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Service Delivery Innovation Profile

Remote Visits by Pediatricians for Sick Children at Inner-City and Other Child Care Centers/Schools Reduce Absences and Emergency Department Use


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Snapshot

Summary

A Web-based telemedicine system known as Health-e-Access allows pediatricians, nurse practitioners, and physician assistants to provide remote diagnosis and consultation for sick children in childcare centers and elementary schools in and around Rochester, NY, including a large developmental center for medically fragile children with severe disabilities. Trained assistants use a personal computer, high-resolution camera, videoconferencing equipment, an electronic stethoscope, and other medical instruments to gather and transmit information on a sick child to the clinician. The care model includes videoconference interaction among child, parent, and clinician as appropriate to clinical and communication requirements. The clinician responds with a diagnosis and treatment recommendations, including prescriptions. The program, which has facilitated more than 11,000 telemedicine visits to date, reduced illness-related absences in childcare by 63 percent and emergency department visits by 22 percent, while easing the burden on working parents by allowing them to stay at work. The program's success has led to expansion to all Rochester City Schools and replication in other settings nationally and locally, including neighborhood centers and senior living communities.

Evidence Rating (What is this?)

Moderate: Evidence includes studies comparing ED visits and other health services for illness for program participants versus a matched control group; absences both pre- versus post-implementation and participants versus a matched control group; and pre- and post-implementation surveys of parents of program participants and providers. Studies also address reproducibility of diagnosis and treatment decisions for telemedicine versus usual care, completion rates of telemedicine visits, and parent and provider satisfaction.
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Developing Organizations

University of Rochester Medical Center
Rochester, NYend do

Date First Implemented

2001
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Patient Population

Vulnerable Populations > Childrenend pp

Problem Addressed

Acute, but not severe, pediatric illnesses are highly prevalent among children in childcare programs and elementary schools. Children are commonly removed from these programs until seen by a doctor and certified as safe to return, resulting in child and parent absences from school and work. In most cases, these illnesses are easily diagnosed and treated and often do not warrant exclusion from the childcare center or school for the safety of other children and staff. Providing these settings with remote access to an offsite physician offers the potential to diagnose and treat children (often with prescriptions delivered to the child site by collaborating pharmacies) quickly and conveniently.
  • High prevalence of acute childhood illness: Children under the age of 15 years with an acute condition account for 71 million physician office visits annually.1
  • No need for illness to cause absence from educational programs: The American Academy of Pediatrics' Health, Mental Health, and Safety Guidelines for Schools recommends that "students and staff who are well enough to carry on with school functions should not be sent home for colds, bronchitis, or the rash of Fifth Disease, because inclusion in these circumstances has not been found to increase the chances others will become ill . . . strep throat is infectious, but not after 24 hours of antibiotic treatment."2 Symptoms concerning to educators may, in fact, be minor; one study found that a temperature of 99 to 99.9 degrees Fahrenheit was considered a fever by 35 percent of daycare staff.3
  • High economic and social costs: The costs associated with childhood illness are high and include health care costs, a parent's time lost from work (which reduces productivity and can have a negative impact on a parent's income and/or employment status), children's time lost from educational programs,4 and transportation costs. For a child with severe disabilities, transportation might require a wheelchair van. One study reported that 40 percent of work missed by parents using childcare was due to a child's illness.5 Furthermore, lack of access to care prompts unnecessary use of the emergency department (ED); studies estimate that between 20 and 70 percent of pediatric visits to EDs are for nonurgent health problems.2,3,4,5
  • Potential to replace less convenient and more costly options for care: Evidence from this group of investigators has shown that 85 percent of pediatric office visits for illness could be managed, instead, by telemedicine.6

What They Did

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Description of the Innovative Activity

