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Telemedicine and telehealth solutions are emerging rapidly in health care and have the potential to decrease costs for insurers, providers, and patients in various settings. Pediatric populations that require specialty care are disadvantaged socially or economically or have chronic health conditions that will greatly benefit from results of studies utilizing telemedicine technologies. This paper examines the emerging trends in pediatric populations as part of a systematic literature review and provides a scoping review of the type, extent, and quantity of research available.
This paper aims to examine the role of remote patient monitoring (RPM) and telemedicine in neonatal and pediatric settings. Findings can be used to identify strengths, weaknesses, and gaps in the field. The identification of gaps will allow for interventions or research to improve health care quality and costs.
A systematic literature review is being conducted to gather an adequate amount of relevant research for telehealth in pediatric populations. The fields of RPM and telemedicine are not yet very well established by the health care services sector, and definitions vary across health care systems; thus, the terms are not always defined similarly throughout the literature. Three databases were scoped for information for this specific review, and 56 papers were included for review.
Three major telemedicine trends emerged from the review of 45 relevant papers—RPM, teleconsultation, and monitoring patients within the hospital, but without contact—thus, decreasing the likelihood of infection or other adverse health effects.
While the current telemedicine approaches show promise, limited studied conditions and small sample sizes affect generalizability, therefore, warranting further research. The information presented can inform health care providers of the most widely implemented, studied, and effective forms of telemedicine for patients and their families and the telemedicine initiatives that are most cost efficient for health systems. While the focus of this review is to summarize some telehealth applications in pediatrics, we have also presented research studies that can inform providers about the importance of data sharing of remote monitoring data between hospitals. Further reports will be developed to inform health systems as the systematic literature review continues.
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A systematic literature review is being conducted to examine the technologies that are currently used in health systems to effectively provide telemedicine coverage for pediatric patients from remote locations. In this paper, we present the results of the scoping review that provides our preliminary findings on the type, extent, and quantity of research available in the literature. While the overall study takes a comprehensive approach in terms of pediatric patient populations studied by disease category, complexity, and patient segment, this paper aims to highlight some emerging RPM and telemedicine trends in the neonatal and pediatric literature. Results from this research can provide an overview of available evidence to inform practitioners, including hospitals and clinics, as well as health technology developers and care providers about the current state of and opportunities in RPM and telemedicine.
We first discuss the steps taken and update on the progress of the comprehensive systematic review. Additionally, some key findings of innovations and emerging technologies in RPM and telemedicine capabilities for pediatric patients are presented. Incremental updates of this review are intended to reduce unintended consequences and costs that come with failing to utilize telemedicine capabilities within and between health systems in various settings.
A systematic literature review is being conducted to gather an adequate amount of relevant research for telehealth in pediatric populations. The fields of RPM and telemedicine are not yet very well established by the health care services sector, and definitions vary across health care systems; thus, the terms are not always defined similarly throughout the literature. A preliminary search helped us to identify which terms provided the most literature on RPM and telemedicine and also helped us identify which databases to use.
A combination of search terms allowed us to obtain 4664 papers, which are relevant to pediatric RPM and telemedicine. All searches included either “child” or “pediatric” and at least one word comparable to “tele-monitoring,” “telehealth,” “telemedicine,” or “remote monitoring.” Some other important search terms were “population health” and “population management.”
We began this search with a scope of the literature relevant to RPM and telemedicine in pediatric populations in PubMed, Compendex, and Ovid. Our search was restricted to peer-reviewed original studies published after January 1, 2008, and papers were collected between July 24 and September 2, 2016. After deleting duplicates, 1768 papers were included for an abstract review and screening. After applying the exclusion criteria, 380 papers were included for full-text review, of which 56 were selected to be included in this review. This review was conducted according to the guidelines of the Preferred Reporting Items for Systematic Review and Meta-Analyses, which visualizes the process of inclusion and exclusion of papers (
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) diagram.
Biometric monitoring (n=59)
Economic benefit (n=13)
Patient or provider satisfaction (n=55)
Teleconsultation (n=36)
Telediagnosis (n=120)
Telemanagement (n=43)
Telepresence (n=14)
Telesupport (n=40)
Adult population (n=224)
Case study (n=32)
Duplicate (n=64)
Irrelevant (n=328)
No specific findings (n=28)
No original research (n=13)
Provider-initiated contact (n=46)
Tele-education (n=86)
Telementoring (n=13)
Report (n=185)
Subjective (n=9)
Telephone-based intervention (n=55)
Review (n=286)
RPM for pediatric patients can be utilized effectively in many different settings for a variety of diseases and with a variety of emerging technologies. In some cases, pediatric patients are monitored in the hospital by a physician who is in a remote location. In other cases, hospitals are using technologies to monitor patients in the hospital, but without contact, thus, decreasing the likelihood of infection or other adverse health effects. Another exciting aspect of RPM is that of monitoring patients at their home via continuous monitors or via self-uploading of patient data from a monitoring device at the home. The majority of studies we have reviewed demonstrate significant positive results, such as improved health outcomes and cost savings to patients and providers, regarding patients who are vulnerable in terms of cardiac health or diabetes. The following sections summarize the emerging themes identified in our scoping review, which examine the role of RPM technologies and provide support for their efficacy.
