When a child has a chronic illness, just getting to a pediatric specialist’s office for a clinic visit can be a significant burden for the child and family. This is especially true for rural families, who may live hundreds of miles from the nearest pediatric specialty clinic. The child must often miss one or more full days of school, and the parents face the burdens of missed time from work and expensive travel. Thus, the human and economic costs of a clinic visit are high for many pediatric patients and their families.
For the pediatric epilepsy patient, telemedicine may represent a partial answer to these problems. The standard-of-care for the pediatric epilepsy patient is one clinic visit per year, with additional visits on an as-needed basis. These additional visits are typically arranged to address medication failures or side effects or to answer parental questions regarding test results or long-term prognosis.
Dr. Charuta Joshi, a child neurologist and epilepsy specialist at the University of Iowa Hospitals and Clinics in Iowa City, is investigating the use of telemedicine as an adjunct to yearly in-clinic visits. According to Dr. Joshi, pediatric epilepsy may lend itself well to telemedicine because the physical examination of the patient can usually be conducted visually, with no need for auscultation or palpation. For most epilepsy patients in follow-up visits, the most relevant signs to search for are those of medication side effects, including nystagmus, ataxia, and lethargy. Auscultation of the heart and palpation of the liver or other organs are rarely helpful or necessary. Thus, a video camera and audio equipment are all that are needed in most cases. In theory, patients can visit telemedicine sites near their homes and communicate faceto- face with epilepsy specialists far away, but in real time, thus accomplishing all of the goals of a clinic visit, with great improvement in cost and convenience to the family.
To investigate the practicality and patient satisfaction with telemedicine, Dr. Joshi recently conducted a phonebased survey of parents whose epileptic children were seen via telemedicine, across the state of Iowa. Her survey Exploring Telemedicine for Pediatric Epilepsy By Daniel J. Bonthius, MD, PhD | Connections Editor Charuta Joshi, MD included qualitative measures (such as adequacy of time spent, privacy concerns, and acceptability) graded on a Likert scale, and quantitative measures (such as travel distance and money saved).
Virtually all of the survey respondents felt positively about the telemedicine experience (see figure). The vast majority reported that they could discuss everything in the telemedicine setting as in the hospital interview. All of the respondents felt that they had sufficient time to discuss issues, and none had privacy concerns. More than 80% of respondents lived greater than 100 miles from the clinic, but less than 50 miles to the telemedicine site and had saved between $100 and $500 in travel costs. Two-thirds of respondents preferred that their next visit be a telemedicine visit. Insurance remunerated all of the patient visits, as they would have for hospital visits at a similar level of billing.
To date, Dr. Joshi’s investigations regarding telemedicine have focused exclusively on follow-up epilepsy patients. She next plans to explore the utility of telemedicine for first-time seizure patients. She also envisions that telemedicine may be practical for pediatric neurology patients with headaches and movement disorders. Dr. Joshi recognizes that telemedicine works better for some patients than for others. “Telemedicine works very well for a subset of patients. In general, the less that the physical exam requires auscultation or palpation, the better it works,” says Joshi. Telemedicine is here to stay and will likely increase as pressures to reduce costs grow.