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The Role of Telemedicine In Child Abuse Medical Evaluations
1. The Role of Telemedicine In Child
Abuse Medical Evaluations
Jordan Greenbaum, MD
Stephanie V. Blank Center for Safe and Healthy
Children
Children’s Healthcare of Atlanta
2. The Problems
• Sexual abuse very common in United
States:
– Estimated 1 in 4 girls, 1 in 7-9 boys
• Physical abuse very common, potentially
very dangerous
• Need (virtually) all children to have
option of exam by qualified professional
– Identify, interpret and treat Injury
– Identify and treat infection
– Provide reassurance to child and family
• Need to minimize trauma to child/family
– No travel long distances
– No have exam by unskilled provider
3. The Problem(s)
• Most medical providers inexperienced, or
reluctant to do abuse exams
• The few trained professionals in Georgia
are isolated, have little interaction
• Need training (esp for physical abuse),
continuing education, second opinions
4. Stakes Are High
• Wrong interpretation of injuries has potential for:
– Placing vulnerable child back in abusive environment
– Wrongly accusing caregiver of abuse
– Breaking up family if child is taken into foster care
– Liability for medical provider/institution
5. Where Do Children Have Their
Exams?
• Community pediatricians/family practice doc’s
• Emergency Department at a community hospital
• Children’s hospital Emergency Department
• Child Advocacy Centers
– Typically focus on sexual abuse exams, not
physical abuse
6. Child Advocacy Centers
• Non-profit organizations of varying size
• Services provided:
– Forensic interviews
– Mental health assessment and treatment
– Medical evaluations (on/off-site)
• Multidisciplinary team investigation
• Exams typically requested by DFCS or law enforcement
• Very limited budgets
• Medical providers of varying background, experience
• Typical center serves several counties in rural Georgia
7. Telemedicine
• Tremendous possibilities IF
– Imaging equipment (colposcope) is compatible
with telemedicine equipment
– Telemedicine equipment provides excellent
resolution
– Imaging equipment and telemedicine
equipment are available (very expensive)
• Colposcope, Intern, software (encrypted)
• T1 line fees
• STARK laws
8. Telemedicine
• Tremendous possibilities IF
– Remote site is interested in providing
services
– Able to recruit and train medical provider to
conduct exams
– Make it EASY to use telemedicine services
– Provide availability for real-time
consultations to fit needs of remote site
9. 2009-2010 Pilot
2
5
• RUS grant 2008 Gainesvi
lle
• Multi-organization collaboration Atlant
L
a
• Launched Jan 2009 Augus
ta
• 5 sites, 29 counties
Swainsb
oro
J
6.3.
11
10. 2009-2010 Pilot
• Services provided: 2
5
– Real-time consultations Gainesvi
lle
– Second opinion photo/case Atlant
L
a
review Augus
ta
– Distance-learning lecture series
for community professionals Swainsb
oro
– Monthly peer review for
medical providers
J
6.3.
11
11. 2009-10 Pilot
• Difficulties marketing to community agencies
– Lack of interest
– Restricted criteria for obtaining exams
– Lack of exams for physical abuse
– Restricted funds for exams
12. 2009-10 Pilot
• Solutions:
– Relationship-building
– MDT presentations
– Working with local CAC
– Distance-learning series
• By end of 2011, ~250 real-time
consultations conducted
13. Expansion of Telemedicine
Network
• Need to convert to cheaper method
– Low cost for equipment and monthly fees
• Began in 2010
• Collaboration:
– Children’s Healthcare of Atlanta
– Child Advocacy Centers of Georgia
– Governor’s Office for Children and Families
• Needs’ assessment:
– Where do kids go for their exams?
– Who are the trained medical providers, and what are their
needs?
– Where is existing GPT equipment, relative to where our
providers practice?
