School nurses offer far more than just Band-Aids these days. As the prevalence of childhood conditions like asthma and diabetes have risen, nurses treat a wide range of problems. Still, only an estimated 40 percent of U.S. schools have a full-time nurse, according to the National Association of School Nurses.
But now telemedicine — virtual doctor visits over video — is increasingly helping nurses do their jobs. Telemedicine programs are making inroads in schools, where a student referred to the nurse can be plopped in front of a screen and connected with a physician. Special computer-connected otoscopes and stethoscopes allow doctors to check ears, noses, throats, and heartbeats from afar.
Proponents say telemedicine in schools can bring benefits such as the ability to treat more complex conditions and keeping chronically ill kids in school.
And a report on a school telemedicine program in Rochester, N.Y., found that it “redressed socioeconomic disparities in acute care access in the Rochester area, thus contributing to a more equitable community.”
But the programs are still relatively new and the ability of schools to fund them long-term isn’t guaranteed. Funding sources can change from year to year, school district to school district. A patchwork of private insurance, Medicaid, grants, and families paying out of pocket covers existing school telemedicine programs.
“The value of telemedicine depends on what your telemedicine model is,” said Dr. Kenneth McConnochie, professor of pediatrics at the University of Rochester Medical Center, where he helped develop the telemedicine program. “For that reason, some kids are gonna get lousy care.”
‘It’s convenient access’
In recent years, several school districts in Dallas, Texas, have started telemedicine programs in partnership with Children’s Health System in Dallas.
Starting with two preschools in 2013, the program eventually grew to reach 97 schools in Texas, and has conducted 4,000 virtual doctor visits at those schools since 2013.
At the schools, nurses use a rolling cart that holds a large, high-definition screen for videoconferencing and a variety of digitally connected medical scopes and tools. An encrypted, HIPAA-secure connection ensures privacy.
“I have the technology to listen to heart sounds, look in ears, at skin and in mouths,” said Dr. Stormee Williams, a pediatrician who sees students via video. “But I can’t check an abdomen, so no tummy aches. And that’s the number one complaint among school-age children. But one school nurse said that she can have them lie down for 10 or 15 minutes, and then they’re ready to go back to class.”
Parents have to fill out a consent form ahead of time allowing their kids to have telemedicine consults. The forms include private insurance information, for families that have it. For those without private insurance, the company can bill Medicaid.
And arrangements like these do more than just make sure kids get treatment — they make the whole process faster and get kids back to class with less interruption.
“It’s not just access, it’s convenient access,” said McConnochie. “Even when kids have access, they still end up sitting in the emergency room for six hours. Telemedicine can eliminate that.”
Many telemedicine programs rely on school nurses to carry out the school end of the visit — which means, in some cases, they’re hampered by the shortage of school nurses. “It basically expands the reach of school nurses, it doesn’t replace them,” explained Dr. Steve North, a specialist in adolescent medicine and the medical director at the 10-year-old Health-e-Schools program, which currently serves 33 schools in western North Carolina.
“The school can only use it if the school nurse is available,” he said. “And schools often share nurses, so at a school with a part-time nurse, a child who gets sick when the nurse isn’t in wouldn’t have access.”
In those cases, North added, the student is simply sent home or picked up by a parent.
The Rochester program gets around that with specially trained telemedicine assistants.
“We use a team of roaming ‘telemedicine assistants’ who go school to school as needed,” McConnochie said. Many of these assistants have had prior experience working in healthcare settings, as health aides, nursing assistants, or emergency medical technicians.
These assistants carry a case containing a laptop, electronic stethoscope, electronic otoscope, and other supplies. And they go to a school when requested to assist on a virtual doctor visit for a sick child.
“This works great for the Rochester program, where they have relatively short distances between schools,” said North.
His program, Health-e-Schools, mostly serves rural areas, where towns and their schools tend to be further apart. And in a pinch, he said, people other than nurses have handled the remote exams.
Generally, for telemedicine consults done at schools, the parents’ insurance is billed. For kids without private insurance, coverage may come from Medicaid, but not universally: Only 23 states and D.C. allow Medicaid reimbursement for school-based telemedicine, according to a 2017 report from the American Telemedicine Association.
