” primary care practices, including how telemedicine visits compare to in- person visits for the same conditions and how telemedicine use impacts longitudinal outcomes and equity for primary care patients. Additionally, we lack understanding of the structures and processes that support primary care practices in using telemedicine in ways that optimally enhance child health and health equity. The overarching goal of this proposal is to identify actionable strategies for promoting the use of telemedicine within primary care in ways that improve child health and health equity, using data from primary care practices from 2018-25. In Aim 1, we will compare visit-level quality of primary care visits for children delivered through telemedicine vs. in-person using electronic health record data from over 1,000 practices including independent practices, health system-affiliated practices, and community health centers. In Aim 2, we will compare child health outcomes for children receiving care in primary care practices with higher vs. lower telemedicine use through comparative interrupted time series analysis of metrics related to preventive, acute, and chronic care. In both of these aims, we will examine the impact of telemedicine on health equity by assessing variation in the effect of telemedicine by child and clinic characteristics. Finally, in Aim 3, we will identify the practice structures and processes that promote or impede use of telemedicine in primary care in ways that improve child health through a qualitative multiple-case study. Through this rigorous mixed-methods approach informed by the Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 model and a Structural Competency framework, we will identify visit-level and child-level impact of telemedicine integration within primary care for children as well as processes supporting health-promoting use of telemedicine. As a result, this examination of telemedicine across preventive, acute, and chronic care activities overall, for subpopulations, and within exemplar practices will provide critical knowledge to inform research, practice, and policy to optimize ongoing use of telemedicine within primary care to promote child health and health equity.