This document summarizes a children's telemedicine program and discusses concussions. It provides an overview of the telemedicine program's network partners, clinical services offered, patient volume since inception, and current and future specialties. It then discusses concussions, including definitions, assessment, management, return to play guidelines, and prevention. The goal of the telemedicine program is to make kids healthier through increased access to specialty care using telehealth technologies.

1. …To make kids better today and
healthier tomorrow.
9.9.13

2. Program Development
Children’s
Telemedicine
Program
Children’s
Physician Group
at Children’s
Specialty Services
Subspecialis
t at Egleston
Children’s
Physician Group
at North Druid
Hills
Marcus
Autism
Additional Clinic
Space
Subspecialis
t at Scottish
Rite
Stephanie
Blank Center
for Safe and
Healthy
Children
• 501(c)3 – Not for Profit
• Network of Partners
• Minimal Partnership Fees:
 Field-Based Telehealth Liaisons
 Support for Credentialing
 Scheduling System
 Centralized PACS System
 24/7 support for network
partners
 Access to Network
Our Program Our Network Partner

3. Clinical Services Offered
Current Specialties and Number of Physicians:
• Allergy and Immunology (1)
• Autism (1)
• Cardiology (1)
• Child Protection (3)
• Concussion/Neurosurgery (1)
• Endocrinology (1)
• Fetal ECHO (9)
• Gastroenterology (1)
• Nephrology (2)
• Pulmonology (2)
• Sports Medicine/Concussion (1)
Coming soon:
• Autism (1)
• Apnea (1)
• Ear, Nose, Throat (1)
• Transplant (1)
• Neurology-Keto patients only (1)
• Pulmonology (1)
Telemedicine: Working Together for Better Care

4. Patient Volume
88
461
823
971
767
0
200
400
600
800
1000
1200
2009 2010 2011 2012 2013
Total/Overall
Number of Patients Seen
Through October 2013
92
355
524
971
91
231
445
767
0 200 400 600 800 1000 1200
CSHC
Specialist
Marcus
Total
2012 - 2013
Through October 2013
Number of Patients Seen
2013
2012
Number of Patients Since Inception: 3,110

5. CONCUSSION:
The Facts and Controversy
David M Popoli, MD
Pediatric and Adolescent Sports Medicine
Medical Director for Telemedicine

6. The Statistics
• 2008 (ED data)
– 60 million youth 5-14 yr in organized sports
– 3.8 million concussions from sport and
recreation
– Underestimated due to under-reporting (1)
• 2009-2010 (H.S. Reporting Information
Online)
– 192 High Schools
– 1056 Concussions

7. Objectives
• Define concussion
• Explain concussion pathway
• Discuss treatment and prevention
• Georgia Return to Play Act 2014
• Discuss controversies

8. Definition
• Consensus Guidelines 2012
• Characteristics
1. Direct or impulsive force
2. Rapid onset
3. Functional
4. Clinical symptoms
5. No abnormality on standard imaging

9. This is Not a “Bump on the Head”

10. The Big Picture

11. What’s Really Happening
Twist/Stretch “Leaks”
Electrical
discharge
Recharge
Mechanical Injury leads to

12. Assessment – What You’ll Be Told
• Symptoms
• School performance
• Activity tolerance
• Sleep
• Appetite
• Mood

13. Assessment -- Symptoms
• Loss of Consciousness
• Amnesia, retrograde or anterograde
• Disorientation
• Appearing dazed
• Acting confused
• Forgetting game rules or play assignments
• Inability to recall score or opponent
• Inappropriate emotionality
• Physical incoordination
• Imbalance
• Seizure
• Slow verbal responses
• Personality changes
• Headache
• Headache
• Nausea or vomiting
• Difficulty balancing
• Vision changes
• Photophobia
• Phonophobia
• Feeling “out of it”
• Difficulty concentrating
• Tinnitus
• Drowsiness
• Sadness
• Hallucinations

14. Assessment – What You’ll Be Told

15. Assessment – What You’ll See
• Mental status
• Coordination/Balance/Walking
• Strength
• Sensation

16. Technology and Concussion
Management
• Computerized neuropsychological testing
• Telemedicine/telehealth

17. Computerized Neuropsychological Testing

18. Computerized Neuropsychological Testing
0
10
20
30
40
50
60
70
80
90
100
Baseline Post Injury
1
Post Injury
2
Post Injury
3
Verbal Memory
Visual Memory
Processing Speed
Reaction Time
6 Days Post 16 Days Post 23 Days Post
Percentile

19. Telemedicine/Telehealth
• Improved clinical reach
• Improved education/awareness
• Convenience
• Cost
• Piece of mind

20. Current Sites
20
*Map and total does not include Child Advocacy Centers
• Participating with 43 presenting
sites throughout Georgia*
• 11 specialties with 23 physicians
- Future: 14 specialties 27 physicians
• Types of presenting sites
- Hospitals
- Primary care offices
- Schools
- Public Health Departments
- DFCS offices

21. Our Community…
21
Research – Abstract accepted by
Pediatric Academic Society
“Resource Savings, Family and
Societal Benefits of a Statewide
Pediatric Telemedicine Program”.
• Patients served live in 63 of the Georgia’s 159 counties
• 40% of all counties
•All outside of the MSA
• 83% of our patients are covered by Medicaid /CMO’s
• Overall cost of miles saved: $171,083 (0.55/mile)
2012 Statistics…Per visit: Median
(Round Trip)
Range
(Round Trip)
Miles Saved 333 72-524
Cost of miles saved $177 $39-$273
Hours Saved Traveling 5.8 2.0-9.0
School days
*Children greater than 5 y/o
76% of our patients would have missed
school to travel to Atlanta
Work Days Missed
*One adult present
>75% of our parents would have missed
a full day of work to travel to Atlanta

22. Management
• Physical and cognitive rest
• Academic accommodations
• RTP stages
• Imaging*
• Medication*

23. Academic Accommodations Algorithm

24. Georgia Return to Play Act
• All public and private schools which provide youth athletic activities
are required:
– Provide information to parents on the nature and risk of concussion and head injuries
– Establish a concussion management and return to play policy to include:
• An Information sheet prior to the beginning of each athletic season
• Youth athlete must be removed from play if exhibiting symptoms
• Youth athlete must be cleared by a healthcare provider before return to play
• Public recreational programs are also required to provide information
to parents on the nature and risk of concussion and head injuries
• Georgia Department of Public Health shall endorse one or more
concussion recognition education courses to inform Georgia citizens of the
nature and risk of concussions in youth athletics
• Effective date: January 1, 2014

25. Return to Play
Stage Exercise Goal
1 None Recovery
2 Light Aerobic Increase HR
3 Sport-Specific Add movement
4 Non-Contact Drills Coordination
5 Controlled-Contact
Drills
Restore
Confidence
6 Full Contact Practice Game Ready
7 Competition Play

26. Cumulative Effects

27. Prevention
• Mouthguards
• Helmets
• Rules/regulations
• Style of play

28. More Information
• Children’s Healthcare of Atlanta
• Centers for Disease Control and Prevention