SummaryPhysicians and nurse practitioners at the Child and Adolescent Abuse Resource and Evaluation (CAARE) Center at the University of California at Davis Children’s Hospital provide 24-hour child abuse evaluation and consultation services via interactive videoconferencing with patients, physicians, and child abuse specialists in six rural hospital emergency departments in underserved regions of northern California.1 The program also provides monthly child abuse training to health care providers in these hospitals who might otherwise forgo such opportunities because of time and travel distances required to attend onsite training. Pre- and post-implementation data suggest that the program enhanced provider knowledge and improved diagnostic accuracy, leading to improvements in quality of care. A 2013 comparative review of rural hospitals using videoconferencing versus controls found higher quality documentation and assessment in the former, as well as higher scores for completeness and accuracy.
See the Results section for updated information related to the quality of examination and accuracy of diagnosis (updated February 2014).Moderate: The evidence consists of a study of 74 live telemedicine consultations examining sexually abused children at six remote sites using a pre–post comparison design and a second study comparing evaluations of 101 sexually abused children at five rural hospitals that use telemedicine consultation with evaluations of 82 children at three hospitals that do not have telemedicine access.
Developing OrganizationsUniversity of California, Davis -- Center for Health and Technology; University of California, Davis -- Child and Adolescent Abuse Resource and Evaluation Center (CAARE); University of California, Davis -- School of Medicine, Department of Pediatrics
Date First Implemented2002
Vulnerable Populations > Children; Rural populations
Problem AddressedChild abuse is a serious problem and can lead to devastating consequences. Although rural areas experience higher rates of child abuse, rural facilities often lack resources necessary to properly identify, assess, and treat abuse victims.1-7
- 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 (such as 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 neglect;2 140 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 or put the victim at continued risk of abuse.7
Description of the Innovative ActivityPhysicians and nurse practitioners at the CAARE Center at the University of California at Davis (UC Davis) Children’s Hospital provide 24-hour child abuse evaluation and consultation services via interactive videoconferencing with patients, physicians, and child abuse specialists in six rural hospital emergency departments (EDs) in underserved regions of northern California. The program also provides monthly child abuse training to health care providers. Key elements of the program include the following:
- 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 at EDs in rural, underserved areas can interact with child abuse experts at UC Davis Children’s Hospital CAARE Center for assistance with history, examination, and interpretation of findings in child abuse cases. The consultation process is described below:
- Remote connection: At the remote site, two health care providers usually are present (i.e., a nurse and physician, or two nurses). The process begins with the remote site obtaining consent from the parent or guardian (if available). The remote site then calls the 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 by using the videoconferencing unit. In addition, those present in the examining room of the rural ED or clinic—pediatric patient, parent/guardian, physician, nurse, law enforcement representative—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 law enforcement representative. The remote providers then perform general and colposcopic examinations to test for physical or sexual abuse and to collect evidence. CAARE experts can view colposcopic images by 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 that CAARE experts agree with remote examiner interpretations of history, examination, and conclusions.
- Digital recordings available: The program digitally records all telemedicine-assisted child abuse examinations to DVDs, which can be reviewed later 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 procedures.
- Monthly telehealth training: UC Davis hosts
monthly training sessions on child abuse issues, as well as photo review
sessions (a process in which practitioners review photos and
accompanying forms to gain consensus regarding a diagnosis), via
broadcasts over secure Internet connections. These interactive sessions
are designed to educate health care providers at EDS and clinics in rural, underserved areas on a variety of topics, including recognition, evaluation,
and treatment of childhood physical and sexual abuse as well as evidence collection in abuse cases. Multipoint control units can be used
to provide training simultaneously to more than one site.
Context of the InnovationUC Davis, 1 of 10 campuses in the University of California system, is a public research university located in the heart of the Central Valley. The CAARE Center, one of numerous medical service and research centers at UC Davis, is a multidisciplinary center that provides comprehensive services to abused and neglected children throughout northern California and statewide child abuse training for medical practitioners through the California Medical Training Center. The UC Davis Center for Health and Technology houses the university’s telemedicine program, which has been nationally recognized as a leader in providing telemedicine services, including video-based telemedicine, distance learning, and applied medical informatics technologies. Although telemedicine is a growing field that is gaining acceptance as a viable option for providing subspecialty care in underserved rural areas,8-11 its effectiveness in assisting health care providers at EDs in such areas with child abuse cases has not yet been scientifically demonstrated. Realizing the importance of recognition, proper assessment, and appropriate, timely treatment of victims of child physical and sexual abuse, the UC Davis Center for Health and Technology and CAARE Center combined their expertise to develop and evaluate this pediatric telemedicine program as a part of the university's larger telemedicine services.