Pediatricians provide remote diagnosis and advice for sick children at childcare centers and elementary schools via a telemedicine program known as Health-e-Access. Telemedicine service is available at over 50 centers and schools. All schools in the Rochester City School District are now served, using mobile telemedicine units that are managed by roaming telehealth assistants. This creates elastic service capacity, allowing quick, convenient assessment of sick children. When a child is sick, a scheduler/coordinator contacts the child's parent and pediatrician. After parental approval, a trained telemedicine assistant uses the equipment to gather and transmit patient data to the pediatrician, who confers with the assistant and parent, diagnoses the condition, and/or recommends next steps. Videoconference interactions among child, parent, and provider are optional. Key elements of the program are as follows:
  • Determining the need for a remote visit: For telemedicine visits at school, child care, or development center sites, staff trained as telemedicine assistants can initiate a remote visit for any acute problem that might require exclusion from the school or childcare setting without a medical evaluation. For child sites lacking an on-site telemedicine assistant, staff may call the family’s primary care physician’s office and ask whether a telemedicine visit is appropriate. Once a sick child is identified (e.g., a child who wakes up from a nap with a fever), the childcare center/school contacts the parent for approval to execute a remote consultation with the pediatrician. In 2009, the program expanded to include other neighborhood settings (e.g., family services center, church, settlement house). Four such after-hours sites now operate, covering five weekday evenings and Saturday mornings. Families may be referred to after-hours telemedicine sites by their primary care physician’s after-hours telephone coverage system.
  • Gathering and sending patient data: Using telehealth units, the telemedicine assistant gathers patient data and saves it to a central server where it is available to the pediatrician via the Internet in advance of the visit. Telehealth units include a teleconferencing camera, an all-purpose digital camera with attachments to enhance imaging of ears, eyes, nose, throat, and skin; and an electronic stethoscope. Forwarded information includes text describing the child's medical history and may include images of ear drums, throat, and/or skin rash; lung sounds; results of a rapid strep test; and other assessments. Because key information that drives medical decisionmaking is generally available at the click of a mouse, a typical telemedicine visit takes the clinician just a minute or 2 for diagnosis and management decisions. Additional time is required for documentation and communication. The system allows prescriptions to be faxed directly to the family's pharmacy of choice.
  • Real-time interaction as needed: When the physician requires additional information or observations that are best obtained through real-time interaction, a videoconference is initiated that enables the physician to view the patient and the patient to view the physician. When parents are present at a visit, videoconferencing is always used because this enhances communication and engagement.
  • Discussion of findings and next steps: Once all information is gathered, the physician videoconferences or telephones the onsite telemedicine assistant and/or the child's parent to discuss findings and next steps. As part of this conversation, the physician offers a diagnosis, guidance on treatment, and, if appropriate, faxes a prescription to a pharmacy. Many pharmacies will deliver to childcare sites, resulting in rapid initiation of treatment and even more time-saving for the family. Occasionally, the clinician recommends further assessment through a visit to the doctor's office, lab testing, or imaging studies (about 3 percent of telemedicine encounters). Diagnosis and treatment recommendations are confirmed and handouts about the child's condition that have been selected by the clinician are printed out on the child-site computer for the parent and child-site staff.
  • Payment: Telemedicine services are reimbursed by all local payers, including Medicaid Managed Care, at the same level as a regular visit. Fee-for-service Medicaid, which is a statewide program that covers about 5 percent of program participants is the only major payer that does not reimburse. Currently, providers absorb the costs of telemedicine visits for these patients. (See the Planning and Development Section for more information on how these payers were convinced to provide reimbursement.)

Context of the Innovation

The University of Rochester Medical Center, located in Rochester, NY, is an academic medical institution comprising Strong Memorial Hospital and Golisano Children's Hospital. With 739 beds and a full range of inpatient and outpatient services, the medical center embodies several missions, including health research, teaching, patient care, and community outreach.

The impetus for the program came from two pediatricians at the University of Rochester Medical Center who were interested in the potential of telemedicine to serve low-income urban patients. Their interest was sparked, in part, by years of seeing children at the medical center's primary care pediatric practice who were healthy but needed a doctor's note approving the child's return to childcare or school after an illness. The pediatricians understood that low-income, hourly-employed parents had particular difficulty leaving work to obtain medical care for their children and faced a significant loss of income when they did.

Health-e-Access is now operational in five urban and suburban childcare centers, all Rochester City School District schools, a center for developmentally disabled children, and four after-hours neighborhood sites. These sites serve a demographically and socioeconomically diverse population.

