Telemedicine: Progress Toward Optimizing Care Delivery (Let’s Not Regress) Free

Infants born extremely premature and those who develop neurologic complications and physiologic derangement have a higher risk of major neurodevelopmental impairments.^1,2  The long-term outcomes of infants in this population are influenced not only by their NICU course, but also their post-NICU care.³  NICU follow up (NFU) clinics provide comprehensive care designed to detect early deviations from neurodevelopmental milestones, intervene with appropriate referrals and services, and monitor progress,⁴  all with the goal of minimizing future functional impairment while helping infants and families cope with existing ones. Unfortunately, attendance in neonatal follow-up appointments has been reported to be as low as 21% to 60%.⁵ 

In this month’s Hospital Pediatrics, Watson and colleagues implemented an innovative model combining predischarge telemedicine consults with a developmental/behavioral pediatrician and postdischarge electronic reminders that improved their NFU clinic attendance rates from 26% to 62%.⁶  It is noteworthy that coronavirus disease 2019-related emergency federal provisions granting reimbursement enabled telemedicine to thrive as a care modality and enabled natural experiments to showcase the benefits and limitations of digitally supported care models in much greater depth.

The authors present a retrospective, cross-sectional study comparing the first NFU clinic visit attendance rate (by 12 months of corrected age) among high-risk neonates discharged from a 51-bed, level 3 NICU. A baseline of 152 neonates born between January 2018 and June 2019 (early cohort) with a 26% follow-up rate was compared with 105 neonates born between May 2020 and May 2021 (late cohort). Interventions done in the late cohort group included:

1. predischarge telemedicine consultation between the family and a behavioral and developmental pediatrician;

2. placement of an appointment reminder for neonatal follow-up clinic in the electronic medical record’s discharge summary and after-visit summary to be seen by the primary care provider and the family, respectively; and

3. in the event that parents refuse the follow-up referrals, the neonatologist would meet with them and discuss the benefits of attending follow-up visits.

Authors report a follow-up rate of 62% postintervention, representing 3.5 times higher odds for successful follow-up clinic attendance in the late cohort (95% confidence interval, 1.7–7.2) after controlling for maternal insurance as a proxy for social–economic status. Mediation analysis was used to discern a 37% effect associated with after-visit summary documentation to parents apart from the effect of electronic medical record documentation.

The authors showed an increased follow-up visit rate in the late cohort associated primarily with predischarge telemedicine consultations and appointment reminders. Since the authors hypothesize that low follow-up rate in the early cohort may be partly because of lack of parental education, an analysis for such associations with “rescue” education that the NICU team provided to reluctant parents would be interesting. Some studies have reported that up to 10% of parents may not believe that NFU is necessary.⁷  Details on how the mediation analysis ascertained effect significance (eg, Sobel test or bootstrapping) would also have been helpful. Associations of neighborhood risk factors with neurodevelopmental outcome and NFU rates are gaining attention.^8,9  The Child Opportunity and/or Social Vulnerability Indices^10,11  are examples of potentially useful equity-risk stratifiers to examine whether presence of neighborhood risk factors is associated with low or high NFU rate in this population.

Before the pandemic, well-designed and executed quality-improvement efforts¹²  had only modest success improving follow-up rates to 78%. During the pandemic at a time when follow-up rates were expected to plummet, neonatal teams leveraged telemedicine to continue seeing patients, and some achieved follow-up visit rates comparable to prepandemic in-person rates (72%).¹³  Such success required fundamental system changes that (1) trained staff on carefully scripted scenarios, (2) onboarded families on how to use the technology, (3) provided “all hands-on deck” institutional support for staffing, resources, and funding, and (4) allowed telephone encounters for families who did not have Internet. Indeed, the pandemic forced many health care organizations to transform their health care system at unprecedented speed by using rapid cycle change management methods.^14–17  State and federal policymakers suspended prepandemic regulations that limited telemedicine; as a result, practitioners were allowed to deliver care across state lines and get reimbursed, avoiding catastrophic breakdowns in access to health care. Meanwhile, clinicians and telemedicine implementers quickly learned lessons that will help redesign a future care model that synergizes telemedicine and in-person care modalities more efficiently and effectively.

The coronavirus disease 2019 pandemic-related expansion of telemedicine reimbursement in the inpatient setting was a key component for this care model, and there is increasing concern that reductions or limitations of telemedicine reimbursement after the pandemic will reduce access to interventions that have been shown to improve care during the public health emergency. This is of particular importance in pediatrics, where subspecialty workforces are concentrated at urban academic medical centers, which is not historically where most children have received emergency and hospital care.^18,19  Additionally, further innovation in pediatric virtual care could stagnate if reimbursement for hospital-based telemedicine consultation ebbs. Recent reductions in the number of pediatric beds at community hospitals has raised concern that higher-acuity and/or complexity patients are increasingly being transferred to distant children’s hospitals; virtual pediatric consultation services may support reversal of this trend.²⁰  However, pediatric subspecialists continue to practice in a predominantly fee-for-service environment, and they are rarely able to engage in innovative virtual, hospital-based care models unless their services are reimbursed on parity with similar in-person care that they could be providing at the same time. Transformation to higher-value care, for example, the use of virtual inpatient consultation to prevent a hospital-to-hospital transfer or increase attendance at an evidence-based NFU clinic, depends on a financial model that supports those providing the virtual care, in addition to those who will reap potential cost savings associated with lower transport costs or better long-term developmental outcomes.

Telemedicine is a disruptive innovation that offers the opportunity to optimize care delivery beyond what had been possible. By facilitating a predischarge connection between parents of high-risk infants and developmental pediatricians (integral members of the postdischarge care team), parents could be more apt to attend the NFU clinic. The authors’ multiintervention approach plugged other holes in the “Swiss cheese” (ie, forgetfulness, lack of education), further mitigating the risk for not attending the NFU. As telemedicine is becoming an indispensable care modality, its impact on health outcomes, the quality and cost of care delivery, individual experience, and equity deserves further investigation and research from the lens of patients, providers, health systems, payers, and policymakers.²¹