Problem Addressed

• High incidence of child abuse: In Federal fiscal year 2006, an estimated 905,000 children were victims of child maltreatment, including physical and sexual abuse. Approximately 9.9 percent of these children (89,500) were living in California at the time of the abuse.²
• Serious consequences: Child maltreatment can result in serious physical, psychological, and behavioral consequences including impaired brain development, poor physical health, cognitive delays, mental disorders (including posttraumatic stress disorder and eating disorders), relationship difficulties, abusive behavior, criminal behavior, and substance abuse.³ Child abuse can also be deadly—in Federal fiscal year 2006, 1,530 deaths nationwide were attributed to child abuse or neglect²; 140 of these deaths occurred in California.
• Higher risk in rural areas: Rural areas experience higher rates of physical and sexual child abuse.⁴ Thirteen rural California counties have the state’s highest rates of referrals for child abuse and neglect.⁵
• Ill-equipped rural facilities: Like their peer institutions in other states, rural hospitals in California have fewer resources and less experienced examiners for identifying cases of pediatric physical and sexual abuse.⁵ In addition, rural hospitals have a shortage of on-call specialists available.⁶ Inadequate assessment and treatment of child abuse can cause unintended additional harm to the victim and/or put the victim at continued risk of abuse.⁷

Description of the Innovative Activity

• Monthly telehealth training: UC Davis hosts monthly training and/or photo review sessions (a process in which practitioners review photos and accompanying forms to gain consensus regarding a diagnosis) on child abuse–related issues that are broadcast over secure Internet connections to remote sites. These interactive sessions are designed to educate health care providers in rural, underserved EDs and clinics on a variety of topics, including recognition, evaluation, evidence collection, and treatment of childhood physical and sexual abuse. Multipoint control units can be used to provide training simultaneously to more than one site.
• Expert consultation through telemedicine: Expert consultation is available 24 hours a day, 7 days a week through interactive videoconferencing; remote sites activate sessions by paging experts at UC Davis. Through this program, health care providers from rural underserved EDs can interact with child abuse experts at UC Davis Children’s Hospital CAARE Center to assist with history, examination, and interpretation of findings in child abuse cases. The consultation process is described below:
  • Remote connection: At the remote site, there are usually two health care providers present (i.e., a nurse and physician, or two nurses). The process begins with the remote site obtaining consent from the parent/guardian (if available). The remote site then calls UC Davis Medical Center to initiate a connection. Once a connection has been established, experts from CAARE Center are able to see the examining room and everyone present using the videoconferencing unit. In addition, the pediatric patient, parent/guardian, physician, nurse and/or law enforcement in the examining room of the rural ED or clinic can interact with the CAARE Center staff in real time.
  • History and examination of patient: The CAARE experts assist remotely throughout the process, which begins with remote providers obtaining history from the patient, parent or guardian, and/or law enforcement. Following history, remote providers perform general and colposcopic examinations to test for physical or sexual abuse, including evidence collection. CAARE experts can view colposcopic images using the video camera.
  • Completion of forms: Remote providers complete state child abuse forms (Office of Emergency Services, state of California), and CAARE experts complete quality assurance forms stating CAARE experts agree with remote examiner interpretations of history, examination, and the conclusions.
  • Digital recordings available: The program digitally records all telemedicine-assisted child abuse examinations to DVDs, which can be reviewed at a later time for additional analysis or used as evidence in judicial proceedings. The program keeps medical documents and DVDs as part of medical records and maintains them as forensic evidence according to standard operating procedure.