Did It Work?

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Results

Pre- and post-implementation data show that the program has cut illness-related absences by more than half in inner-city locations; a community-based controlled trial found that the program reduced ED visits by almost one-fourth; and surveys suggest that the remote visits allow more parents to stay at work. Key results are as follows:
  • Fewer absences due to illness: A study in five inner-city childcare centers found that absences due to illness declined from 8.78 to 4.07 per 100 child days after implementation of the program, a decline of 63 percent after adjustment for potential confounders in a multivariate analysis. Of the 940 telemedicine encounters conducted between January 1, 2001 and June 30, 2003, pediatricians recommended exclusion from childcare in only 7 percent of cases; in only 2.8 percent of cases was an in-person visit recommended.
  • Fewer ED and physician visits: A community-based trial comparing health services utilization over a 6-year period of children with telemedicine access with utilization of a closely matched control group without telemedicine access (total of 39,304 child-months of observation) found that children served by the program had 22 percent fewer ED visits. Telemedicine and control children observations were matched on age, sex, month of the year, insurance type, and socioeconomic index. Also of note, a survey of parents following their child's first use of telemedicine found that in 93.8 percent of cases, the parent would have taken his or her child to a physician or an ED if the program had not been available. Finally, secondary analysis of an administrative data set, including ED visits at the University of Rochester Medical Center in 2006, estimated that the program had the potential to avoid 28 percent of ED visits.
  • Less missed work for parents: The aforementioned survey also showed that 91.2 percent of parents said that a telemedicine visit had enabled them to remain at work.

Evidence Rating (What is this?)

Moderate: Evidence includes studies comparing ED visits and other health services for illness for program participants versus a matched control group; absences both pre- versus post-implementation and participants versus a matched control group; and pre- and post-implementation surveys of parents of program participants and providers. Studies also address reproducibility of diagnosis and treatment decisions for telemedicine versus usual care, completion rates of telemedicine visits, and parent and provider satisfaction.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Purchase and later development of technology: For the initial demonstration project, the pediatricians obtained commercially available computer equipment and telehealth units with peripheral devices. In initial studies of the program, the equipment was found to lack stability and did not fit workflow requirements of the program well (particularly workflow in a busy pediatric primary care office). Subsequently, Health-e-Access contracted with internet-based software developers and computer system integrators to create a customized telemedicine system with software and protocols tailored to the workflow and process requirements of the program. A commercial venture, TeleAtrics, arose from that endeavor.
  • Initial demonstration project: An initial demonstration project was implemented in May 2001 with three inner-city childcare centers, with pediatric encounters handled by the two medical center pediatricians and one nurse practitioner. Health-e-Access staff trained on-site telemedicine assistants to perform their roles. As Health-e-Access clinicians gained experience in conducting telemedicine visits, they developed further understanding of the strengths and weaknesses of their telemedicine model and identified technical and organizational refinements that would promote effectiveness and efficiency and facilitate integration of the Health-e-Access system in busy primary care office settings.
  • Ensuring payer reimbursement: Program developers contacted medical directors at local payers (commercial payers and payers offering Medicaid managed care products) to obtain agreement to reimburse primary care practices for providing telemedicine services for the duration of the demonstration project. After payers saw evidence of the program's potential to reduce ED visits based on the impact of the demonstration project, they agreed to continue reimbursing services on an ongoing basis.
  • Program expansion: Based on the program's success, Health-e-Access expanded to several additional settings, including neighborhood centers in January 2009 (with evening and weekend hours), all Rochester City Schools in September 2010 (through mobile telemedicine units operated by roaming telemedicine assistants), and senior living communities in October 2010 (also through roaming telemedicine assistants). The Health-e-Access Geriatric Program is described more fully in a separate Innovations Profile.
    • Soliciting childcare center/elementary school participation: Program developers contacted childcare centers to solicit their participation. Developers provided site tours and demonstrations of the telemedicine technology to win their support.
    • Soliciting other facilities: In 2009, the program expanded to include to include other neighborhood settings (e.g., family services center, church, settlement house). Four such after-hours sites now operate, covering five weekday evenings and Saturday morning. In addition, the program serves a large, multisite facility, providing services for children with severe developmental disabilities, many of whom are also medically fragile.
    • Enlisting physician participation: Five practices serving roughly 80 percent of the children living in the primary target area (inner-city Rochester) are most heavily involved. Program developers contacted the physicians at these practices and highlighted the convenience of the program for families; most pediatricians were highly service-oriented and quickly understood the value of the program. Five additional practices that serve primarily suburban children have also participated.
    • Initial training and evaluation of technicians: The onsite telemedicine assistants must undergo a 12- to 16-hour, hands-on training program that focuses on symptom-driven protocols, electronic forms that guide the collection of medical history, and use of telemedicine peripheral devices. Additional skills addressed during training include obtaining vital signs, performing rapid streptococcal antigen testing, and administering nebulized medication. Once they complete training, telemedicine assistants are "on probation," and must demonstrate their competence during a 2-month internship in which they have to complete two (actual or simulated) telemedicine visits per week. This activity level criterion is important for sites that have their own telemedicine assistant. On completing the internship, the telemedicine assistants receive certification by Health-e-Access.
    • Ongoing performance evaluation: Once trained and certified, staff have to maintain their proficiency over time. The program's software includes performance evaluation tools—before the pediatrician closes out a visit, he/she must complete a brief rating of the telemedicine assistant's performance. The telemedicine assistant also has the opportunity to rate the clinician's performance during the developmental stage. To maintain their certification, telemedicine assistants must receive consistently good evaluations.
    • Piloting program to enhance management of other conditions: In 2011, local pilot funding was obtained to use this telemedicine network to enhance management of common chronic problems in childhood such as asthma and attention deficit hyperactivity disorder. Findings to date based on qualitative methods suggest that telemedicine enhanced, school-based chronic care management has tremendous potential.