ResultsFindings from a study of 74 live telemedicine consultations examining sexually abused children at six remote sites suggest that program participation leads to positive changes in child abuse examination and data collection methods used, which are consistent with best practices associated with diagnostic accuracy. In a second study, conducted in 2013, an independent expert found higher quality examination images, documentation, and assessment in five rural telemedicine hospitals compared with three hospitals lacking access to telemedicine consultation.
Moderate: The evidence consists of a study of 74 live telemedicine consultations examining sexually abused children at six remote sites using a pre–post comparison design and a second study comparing evaluations of 101 sexually abused children at five rural hospitals that use telemedicine consultation with evaluations of 82 children at three hospitals that do not have telemedicine access.
- Changes and corrections to data gathering and examination techniques: 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 8 out of 9 acute sexual assault cases.12
- 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 7.12
- High-quality evaluations: Comparing the documentation for 101 children who were evaluated at telemedicine hospitals with 82 children evaluated at control hospitals revealed that the telemedicine hospitals had significantly higher quality scores for the general exam, genital exam, documentation of examination findings, and overall assessment. The telemedicine hospitals also had significantly higher total scores for completeness and accuracy. (Updated February 2014.)
Planning and Development ProcessKey steps in the planning and development process include the following:
- 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 underserved rural areas as defined by the Health Resources and Services Administration.
- 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 the 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: The UC Davis CAARE Center provides around-the-clock consultations from two full-time nurse practitioners who are sexual abuse experts and three full-time physicians who are physical abuse experts. 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 vary depending on volume. Ongoing consultation costs depend on State, county, and law enforcement reimbursement for evidence examinations.
Funding SourcesHealth Resources and Services Administration, Maternal and Child Health Research Program
Currently, the two pilot programs are self sustaining through their respective law enforcement and district attorney's offices. The additional research sites are fully funded by a grant from the Health Resources and Services Administration's Maternal and Child Health Research Program.
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 personnel interested in conducting these examinations and expanding their repertoire. The sites must also have the appropriate 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 to 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.
Contact the InnovatorJames Marcin, MD, MPH
University of California, Davis School of Medicine/Pediatrics
2516 Stockton Boulevard
Sacramento, CA 95817-2208
Phone: (916) 734-4726
Fax: (916) 456-2235
Innovator DisclosuresDr. Marcin has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
References/Related ArticlesMarcin JP, Ozuah OP, Burton D, et al. Telemedicine in physical and/or sexual abuse. In: Wootton R and Batch J, editors. Telepediatrics: telemedicine and child health. London: Royal Society of Medicine Press; 2004.
Marcin J. Increasing access and improving the care delivered to abused children in rural, underserved hospitals with telemedicine. MCH Research Program, U.S. Department of Health and Human Services, Health Resources and Services Administration Web site. 2007. Available at: http://www.mchb.hrsa.gov/RESEARCH/project_info.asp?ID=75.
MacLeod KJ, Marcin JP, Miyamoto S, et al. Using telemedicine to improve the care delivered to sexually abused children in rural, underserved hospitals. Pediatrics. 2009;123(1):223-8. [PubMed]
1 All six participating emergency departments are “underserved,” according to the Health Resources and Services Administration's definitions of health professional shortage area, medically underserved areas, and medically underserved populations.
U.S. Department of Health and Human Services, Administration for Children and Families. Child welfare information gateway [Web site]. Available at: http://www.childwelfare.gov
4 Straus MA, Gelles RJ, Smith C. Physical violence in American families: risk factors and adaptations to violence in 8,145 families. New Brunswick, NJ: Transaction; 1990. Note: Socioeconomic status and race/ethnicity were found to be better predictors of child abuse than rural status.
5 Albert VN, Barth RP. Predicting growth in child abuse and neglect reports in urban, suburban, and rural counties. Social Service. 1996;70(4):58-82.
Marcin JP, Ellis J, Mawis R, et al. Using telemedicine to provide
pediatric subspecialty care to children with special health care needs
in an underserved rural community. Pediatrics. 2004;113(1 Pt 1):1-6. [PubMed]
Nesbitt TS, Marcin JP, Daschbach MM, et al. Perceptions of local health
care quality in 7 rural communities with telemedicine. J Rural Health.
Marcin JP, Nesbitt TS, Kallas HJ, et al. Use of telemedicine to provide
pediatric critical care inpatient consultations to underserved rural
Northern California. J Pediatr. 2004;144(3):375-80. [PubMed]
Callahan CW, Malone F, Estroff D, et al. Effectiveness of an
Internet-based store-and-forward telemedicine system for pediatric
subspecialty consultation. Arch Pediatr Adolesc Med. 2005;159(4):389-93. [PubMed]
MacLeod KJ, Marcin JP, Boyle C, et al. Using telemedicine to improve the
care delivered to sexually abused children in rural, underserved
hospitals. Pediatrics. 2009;123(1):223-8. [PubMed]
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Original publication: April 14, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: March 26, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: February 17, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.