Optimizing Pediatric Subspecialty Care Through Telemedicine and e-Consultations

在美国，超过四分之一的儿童患有慢性疾病。这些孩子中有很多 需要儿科专科医生的护理。然而，24%的儿童需要专科护理 由于地理和社会经济障碍，难以获得这种护理。远程医疗是一部小说 通过使用双向远程提供儿科专科来克服这些障碍的方法 视听技术。早期数据表明，远程医疗在扩大获取机会和减少 儿科专科护理方面的差距。然而，人们对远程医疗的了解很少，几乎没有研究 检查它目前是如何使用的，或者如何更有效地使用它。这样的数据很重要，因为不重要 远程医疗的扩展既有潜在的危害，也有潜在的好处，包括 不适当的使用，不必要的过度使用，或者如果新技术只提供给 人口的一个子集。迫切需要确定远程医疗使用的当前决定因素，障碍 使用和优化策略，通过将专科远程医疗整合到患者中来确保适当使用- 中心医疗院。这项研究的总体目标是制定可行的战略，以推动 通过远程医疗提供儿科专科护理，以克服差距和改善儿童健康。 在目标1中，我们将确定与以下因素相关的患者、专科医生、初级保健和系统级因素 通过对一个大型全州医疗补助计划的分析，远程医疗在门诊儿科专科护理中的应用 数据库。在目标2中，我们将确定医生对使用远程医疗进行非卧床儿科治疗的障碍 通过全国调查提供专科护理。在目标3中，我们将使用来自先前目标的数据以及临床医生和 家长的意见，以开发一个多面手-小组专家电子咨询平台，以改进适当使用 门诊儿科专科护理的远程医疗。通过这些目标，我们将显著改善我们的 了解远程医疗在改善慢性病儿童护理机会方面的作用， 为未来的干预措施铺平道路，以便通过适当的远程医疗手段优化结果。使用 来自坚定导师的指导和强有力的机构支持，PI也将获得必要的 密集的指导、教育和研究经验，以成为一名独立的调查人员， 支持高级统计模型、实施科学和职业发展目标 临床信息学。这项工作将提供必要的初步数据，以支持未来的赠款申请 在观察数据中检查远程医疗使用的影响，并进行先导随机对照试验 本文所开发的电子咨询平台。有了这些新的技能和新颖的初步数据，PI将 准备领导大型研究，以检查和改善创新在儿科卫生领域的传播和影响 提供护理，最终改善需要专科护理的儿童的结局，并促进NICHD 确保所有儿童充分发挥其健康和富有成效的生活的潜力的使命。

Over one quarter of children in the United States live with chronic health conditions. Many of these children require care from pediatric subspecialist physicians. However, 24% of children in need of subspecialty care have difficulty accessing this care due to geographic and socioeconomic barriers. Telemedicine is a novel approach for overcoming these barriers by delivering pediatric subspecialty across a distance using two-way audio-visual technology. Early data suggest that telemedicine has great potential to expand access and reduce disparities in pediatric subspecialty care. Yet much about telemedicine is poorly understood, with few studies examining how it is currently used or how to use it more effectively. Such data are important because uncritical expansion of telemedicine poses potential harms as well as potential benefits, including the potential for inappropriate use, unnecessary overuse, or exacerbated disparities if new technology is afforded to only a subset of the population. A critical need exists to identify current determinants of telemedicine use, barriers to use, and optimal strategies to ensure appropriate use by integrating subspecialty telemedicine into the patient- centered medical home. The overall goal of this study is to develop actionable strategies to advance the delivery of pediatric subspecialty care through telemedicine to overcome disparities and improve child health. In Aim 1, we will determine patient, subspecialist, primary care, and system-level factors associated with the use of telemedicine for ambulatory pediatric subspecialty care through analysis of a large, state-wide Medicaid database. In Aim 2, we will identify physician-perceived barriers to use of telemedicine for ambulatory pediatric subspecialty care through a national survey. In Aim 3, we will use data from prior aims along with clinician and parent input to develop a generalist-subspecialist e-consultation platform to improve appropriate use of telemedicine for ambulatory pediatric subspecialty care. Through these aims, we will significantly improve our understanding of the role of telemedicine in improving access to care for children with chronic conditions, setting the stage for future interventions to optimize outcomes through appropriate telemedicine use. With guidance from committed mentors and strong institutional support, the PI will also receive the necessary intensive mentorship, didactic education, and research experience to become an independent investigator, supporting career development objectives in advanced statistical modelling, implementation science, and clinical informatics. This work will provide essential preliminary data to support future grant applications to examine the impact of telemedicine use in observational data and to perform a pilot randomized controlled trial of the e-consultation platform developed herein. With these new skills and novel preliminary data, the PI will be poised to lead large studies to examine and improve the diffusion and impact of innovations in pediatric health care delivery, ultimately improving outcomes for children in need of subspecialty care and furthering NICHD’s mission of ensuring that all children achieve their full potential for healthy and productive lives.