Resources Used and Skills Needed

  • Staffing: The program employs a coordinator and a nurse manager. Some telemedicine assistants are existing schools/childcare staff members. Telemedicine assistants may or may not have had prior health care training or experience. In schools, school nurses may serve as telemedicine assistants, but in situations where they are too busy with other mandated responsibilities, telemedicine visits are handled by health aides. Large child sites (e.g., a childcare center with 150 preschool children) can be served efficiently with an onsite, dedicated telemedicine assistant. Multiple small sites (e.g., childcare for 5 to 10 children based in a family home) can be served much more efficiently with a roaming telemedicine assistant using a mobile telemedicine unit with wireless connectivity. Most participating elementary schools are now served by roaming telemedicine assistants as well.
  • Costs: Health-e-Access costs $115,000 annually to cover the salary and benefits for the coordinator and nurse manager. In addition, the telemedicine equipment costs roughly $15,000 for hardware, software, setup, and training. TeleAtrics charges schools and childcare centers a $4,000 annual fee after the first year for software licensing, connectivity, and support. Physician practices pay a small setup fee but no annual fee for participation, thus allowing them to view images, participate in videoconferences (see below), and share other information and services enabled through Health-e-Access.
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Funding Sources

Agency for Healthcare Research and Quality; Maternal and Child Health Bureau-Health Resources and Services Administration; New York State Department of Health; U.S. Department of Commerce Technology Opportunities Program; Robert Wood Johnson Local Initiative Funding Partners Program; Rochester Primary Care Network; New York Healthcare Foundation
Pilot funding came from the U.S. Department of Commerce Technology Opportunities Program. Funding for initial program expansion was provided by the Robert Wood Johnson Local Initiative Funding Partners Program plus matching funds generated locally (multiple local foundations and individual donors) under the leadership of the Rochester Area Community Foundation. Subsequent funding from the Agency for Healthcare Research and Quality and the Maternal and Child Health Bureau of the Health Resources and Services Administration enabled broader expansion, integration into primary care medical offices, and rigorous evaluation.

