Pediatric inpatient care in community hospitals is often limited by budget constraints and regionalization of children’s health services.1 Many smaller hospitals struggle to maintain around-the-clock, in-house pediatric presence, which can lead to delays in admission or the need to transfer pediatric patients to tertiary referral centers. These pressures have intensified as pediatric hospital medicine faces a growing shortage of clinicians and a rising burden of clinical and administrative responsibilities.2,3In response, many health systems are exploring ways to sustain community-based pediatric care while preserving safety and quality. Telemedicine has been successfully used in adult medicine for critical care, stroke, and hospitalist coverage.4,5 Pediatric subspecialties have similarly leveraged telehealth for remote subspecialty consultations, chronic disease management, and behavioral health support.6,7 In this issue of Hospital Pediatrics, Van Muers and colleagues expand the role of telemedicine, providing descriptive data for a pediatric telehospitalist program in which a pediatric hospitalist uses telemedicine, ie, synchronous, bidirectional audiovisual communication, to conduct remote overnight admissions and manage patient care from afar.8In this commentary, we explore the potential benefits and challenges of a pediatric telehospitalist model to support local pediatric care in community hospitals, including safety, appropriate use, workflow and medico-legal concerns, patient and family experience, and equity. Throughout, we discuss necessary future investigations and guiding principles for safe, equitable implementation for future telehospitalist models.The telehospitalist model has many potential benefits. By helping to sustain 24/7 access to pediatric expertise, the model has the potential to help facilitate more timely decision-making and initiation of treatment, minimizing delays in care and need for emergency department (ED) boarding, as well as unnecessary interhospital transports. In this sense, it aligns well with health systems’ efforts to preserve care closer to home, improve bed use, and optimize pediatric capacity.9 It also provides support for community nurses and emergency physicians who may have less expertise in caring for pediatric patients10 while preserving the pediatric hospital medicine workforce by allowing for more flexible scheduling, potentially improving hospitalist retention and mitigating burnout.11However, despite its promise, the telehospitalist model raises important considerations and complex challenges that must be addressed before broader implementation. Foremost among its challenges are the clinical limitations. The virtual format of telehospitalist evaluation inherently limits physical assessment.12,13 Subtle clinical findings such as perfusion, respiratory effort, and tone can be difficult to appreciate remotely, even with the highest-quality video. This limitation could have unintended consequences in terms of both safety (eg, patients who are sicker than initially evaluated) and necessity of hospitalization (eg, patients who are not as sick as initially evaluated and may not have required inpatient admission).Although Van Muers and colleagues observed few safety events, the reported 3% care escalation rate exceeds average postadmission unexpected intensive care unit transfer rates of 1%.14 This difference merits attention but should be interpreted cautiously because the present study’s small sample size limits precision for estimating rare safety outcomes. In fact, the highest-risk safety events within the pediatric population are quite rare; therefore, detection of meaningful differences among care models may require substantially larger patient volumes. To support safe care delivery, telehospitalist programs should also define inclusion and exclusion criteria to delineate which patients are appropriate for virtual admission decisions and which require in-person evaluation. Furthermore, contingency planning to ensure an appropriate response in the event of deterioration following admission is critical to patient safety. In the presently described telehospitalist model, the telehospitalist could contact the community-based on-call physician for in-person evaluation.Another important question is whether overnight admissions conducted by the telehospitalist were clinically necessary. The authors report a median length of stay of less than 1 day, noting that this duration was shorter than prior published estimates for children admitted by in-person physicians. Although the authors infer that this is because of selection bias, with more-complex patients being less likely to be admitted by telehospitalists, another interpretation is that some patients admitted by the telehospitalist may not have required admission if evaluated in-person. This potential concern of overuse, with potentially avoidable admissions and unnecessary interventions, should be further explored before considering a telehospitalist model for broader implementation.In addition to the aforementioned clinical concerns, the telehospitalist model presents important workflow, medico-legal, and reimbursement considerations. Success will rest on well-defined processes among ED physicians, the nursing team, the telehospitalist, and the in-person hospitalist, with clear expectations for documentation, order entry, appropriate physician contacts, and handoffs. Telemedicine audiovisual platforms must be highly reliable, with robust information technology support and, ideally, integration with the local electronic health record. Credentialing, licensure, and malpractice coverage across facilities must be clarified in advance. Policies should define the physician payment structure when covering multiple institutions, as well as billing mechanisms, while accounting for ongoing variability and instability in telemedicine reimbursement among insurers.The patient and family experience must also be carefully studied. Whereas many families have expressed satisfaction with telemedicine in certain scenarios, some families may express hesitation when their child is evaluated by a remote physician in an emergency setting.12 Although technology allows physicians to be virtually “present,” it introduces a physical and relational distance to the patient-physician relationship in comparison with in-person evaluation. Prior work in pediatric telemedicine emphasizes the importance of clear communication, empathy, and visible collaboration between on-site and remote physicians in overcoming this distance to maintain compassionate connection between patients and their health care team.15Finally, equity is a central consideration in adopting a telehospitalist model. Telehospitalist coverage must not create a 2-tiered system in which resource-limited hospitals receive less-comprehensive care, with telemedicine serving as a rationale for further reducing local pediatric investment. Prior work has shown that rural-residing children with medical complexity are more likely than their urban counterparts to present to hospitals without dedicated pediatric services.16 This pattern underscores the structural vulnerability of rural and community settings where limited pediatric staffing and infrastructure often necessitate interfacility transfer for patients with higher illness severity or complexity. Telehospitalist services should serve as an adaptive strategy that improves equitable access to pediatric expertise across the region, augmenting, rather than replacing, the in-person pediatric workforce that currently exists in community settings.After the aforementioned research is conducted to more clearly define appropriate scope, delineate workflows and policies, and ensure equity and positive patient experience, successful implementation of telehospitalist programs will require ongoing structured planning, iterative evaluation, and transparent collaboration between tertiary and community partners. Process and outcome metrics, such as ED-to-admission time, transfer rates, family experience, and safety events, should be well-defined and tracked over time.17 Real-time feedback from nursing teams, emergency physicians, families, and hospitalists must be incorporated into iterative Plan-Do-Study-Act cycles to refine operations and support sustainability.In conclusion, telehospitalist programs offer a promising evolution in pediatric hospital medicine, particularly to ensure pediatric expertise for lower-resourced community settings. By leveraging technology to extend the reach of skilled pediatric hospitalists, they can sustain local access to pediatric care, support community health care teams, and strengthen regional systems of care. However, the success of such models will rely not only on technological capability, clearly defined workflows, and supportive policies but also on building a strong foundation of trust that ensures patient safety, appropriateness of care, equity, and a strong patient and family experience of care. With these prerequisites, we can reimagine what it means to be present for our patients and communities in an increasingly connected world.
Hamline et al. (Mon,) studied this question.