Equipment and Telecommunications

Telemedicine videoconferencing units that are used for interactive telemedi­cine can range from low-end, software-based systems to high-end, turnkey systems. Software-based systems can be used with a personal computer and a Web cam, so that the computer makes the call and uses the Web cam as the video source.

Two videoconferencing units can then be linked by a variety of telecommunication connection methods. In general, a minimum, clinically useful connectivity speed of 384 kilobits per second (kbps) is recommended for standard video, and 1 megabits per second (mbps) is recommended for high-definition video. Currently, most long-range connections are made using high-speed Internet, Integrated Services Digital Network (ISDN) lines, T1 lines (or fractionated T1 lines), or satellite. More recently, cellular tele­communications technologies are being used as higher-connection speeds become more available and more widespread. Each of these has advantages and disadvantages in terms of cost, feasibility, and reliability. If the Internet or cellular telecommunications are used, connection speeds can vary, and resulting audio-video quality may be unreliable. Further, to use the Internet, modifications to allow encryption must be made so that the connections are compliant with the Health Insurance Portability and Accountability Act (HIPAA [Pub L No. 104-191]). A common solution is the use the turnkey systems' built-in encryption or to establish a virtual private network (VPN) tunnel. An alternative solution is to choose a connection method that is naturally more secure, like a point-to-point connection used by ISDN or T1 lines. A point-to-point connection is one where only the 2 end points can use the connection to communicate, unlike a shared connection such as the Internet.

New Improved Telemedicine Delivery System and Incorporation Into the Transport Process

With the development of smart phones, tablets, and video conferencing, telemedicine has taken a more dramatic use in pediatric transport. The days of fixed systems being wheeled into units between parties are gone, and transport has now become easier and less cumbersome. The current land line base system is superior in quality, but for the transport teams and their base unit communication, it is now more than just purely verbal communication between parties, teams have incorporated file transfers (eg, radiographs, computed tomography scans, ultrasonographic images) and video chatting as the way of new transport communications process. Various transport systems have, through their legal departments, have set up protocols, communication policies, HIPAA guideline compliance, and most importantly, ways for this video/file sharing to be stored for a set period of time for quality assurance and other processes. This file sharing and video chatting by the transport teams to the base unit (medical control unit: pediatric emergency department, pediatric intensive care unit, and the neonatal unit) has, per reports from various pediatric transport teams' medi­cal directors (Vanderbilt pediatric and neonatal transport program and other programs), improved efficiency for medical interventions, triaging, pediatric trauma leveling, and utilization or activation of the surgical teams/operating room. Certain transport programs have incorporated file sharing and video chatting into the initial phase of the transport process between the referring and receiving units by using smartphones to e-mail or text with attached video/picture or to video chat. Setting up these systems must be approved by both units' compliance offices and legal departments and incorporated into their transfer agreements between the parties. As technology improves, the role of telemedicine will take a dramatic new direction with more use, easier application, improved transport triaging, and great efficiency in the care delivered to the critical ill and injured pediatric and neonatal patients.

With any new adaption or improvement to the transport process, research into the benefits of these new forms of communication needs to be performed and published by the various transport programs.

The Use of Telemedicine in Pediatrics

The use of telemedicine has been continuing to increase in recent years. This is related to improved videoconferencing equipment and telecom­munications quality, more affordable equipment and telecommunications systems, and increased patient and provider comfort with these technologies. Further, because of the increased recognition of the effectiveness of telemedi­cine, particularly in terms of addressing barriers to access for those living in remote and/or underserved communities, there has been an increase in interest and investments by governments (federal, state, and local) as well as health care systems and health insurers.

It is common that children living in rural and underserved communities have limited access to specialists and other regionalized care, compared with children living in suburban and urban communities.^1-3 As a result, telemedi­cine in pediatrics is used in many settings to enhance or expedite health care services. Most commonly, telemedicine is used in the delivery of outpatient specialty consultations to children in rural communities and focuses on children with special health care needs.^4-9 However, telemedicine is increas­ingly being used to assist in emergency and critical clinical scenarios.

The Use of Telemedicine in Transport Medicine

The use of telemedicine technologies to deliver real-time patient informa­tion, electronically monitored data, and/or video for transport medicine is in its infancy. These technologies may have the potential to improve care at any point during emergency medical services for children: from the scene of a medical emergency, during transport to the closest emergency department, during the initial emergency department resuscitation, during the arrival of the pediatric transport team, and during transport to the children’s hospital offering definitive care.

Scene Telemedicine

To enable videoconferencing from the scene of an accident, mass casualty, or other disaster that would require medical triage, telemedicine could be deployed in a variety of ways.¹⁴ Videoconferencing equipment could be delivered by any first responder, including helicopter for remote or difficult to get to locations. Once delivered, broadband telecommunications is needed to connect to an emergency department or command center. Currently, broadband telecommunications access is limited in remote locations and, in most circumstances, would require satellite connectivity. More recently, telecommunication systems that aggregate wireless data connections have been tested as a means of providing broadband connectivity to mobile and/ or remote locations.^15,16 Once deployed, telemedicine could be used to assist in first responder therapies as well as triaging. As one can imagine, scene telemedicine would have theoretical advantages in cases of medical emergen­cies involving infectious, biological or chemical emergencies.

Telemedicine During Transport

There are several programs in the United States that have incorporated videoconferencing and telemedicine during medical transport. Standard medical monitoring devices and/or videoconferencing equipment have the capability of transmitting data and video if adequate bandwidth is available to the moving vehicle transporting the patient. One option used by some emergency medical services systems is to use wide area wireless networks, such as the ones established in Tucson, AZ, and Baton Rouge, LA. In these cities, first responders are connected to a city wide Wi-Fi network to be able to transmit medical data to regional emergency departments. Another option to provide mobile broadband is to use the collective bandwidth of cellular providers.^15,16 Presumably, over time, newer technologies will allow for easier and less expensive mobile broadband telecommunication solutions.

The utility of telemedicine during transport has not yet been defined. Despite several city and county emergency medical systems enabling the use of this technology for transmission of videoconferencing during transport, little data exists that demonstrates this impacts quality of care and/or patient outcomes. Research will be needed to identify which types of transports, which modes of transports, and for which types of patients this technology may assist in transport medicine.

Telemedicine in Emergency Departments

There have been several studies that have investigated the use of telemedicine to provide consultations to children and/or adults seeking care in remote emergency departments that otherwise lack access to specialty providers. Most publications have been descriptive, reporting feasibility and anecdotal results; however, more recent investigations are demonstrating improve­ments in emergency department quality of care when videoconferencing is used to incorporate regionalized consultants.^19-25 In some instances, the installation of videoconferencing systems in critical access hospitals have created a new model of emergency care in which emergency medicine physicians can assist physician extenders who work in underserved or criti­cal access hospitals.^26-28 Similar to scene telemedicine, emergency depart­ment telemedicine can be used to assist emergency medicine physicians in the stabilization and initiation of critical care therapies, particularly if subspecialty physicians can be of service.