More recent funding has come from New York State, New York State Health Department-Health Care Efficiency and Affordability Law (HEAL), Rochester Primary Care Network, and the New York Healthcare Foundation. The Health-e-Access Telemedicine Network is also financed through reimbursement for visits from all major payers (Medicaid managed care organizations included) in the Rochester area except fee-for-service Medicaid. Successful negotiations among payers and providers, sufficient increases in volume of telemedicine visits, and reasonable allocations from provider organizations to Health-E-Access infrastructure are both required to allow sustainability of this telemedicine infrastructure based entirely on health service revenue streams. Sustainability is projected for 2012.end fs

Tools and Other Resources

AHRQ's Healthcare 411 podcast series features Kenneth McConnochie, MD, describing the Health-e-Access project, a telemedicine project in Rochester, NY, that allows sick kids to obtain a long-distance diagnosis. Available at: http://healthcare411.ahrq.gov/podcast.aspx?id=302

AHRQ's Healthcare 411 podcast series features Cindy Brach, MPP, health policy researcher, AHRQ's Center for Delivery, Organization, and Markets, describing the innovation as a case study for health care innovation and adoption decision-making. Available at: http://healthcare411.ahrq.gov/featureAudio.aspx?id=848

American Academy Of Pediatrics. Health, Mental Health, and Safety Guidelines for Schools (Section 4-22, Exclusion from School for Illness or Injury). Available at: http://www.nationalguidelines.org/guideline.cfm?guideNum=4-22

A PowerPoint presentation by Kenneth McConnochie, MD, about the Health-e-Access program is available on the AHRQ Health Information Technology (HIT) Web site at: http://www.ahrq.gov/news/events/conference/2008/McConnochie.html.

McConnochie KM, Wood N, Herendeen N, ten Hoopen CB, Roghmann KJ. Telemedicine in urban and suburban childcare and elementary schools lightens family burdens. Telemedicine and e-Health. 2010;16:533-42.

Watch related video from the Frontline Innovators series

Discovery Channel – November 2011
http://dsc.discovery.com/videos/patient-ed-health-it-part-4.html

CBS National Evening News – 2008 
http://www.teleatrics.com/media/

ABC National Evening News – 2007
http://www.teleatrics.com/media/

Adoption Considerations

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Getting Started with This Innovation

  • Solicit payer agreement to reimburse telemedicine visits by emphasizing the cost savings potential due to fewer ED visits. Insurers should reimburse at greater than the rate of the usual office visit for illness, as they generally do for visits to urgent care centers. As with urgent care center visits, telemedicine visits visits often allow ED visits to be avoided. Moreover, with the Health-e-Access telemedicine model, most telemedicine visits are conducted within the primary care medical home. Such continuity of care not only avoids large payments for an ED visit; continuity is also associated with less "defensive medicine" (e.g., fewer laboratory and imaging studies).
  • Engage payers and provider organizations on the issue of telemedicine infrastructure costs. Infrastructure components include the following: telehealth assistants; training of clinicians and telemedicine assistants for use of the technology and for collaboration; management of telephone calls about illness, including triage to telemedicine or inperson care; technical and clinical troubleshooting and quality control; and telemedicine hardware, software, and connectivity. Infrastructure might logically be financed from a "facility fee" carve-out from usual office visit reimbursement, from supplemental financing from insurance organizations or industry, from subscription fees paid by parents, or from a combination of the above.
  • Approach childcare centers, schools, or other sites that are especially oriented towards serving family needs and elicit their commitment to the program. Although the program can work anywhere, childcare centers with an altruistic mission tend to be more effective partners.
  • Identify and accommodate site-specific needs when possible, as failing to address these needs could have a negative impact on the success of the program. Some medical practices, for example, would rather "squeeze in" telemedicine visits between regularly scheduled patients, whereas others prefer to allocate specific appointment slots for telemedicine visits.
  • Consider sharing telemedicine assistants, especially among smaller childcare centers and schools. A telemedicine assistant with portable telemedicine equipment and wireless broadband technology can serve several sites, leading to enhanced cost-effectiveness (because childcare centers can share the salary and equipment cost).

