The telemedicine intervention in chronic disease management promises to involve patients in their own care, provides continuous monitoring by their healthcare providers, identifies early symptoms, and responds promptly to exacerbations in their illnesses. This review set out to establish the evidence from the available literature on the impact of telemedicine for the management of three chronic diseases: congestive heart failure, stroke, and chronic obstructive pulmonary disease. By design, the review focuses on a limited set of representative chronic diseases because of their current and increasing importance relative to their prevalence, associated morbidity, mortality, and cost. Furthermore, these three diseases are amenable to timely interventions and secondary prevention through telemonitoring. The preponderance of evidence from studies using rigorous research methods points to beneficial results from telemonitoring in its various manifestations, albeit with a few exceptions. Generally, the benefits include reductions in use of service: hospital admissions/readmissions, length of hospital stay, and emergency department visits typically declined. It is important that there often were reductions in mortality. Few studies reported neutral or mixed findings.

Executive SummaryThis document reflects the strongly held views and perspective of a diverse group of healthcare academicians, researchers, providers, and industry representatives from across the country who share a belief in the necessity of healthcare reform and the centrality of telemedicineor information technology-enhanced healthcare-in that reform.The need for reform stems from long-standing problems in our health system, and the central role of telemedicine derives from an ever-expanding body of research and experience that attests to its merit in addressing these problems. Despite the fact that the United States spends more on healthcare than any other country, both in absolute numbers and on a per capita basis, the health status of Americans ranks relatively low when compared with that of people in other developed nations. Moreover, the general discrepancy between expenditures and health status indicators in the United States masks significant differentials among segments of the population, based on socio-economic, geographic, cultural, ethnic, and other factors. Hence, we continue to suffer from inequities in access to healthcare, inefficiencies in the delivery of care, escalating costs, and the prevalence of adverse lifestyles that exacerbate these problems.Much attention has been devoted to the utility of the electronic health records (EHRs) as a means to improving the healthcare system. Yet, despite its potential benefits, the EHR represents only a partial solution to the problems we face. A broader focus on telemedicine (also frequently referred to as telehealth or e-health) that incorporates EHRs is a more prudent and effective approach. We believe that an exclusive concern with developing system-wide EHRs, while laudable and potentially valuable in improving one sector in healthcare delivery, would ultimately increase the cost of care without contributing to necessary changes in the rest of the system. National Telemedicine Initiatives: Essential to Healthcare Reform © MARY ANN LIEBERT, INC. • VOL. 15 NO. 6 • JULY/AUGUST 2009 TELEMEDICINE and e-HEALTH 601 NATIONAL TELEMEDICINE INITIATIVES Telemedicine technology embodies the electronic acquisition, processing, dissemination, storage, retrieval, and exchange of information for the purpose of promoting health, preventing disease, treating the sick, managing chronic illness, rehabilitating the disabled, and protecting public health and safety. Telemedicine systems consist of collaborative health networks, facilities, and organizations dedicated to these objectives. Over the past several decades, telemedicine systems have demonstrated the capacity to do the following: • Improve access to all levels (primary, secondary, and tertiary) of healthcare for a wide range of conditions-including, but not limited to, heart and cerebrovascular disease, endocrine disorders such as diabetes, cancer, psychiatric disorders, and trauma; as well as services such as radiology, pathology, and rehabilitation. • Promote patient-centered care at lower cost and in local env...

This is a prepublication version of an article that has undergone peer review and been accepted for publication but is not the final version of record. This paper may be cited using the DOI and date of access. This paper may contain information that has errors in facts, figures, and statements, and will be corrected in the final published version. The journal is providing an early version of this article to expedite access to this information. The American Academy of Pediatrics, the editors, and authors are not responsible for inaccurate information and data described in this version.

Remote patient management (RPM) offers renal health care providers and patients with end-stage kidney disease opportunities to embrace home dialysis therapies with greater confidence and the potential to obtain better clinical outcomes. Barriers and evidence required to increase adoption of RPM by the nephrology community need to be clearly defined. Ten health care providers from specialties including nephrology, cardiology, pediatrics, epidemiology, nursing, and health informatics with experience in home dialysis and the use of RPM systems gathered in Vienna, Austria to discuss opportunities for, barriers to, and system requirements of RPM as it applies to the home dialysis patient. Although improved outcomes and cost-effectiveness of RPM have been demonstrated in patients with diabetes mellitus and heart disease, only observational data on RPM have been gathered in patients on dialysis. The current review focused on RPM systems currently in use, on how RPM should be integrated into future care, and on the evidence needed for optimized implementation to improve clinical and economic outcomes. Randomized controlled trials and/or large observational studies could inform the most effective and economical use of RPM in home dialysis. These studies are needed to establish the value of existing and/or future RPM models among patients, policy makers, and health care providers.