The management of type 1 diabetes in children can be challenging. Several research teams have examined the role of RPM in the management of type 1 diabetes for children, which especially helps to alert families and health professionals of hyper- and hypoglycemic critical concerns [
Pena et al [
The remainder of studies highlighted real-time RPM utilizing a continuous glucose monitoring (CGM) system, which simply required patients to wear a monitoring device. Three systems used CGM in association with an insulin pump so that alarms were triggered when glycemic values were critical, but insulin pumps were used to treat the critical values while the alarm was working to alert both parents and remote clinician teams of the concern [
The real-time CGM systems were able to shorten the length of hypoglycemic events in children, thus, preventing any adverse health outcomes associated with hypoglycemic events [
Cardiovascular implantable devices are increasingly being used in the pediatric population as a method of long-term RPM [
Researchers found several benefits from remotely monitoring pediatric patients with implantable cardiac devices. Leoni et al [
One of the benefits of telemedicine is that it allows access to specialists and subspecialists in settings where it may not be feasible or possible. Robotic telepresence (RTP) is a form of telemedicine that allows face-to-face contact between a specialist and a patient in a hospital [
Garingo et al [
In addition to the capabilities summarized previously, telemedicine can be used for consultations and diagnosis of health concerns from remote settings. Patients and providers can save on travel time and costs, and patients who are unable to travel will benefit from specialty physician consultation via videoconferencing. In emergent cases, physicians are able to provide timely feedback to families and patients who would otherwise have to incur a great deal of costs on ground or air ambulance [
Dharmar et al [
Another study examined the role of mobile telemedicine units in low-income, inner-city neighborhoods of Rochester, New York [
Some technologies discovered from the literature review are relevant to telemedicine, yet they fail to utilize the aspects of RPM. Below we discuss two such systems: closed-loop systems and noncontact heart rate monitoring.
Both Ly et al [
Similar to closed-loop systems, several health systems are using telemedicine in hospitals, which do not require continuous physician monitoring. This creates an opportunity for sharing data with remote locations.
Several previous researchers have documented the development of robust methods for automated computation of heart rate of infants in the NICU [
Aarts et al studied patients in the NICU in California and the Netherlands through noncontact PPG with an objective of exploring potential challenges of the noncontact PPG technique [
There are two major limitations to noncontact PPG as identified by Aarts et al [
Bal conducted a similar study of webcam-based PPG for heart rate and oxygen saturation of healthy infants and NICU patients in Turkey [
Contactless heart rate monitoring is important in the NICU because it can help avoid infection, thus, decreasing health care cost and stress on families. Additionally, this technique is simple, inexpensive, and effective with the appropriate parameters in place such as light and distance to the camera. Neither research mentioned was disruptive of hospital or clinician flow. The avoidance of touching and repositioning infants allows patients proper rest and development within the incubator.
Our scoping review showed that research on telemedicine applications for pediatric populations is limited, and of the existing research, many studies are severely limited by small sample sizes and convenience samples of participants. In addition, much of the research on telemedicine technologies for pediatrics relies on the satisfaction of parents and caregivers of children with varying diseases. Further research can be strengthened with the education of parents about the importance of enrolling their children in studies that utilize telemedicine services to improve adherence to care management plans and sustainability of the care model. While the benefit for a limited set of diseases is apparent, the effects of telemedicine on patient care and clinical outcomes need to be examined further for a wider range of conditions. By filling this gap in research, health care providers will find opportunities for greater utilization of telemedicine in their health systems.
Based on our findings, there are a wide variety of ways in which telehealth can be used effectively in a health system. Our brief report covers a limited scope of the types of services and devices that are being effectively used for RPM and telemedicine in pediatrics. These include CGM of pediatrics with type 1 diabetes, home monitoring of cardiovascular implantable devices, remote robotic telemedicine in the NICU, and remote consultation and diagnosis. We also presented closed-loop insulin delivery without remote monitoring and noncontact heart rate monitoring of infants in the NICU. The results of our systematic literature review may shed more light on potential research areas or adoption decisions by summarizing some of the more innovative and emerging telehealth capabilities being used throughout pediatric and neonatal health systems. However, this scoping review may help health care providers to remain current with the large plethora of emerging technologies and trends.
Our findings presented in this paper are also limited to studies in developed countries. One application has been reviewed in Malawi, Africa, a developing country. While this study was not necessarily relevant to the scope of this brief review, it may be important for future research and telehealth applications. In developing countries, access to a quality internet connection is rare, yet in larger cities, it is becoming more widely utilized by health systems and hospitals. Effective telemedicine consultations require high-quality equipment with appropriate internet connection and strong service coordination [
Some other aspects of RPM and telemedicine that have not been addressed in this report, but will be addressed in future reports, are cost savings to patients, families, and hospitals; the role of telesupport and telepresence between clinicians and providers; telediagnosis of a variety of diseases and medical conditions; and the importance of telemedicine in improving patient, family, and provider satisfaction.
Despite the limited applications of telemedicine in pediatric and neonatal settings, current technologies show promise in several domains. Small sample size continues to be the main limitation of telemedicine studies in pediatrics. Continued research in telemedicine and RPM applications to a wider range of conditions will further emphasize the need for emerging trends in pediatric health systems. The information presented can inform health care providers of the most widely accepted forms of telemedicine for patients and their families and of the telemedicine that is most cost efficient for health systems. While the focus of this report is on RPM, we have presented some research studies that can inform providers about the importance of data sharing of remote monitoring data between hospitals. Continued reports of findings from this scoping literature review will educate key informants about the importance of telemedicine for pediatric populations and their families.
continuous glucose monitoring
electrocardiograph
neonatal intensive care unit
photoplethysmography
remote patient monitoring
robotic telepresence
We would like to acknowledge Texas Children’s Hospital and Rakesh Mehta for the inspiration on a topic for this literature review. This research was funded by a National Science Foundation Industry–University Cooperative Research Centers Program agreement between National Science Foundation Center for Health Organization Transformation and Texas Children’s Hospital. One of the coauthors affiliated with Texas Children’s Hospital, SRS, has contributed to the design, analysis, and writing of the manuscript.
None declared.