Sustaining This Innovation

  • Pursue ongoing grant funding to cover the costs of telemedicine infrastructure until agreements about covering infrastructure costs are negotiated successfully.
  • Continually track and share data on the impact of the program; payers will be particularly interested in data showing reduced health care utilization and costs, which will likely encourage them to continue providing reimbursement for program services.

Spreading This Innovation

In the Rochester area, the Health-e-Access telemedicine infrastructure is now also being used for acute illness care among older adults dwelling in senior living communities and for school-based management of common chronic problems of childhood, such as asthma and attention deficit disorder. The Health-e-Access program has also been replicated at My Health-e-Schools, Mitchell and Yancy Counties, North Carolina.

Additional Considerations

  • Children who are more than mildly ill do not go to childcare or school. Thus, to extend the convenience of neighborhood telemedicine access to more families, other neighborhood access sites are important, especially early in the evening (after usual medical office hours) when pediatric emergency departments are busiest.
  • To optimize efficiency and effectiveness of care for acute childhood illness, full integration of telemedicine and telephone management in primary care is critical.
  • Telemedicine enables a high level of elasticity of capacity in health services, allowing providers almost anywhere (including their own homes) to bring their professional expertise to wherever surges in demand for care might occur. This consideration is especially relevant in light of anticipated epidemics (e.g., swine flu).

More Information

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Contact the Innovator

Kenneth M. McConnochie, MD, MPH
Director, Health-e-Access Telemedicine Network
Professor of Pediatrics
University of Rochester Medical Center
Box 777 – Pediatrics
601 Elmwood Avenue
Rochester, NY 14642
(585) 273-4119
E-mail: ken_mcconnochie@urmc.rochester.edu

Innovator Disclosures

Dr. McConnochie 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 Articles

McConnochie KM, Conners GP, Brayer AF, et al. Effectiveness of telemedicine in replacing in-person evaluation for acute childhood illness in office settings. Telemed J E Health. 2006;12(3):308-16. [PubMed]

McConnochie KM. Potential of telemedicine in pediatric primary care. Pediatric in Rev. 2006:27(9):e58-65. [PubMed]

McConnochie KM, Wood NE, Kitzman HJ, et al. Telemedicine reduces absence resulting from illness in urban child care: evaluation of an innovation. Pediatrics. 2005;115(5):1273-82. [PubMed]

McConnochie KM, Connors GP, Brayer AF, et al. Differences in diagnosis and treatment using telemedicine versus in-person evaluation of acute illness. Ambul Pediatr. 2006;6(4):187-95. [PubMed]

McConnochie KM, Wood N, Herendeen N, et al. Integrating telemedicine in urban pediatric primary care: Provider perspectives and performance. Telemedicine and e-Health. 2010;16(3):280-8. [PubMed]

McConnochie KM, Wood NE, Herendeen NE, et al. Acute illness care patterns change with use of telemedicine. Pediatrics 2009;123:e989-95. [PubMed]

Footnotes

1 Cherry DK, Burt CW, Woodwell DA. National Ambulatory Medical Care Survey: 2001 summary. Adv Data. 2003:11(337):1-44. [PubMed] Available at: http://www.cdc.gov/nchs/data/ad/ad337.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)
2 Isaacman DJ, Davis HW. Pediatric emergency medicine: state of the art. Pediatrics. 1993;91(3):587-90. [PubMed]
3 Luo X, Liu G, Frush K, et al. Children's health insurance status and emergency department utilization in the United States. Pediatrics. 2003;112(2):314-19. [PubMed]
4 Nourjah P. National Hospital Ambulatory Medical Care Survey: 1997 emergency department summary. Adv Data. 1999;(304):1-24. [PubMed] Available at: http://www.cdc.gov/nchs/data/ad/ad304.pdf
5 McCaig LF, Ly N. National Hospital Ambulatory Medical Care Survey: 2000 emergency department summary. Adv Data. 2002;326:1-31. Available at: http://www.cdc.gov/nchs/data/ad/ad326.pdf
6 McConnochie KM, Conners GP, Brayer AF, et al. Effectiveness of telemedicine in replacing in-person evaluation for acute childhood illness in office settings. Telemed J E Health. 2006;12(3):308-16.
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Original publication: July 07, 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 13, 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.