Purpose: The vulnerability of postacute and long-term care (PA/LTC) facility residents to COVID-19 has manifested across the world with increasing facility outbreaks associated with high hospitalization and mortality rates. Systematic protocols to guide telehealth-centered interventions in response to COVID-19 outbreaks have yet to be delineated. This article is intended to inform PA/LTC facilities and neighboring health care partners how to collaboratively utilize telehealth-centered strategies to improve outcomes in facility outbreaks. Methods: The University of Virginia rapidly developed a multidisciplinary telehealth-centered COVID-19 facility outbreak strategy in response to a LTC facility outbreak in which 41 (out of 48) facility residents and 7 staff members tested positive. This strategy focused on supporting the facility team remotely using rapidly deployed technologic solutions. Goals included (1) early identification of patients who need their care escalated, (2) monitoring and treating patients deemed safe to remain in the facility, (3) care coordination to facilitate bidirectional transfers between the skilled nursing facility (SNF) and hospital, and (4) daily facility needs assessment related to technology, infection control, and staff well-being. To achieve these goals, a standardized approach centered on daily multidisciplinary virtual rounds and telemedicine consultation was provided. Results: Over a month since the outbreak began, 18 out of 48 (38%) facility residents required hospitalization and 6 (12.5%) died. Eleven facility residents have since returned back to the SNF after recovering from their hospitalization. No staff required hospitalization. Conclusions: Interventions that reduce hospitalizations and mortality are a critical need during the COVID-19 pandemic. The mortality and hospitalization rates seen in this PA/LTC facility outbreak are significantly lower than has been documented in other facility outbreaks. Our multidisciplinary approach centered on telemedicine should be considered as other PA/LTC facilities partner with neighboring health care systems in responding to COVID-19 outbreaks. We have begun replicating these services to additional PA/LTC facilities facing COVID-19 outbreaks.

Telehealth and remote monitoring of a patient's health status has become more commonplace in the last decade and has been applied to conditions such as heart failure, diabetes mellitus, hypertension, and chronic obstructive pulmonary disease. Conversely, uptake of these technologies to help engender and support home RRTs has lagged. Although studies have looked at the role of telehealth in RRT, they are small and single-centered, and both outcome and cost-effectiveness data are needed to inform future decision making. Furthermore, alignment of payer and government (federal and state) regulations with telehealth procedures is needed along with a better understanding of the viewpoints of the various stakeholders in this process (patients, caregivers, clinicians, payers, dialysis organizations, and government regulators). Despite these barriers, telehealth has great potential to increase the acceptance of home dialysis, and improve outcomes and patient satisfaction while potentially decreasing costs. The Kidney Health Initiative convened a multidisciplinary workgroup to examine the current state of telehealth use in home RRTs as well as outline potential benefits and drawbacks, impediments to implementation, and key unanswered questions.

A dvancements in technology and broadband have revolutionized the current practice of medicine. The field of pediatric cardiology is no exception given the need for prompt diagnosis and reliance on cardiac imaging to identify infants and children with potentially life-threatening cardiovascular disease. As the relationship between telemedicine and pediatric cardiology has advanced, it has created a need to develop a broad, comprehensive document reviewing all the various aspects of telemedicine in pediatric cardiology. For more than a decade, a significant body of literature has been published describing individual experiences and practices, yet there remains no comprehensive statement or document summarizing this rapidly advancing field. In an effort to describe the collective experience and to provide structure and guidance for pediatric cardiology practitioners and healthcare providers, we have developed a scientific statement on the use of telemedicine in pediatric cardiology.Specific areas explored in this document include both neonatal and fetal teleechocardiography, implications for training community sonographers, pulse oximetry programs, qualitative improvement and appropriate use criteria initiatives, and remote electrophysiological monitoring. This document also includes teleconsultation and teleausculation, direct-to-consumer and home monitoring programs, and a look into the use of telemedicine and pediatric cardiology in the intensive care setting. Furthermore, a detailed review of the legislative, public policy, and legal aspects of telemedicine is provided, along with financial and reimbursement information.Several terms are used in the literature interchangeably; a brief explanation is provided to help readers of this document. The term telehealth is defined as the use of technology to bridge distances in any aspect of medicine; telemedicine is the specific application of technology to conduct clinical medicine at a distance. The term telecardiology is defined as the broad application of telemedicine in the field of cardiology specifically, and tele-echocardiography is the most common application used within this field. ECHOCARDIOGRAPHY AND TELEMEDICINEEchocardiography is the most commonly used noninvasive cardiovascular imaging modality and is considered to be both safe and cost-effective. Tele-echocardiography can be described as a process in which a provider or a technician obtains cardiovascular ultrasound images from a given patient and these images are subsequently transmitted to an offsite location where a cardiologist can provide further analysis and interpretation. Thus, tele-echocardiography enables expert interpretation and consultation in a rapid and potentially geographically disparate fashion, enabling prompt and accurate decision making involving triage, transport, and therapeutic priorities. Tele-echocardiography is now routinely used across the age and subspecialty spectrum in pediatric cardiology.

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