In the states that don’t allow Medicaid to cover the visits, grants or local government funds can pay for telemedicine programs. Some school districts use local government funds earmarked for public health initiatives. Others rely heavily on education or health grants.
“We see all patients, regardless of their ability to pay,” North said. “We have a very generous sliding scale for patients without insurance or who are underinsured. Students who are uninsured or have extremely high-deductible plans and have a household income less than 400 percent of the federal poverty level are seen at no cost to the family.”
A former schoolteacher, North started Health-e-Schools in 2007 with money from a fellowship grant. Today, the group purchases the necessary equipment with government and foundation grants, and both North and a nurse practitioner see and treat schoolchildren. Still, telemedicine in schools is “a relatively new concept,” North said, and there isn’t an established or recommended way to go about creating a school-based telemedicine program. “There’s not an easy entry point.”
Many schools do it through partnerships with hospitals, local government, a nonprofit social service agency, or a for-profit company. The Sioux Falls School District in South Dakota set up a telemedicine program for its 31 schools with Catholic-based health care provider Avera Health. Some school districts provide telemedicine through city or county health departments. Others contract with companies like 24/7 Kid Doc.
But all this variation makes for a model that is unevenly applied and difficult to maintain for keeping kids healthy, said Williams. She pointed out that because Texas opted out of Medicaid expansion under the Affordable Care Act, the school telemedicine program needed a state waiver to get Medicaid funding.
“One thing we need is sustainability,” she said. “Waivers and grants aren’t going to last forever.”
No effective medical treatment can ever come from anything but face to face contact in the real world but since the quality of Allopathic medicine which results from around 8 minutes with the doctor, is so poor, virtual medicine is not likely to look too bad.
Real medicine, effective medicine, requires time, attention and knowledge of the patient by the doctor.
I fully agree that effective care requires time, attention and knowledge of the patient. That is a key reason why the objective of the telemedicine model we developed is to provide “healthcare when and where you need it by providers you know and trust”. To flesh that out –
– Visits should be provided within the primary care medical home. Continuity of care promotes trust and commitment. “The secret to the care of the patient is caring for the patient.” — Francis Peabody, 1927
– In order for visits to be provided within the medical home, primary care providers must become telemedicine providers. (Yes, that’s obvious, but only if you think a little. )
– Including video interaction with the patient/parent greatly enhances the potential for establishing and maintaining a caring relationship. This is especially important if the patient does not yet know you well.
– Diagnostic tools that are a part of your telemedicine model should “fit” the clinical problems being addressed. For example, for many sick children, a middle ear exam is one of the essentials. Accordingly, an electronic imaging otoscope is one of the essential components of a telemedicine service caring for children with symptoms of illness.
Listed are some research and synthesis publications supporting this perspective.
Ronis SD, McConnochie KM, Wang H, Wood NE.. Urban telemedicine enables equity in access to acute illness care. Telemed and e-Health. 2017;23:105-112. doi: 10.1089/tmj.2016.0098. Epub 2016 Jul 6.
McConnochie KM, Wood NE, Alarie C, Ronis S. Care offered by an information-rich pediatric acute illness connected care model. Telemedicine and e-Health 2016; DOI: 10.1089/ tmj.2015.0161/22(6):1-7.
McConnochie KM. Pursuit of Value in Connected Healthcare. Telemedicine and e-Health 2015;21(11):863-869
McConnochie KM, Ronis SD, Wood NE, Ng PK. Effectiveness and Safety of Acute Care Telemedicine for Children with Regular and Special Health Care Needs. Telemedicine and e-Health. 2015; 21(8):611-621.
McConnochie KM. Potential of telemedicine in pediatric primary care. Pediatrics in Review. September 2006, online edition. American Academy of Pediatrics, Elm Grove, IL.
McConnochie KM, Wood NE, Herendeen NE, Ng P, Noyes K, Wang H, Roghmann KJ. Acute illness care patterns change with use of telemedicine. Pediatrics 2009;123: e989-e995
McConnochie KM, Tan J, Wood NE, Herendeen NE, Kitzman HJ, Roy J, Roghmann KJ. Acute illness utilization patterns before and after telemedicine in childcare for inner-city children: A cohort study. Telemedicine and e-Health 2007,13:381-390
Kenneth M. McConnochie, MD, MPH
Professor of Pediatrics
University of Rochester Medical Center
Rochester, NY 14642
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