16. Child Advocacy Centers & Telemedicine Sites
1: Scottish Rite, Atlanta
E 2 Telemedicine Hub 2: Synergy Health, Hiawassee
D 3: A Child’s Voice, Loganville
Existing GPT Sites
5 4: Sunshine House, Swainsboro
Future Lync Sites
Non-Telemed CAC 5: Power House for Kids, Toccoa
N 6: Sadie’s House, Douglas
Rome H Gainesville
7: Crescent House/Medical Center of Central
P Georgia, Macon
1 3C L
Q Athens
T A: Firefly House, Albany
Atlanta B: Children’s Advocacy Center of Grady
County, Cairo
R C: Gwinnett Sexual Assault Center &
Augusta
Children’s Advocacy Center, Duluth
D: Appalachian Children’s Center, Ellijay
LaGrangeG E: Child Advocacy Center of the Lookout
7 Mountain Judicial Circuit, Ft. Oglethorpe
Macon F: Helen’s Haven, Hinesville
4 G: Children’s Advocacy Center of Troup
Columbus Swainsboro County, LaGrange
H: Harbor House, Rome
I: Satilla Advocacy Services/Satilla Regional Medical
Center, Waycross
Savannah J: Children’s Advocacy Center of Lowndes
K O
County, Valdosta
F K: The Gateway Center, Cordele
L: The Cottage Children’s Advocacy Center,
Albany A 6
Athens
M: Hero House, Moultrie
M I N: Edmonsdson-Telford Center for Children,
Waycross S Gainesville
O: Coastal Children’s Advocacy Center, Savannah
B Valdosta J P: Harmony House, Royston
Q: Safe Path CAC
R: Rainbow Connection CAC
S: Golden Aisles/St Simmons Pediatrics
6.3.11 T: The Tree House
17. Child Advocacy Centers & Telemedicine Sites
E 2 County served and
has interagency 1: Scottish Rite, Atlanta
D
agreement with 2: Synergy Health, Hiawassee
5 3: A Child’s Voice, Loganville
an existing
telemedicine-capable 4: Sunshine House, Swainsboro
N 5: Power House for Kids, Toccoa
Rome H Gainesville CAC
6: Sadie’s House, Douglas
P 7: Crescent House/Medical Center of Central
3C County served and
1 L Georgia, Macon
has interagency
Athens
Atlanta agreement with a
future telemedicine- A: Firefly House, Albany
capable CAC B: Children’s Advocacy Center of Grady
County, Cairo
Augusta C: Gwinnett Sexual Assault Center &
Children’s Advocacy Center, Duluth
LaGrangeG D: Appalachian Children’s Center, Ellijay
E: Child Advocacy Center of the Lookout
7 Mountain Judicial Circuit, Ft. Oglethorpe
Macon F: Helen’s Haven, Hinesville
4 G: Children’s Advocacy Center of Troup
Columbus Swainsboro County, LaGrange
H: Harbor House, Rome
I: Satilla Advocacy Services/Satilla Regional Medical
Center, Waycross
Savannah J: Children’s Advocacy Center of Lowndes
K O
County, Valdosta
F
K: The Gateway Center, Cordele
L: The Cottage Children’s Advocacy Center,
Albany A 6
Athens
M: Hero House, Moultrie
I N: Edmonsdson-Telford Center for Children,
M
Waycross Gainesville
O: Coastal Children’s Advocacy Center, Savannah
B Valdosta J P: Harmony House, Royston
Q: Safe Path CAC
R: Rainbow Connection CAC
S: Golden Aisles/St Simmons Pediatrics
6.3.11 T: The Tree House
18. Future Directions
• Continue statewide expansion of telemedicine program
• CSEC multidisciplinary teams
• Mental Health mentoring/consultation
• Psychiatric consultation (evaluation for medication)
20. In Summary
•Telemedicine has an important role in child protection
assessments
•Challenges differ from other medical fields
•Need for cheap equipment
•Need for providers with basic training at presenting
site
•Future expansion: medical and mental health
Editor's Notes
Inexperienced providers may not be familiar with current research, may not testify well, may hedge rather than state an opinion, may fail to do thorough workup to rule out other injuries, may not work well with investigators/attorneys. NIS-4 data (2005-2006): 323,000 children experienced demonstrable harm as a result of physical abuse (4.4 per 1000 kids) Endangerment stat’s (children abused who were harmed or at risk of harm): over 476,000 kids (6.5 per 1000) Identifying sentinel injuries may prevent devastating injury in future
Inexperienced providers may not be familiar with current research, may not testify well, may hedge rather than state an opinion, may fail to do thorough workup to rule out other injuries, may not work well with investigators/attorneys. Discuss reasons for children needing exams (reassurance more than anything else)
1 site in Jan 2009, 2 nd at end of 2009, others in 2010 Collaboration: DFCS, GPT, Children’s, 5 local CACs These sites serve approximately 29 of the 159counties in Georgia. The first site began telemedicine services in January 2009 and the most recent 2 sites began in May 2010. In 2006, there were approximately 175,700 children living in the 29 counties and approximately 10,000 reports of child maltreatment. Thus, the potential impact for the local population is enormous.
1 site in Jan 2009, 2 nd at end of 2009, others in 2010 Collaboration: DFCS, GPT, Children’s, 5 local CACs These sites serve approximately 29 of the 159counties in Georgia. The first site began telemedicine services in January 2009 and the most recent 2 sites began in May 2010. In 2006, there were approximately 175,700 children living in the 29 counties and approximately 10,000 reports of child maltreatment. Thus, the potential impact for the local population is enormous.
Talk to MDTs about importance of getting medical exams, availability of telemed
No monthly T1 line fees No intern No expensive colposcope