References/Related Articles

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Innovator Disclosures

Results

• Changes and corrections to data gathering and examination techniques: According to information provided in February 2011, telemedicine consultation resulted in additions or changes to initial histories and data gathering in 40 out of 74 cases, made significant changes or additions to specific physical examination techniques in 57 out of 70 cases, changed examination methods to include use of adjunct techniques in 29 out of 70 cases, and revised methods for collecting forensic evidence in eight out of nine acute sexual assault cases.⁸
• Overall effectiveness ranked high: CAARE Center staff used a seven-point Likert scale to evaluate the overall effectiveness (with 1 being not very effective and 7 being very effective) of telemedicine on the examination of 74 patients and found that 63 (85 percent) scored a 5 or higher, with the majority (70 percent) of those 63 consults ranked at 7.⁸

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Pilot study and site selection: The program recruited two intervention sites to participate in a pilot project. Positive findings from this pilot project led to the recruiting of five additional intervention sites, along with five comparison sites. All participating ED sites were located in rural, underserved areas according to Health Resources and Services Administration definitions.
• Establishing equipment: All intervention and remote sites received pagers to contact experts at UC Davis 24 hours a day. Videoconferencing units were connected with fractionated T1 lines, triple Integrated Services Digital Network lines, or secure and encrypted high-speed Internet connections to provide confidential interactive audio and video consultations (minimum of 384 kbps). Sites received digital video cameras to provide high-definition images of injuries in sexual abuse cases, as well as DVD recorders to record all child abuse examinations.
• Training and technical assistance: All intervention sites received an overview lecture on telemedicine, a lecture on the child abuse telemedicine program, and onsite equipment training. A telemedicine technician from UC Davis Center for Health and Technology and CAARE experts reviewed the process and use of videoconferencing unit, digital video camera, and DVD recorder prior to program implementation. Technicians from UC Davis Center for Health and Technology provide ongoing onsite equipment training twice annually or as needed. Technicians also conduct test calls at least monthly to test equipment and increase remote provider familiarity with the equipment and operating procedures.
• Ongoing evaluation: The program collects data to assess diagnostic accuracy and quality of care on an ongoing basis from both intervention and comparison sites.

Resources Used and Skills Needed

• Staffing: At UC Davis' CAARE Center, two full-time nurse practitioners who are sexual abuse experts provide remote consultations 24 hours a day/7 days a week, and three full-time physicians who are physical abuse experts provide consultations around the clock. These same nurse practitioners and physicians also provide monthly child abuse training to remote sites. Personnel from UC Davis Center for Health and Technology conduct the initial equipment training and provide ongoing technical assistance related to the use of technology and protocol for consultations. At each participating remote site, a telemedicine coordinator is identified to oversee program operations, including assigning staff roles, scheduling examinations, testing equipment, and conducting quality assurance. This person typically requires a range of between 10 and 25 percent time depending on the remote site volume.

• Cost: The cost of equipment at remote sites ranges from $15,000 to $25,000, depending on capital needs. Telecommunications costs range from $50 to $200 per month, depending on type of telecommunications used (high speed Internet, Integrated Services Digital Network, or fractionated T1). Staff costs range depending on volume. Ongoing consultation costs are dependent on State, county, and/or law enforcement reimbursement for evidence examinations.

Funding Sources

Getting Started with This Innovation

• Obtain buy-in and commitment: It is critical to secure the commitment of dedicated child abuse experts to provide assessments and consultations through telemedicine channels, along with the willingness of rural providers to seek and accept expert guidance. Support from clinical personnel and administration with a “champion” (i.e., telemedicine coordinator at the remote site) is essential.
• Strive for balance between need and commitment: Remote sites must have the personnel interested in conducting these examinations and expanding their repertoire, and the volume of cases to justify the program—too little volume and the program may not work; too much volume and the program may not be necessary.
• Garner the support of the criminal justice system: It is important to involve local law enforcement and the district attorney’s office in supporting the program.

Sustaining This Innovation

• Actively pursue alternative funding sources: Because public funding can shift with new budget priorities, and grant funding is usually time limited, active pursuit of alternative funding sources, including third-party reimbursement, is essential. It is possible to make this program "self-sufficient" through third-party reimbursement from State, county, and law enforcement sources (whoever assumes responsibility for payment of examinations).

• Provide competent, responsive technical assistance: Users of the system need ongoing access to guidance on efficient use of the telemedicine technology, and prompt resolution of technical problems. Quality information technology and videoconferencing personnel to establish, maintain, and troubleshoot telecommunications and equipment are essential for the success of the program.