In late November, on the first cold morning of the season, a second-grader at Ducketts Lane Elementary School in Elkridge, Maryland, had trouble breathing during recess.
When the school nurse, Veronica DeSimone, examined the girl, she heard wheezing in her chest and determined that the child was having an asthma attack.
The nurse would have administered relieving medication, but the girl’s parents hadn’t yet signed a permission form or delivered their daughter’s medicine to the Howard County school. The girl’s father, the only parent available, was at work, at least an hour away. There was no time to wait for him to come get his daughter.
Not long ago, DeSimone would have had to call an ambulance to take the child to the emergency room, forcing her to miss the rest of her classes that day.
Instead, DeSimone set up an online video and audio link to a pediatrician at Howard County General Hospital’s emergency room. Having previously received permission from the girl’s parents to participate in the school’s telemedicine program, DeSimone examined her with a digital stethoscope, which allowed the pediatrician to listen to the girl’s lungs remotely.
The doctor quickly confirmed DeSimone’s diagnosis and directed her to administer the necessary medicine. Within 10 minutes, the child was breathing normally and back in class.
Telemedicine, increasingly used in prisons, nursing homes and remote areas, is becoming more common in schools. According to the American Telemedicine Association, at least 18 states authorize Medicaid reimbursement for telemedicine services provided in schools. In addition, 28 states and the District require private insurers to cover telemedicine appointments as they would face-to-face doctor visits.
Telemedicine can’t always replace an in-person examination — a doctor often has to touch a patient, for example, to diagnose the cause of abdominal pain — but it does make it less likely that a child will miss class for a visit to the doctor’s office or ER.
“The piece for me that is so exciting is how many more kids are able to stay in school,” said Heidi Balter, principal of Ducketts Lane, which was outfitted with telemedicine equipment a year ago.
Many states still limit Medicaid reimbursement for telemedicine, and, according to the American Telemedicine Association, 24 states specify settings, such as a doctor’s office, where a patient must be in order to participate in a telemedicine appointment.

Restrictions falling away

In Texas, the state medical board is involved in a legal dispute over its insistence that “a doctor-patient relationship” be established before telemedicine can be used. The dispute, however, doesn’t apply to school telemedicine as long as a school nurse is present.
But as state policymakers become more accustomed to telemedicine and familiar with its benefits, “we’re seeing many of the restrictions falling to the wayside,” said Latoya Thomas, the director of state policy for the American Telemedicine Association.
The impetus for school telemedicine in Howard County came from Ken Ulman, who was the county executive there until 2014. He said he believed that health disparities in lower-income areas of the county were depressing student achievement and that telemedicine might help.
In 2015, the county chose Ducketts Lane and five other elementary schools to be the first to offer telemedicine services. All of the schools drew students from economically disadvantaged areas and all had full-time nurses.
The county found a willing partner in Howard County General, which was looking for ways to expand access to its services. The hospital agreed to pick up the costs of making its emergency room pediatricians available for telemedicine calls from the six schools.

The county government picked up the tab for the $27,000 in telemedicine technology that each school required, including a video monitor, a camera and digital stethoscopes and otoscopes.
Two local pediatric practices also agreed to make their doctors available; unlike Howard County General, they are not forgoing reimbursement but instead are billing and private insurers if the child has such coverage. Maryland Medicaid covers telemedicine only when a doctor or nurse practitioner is present during the exam. (Most school nurses are registered nurses, not nurse practitioners.)

Conjunctivitis vs allergy
Telemedicine doctors are often able to rule out a contagious condition, recognizing, for example, that a student’s reddened eyes are the result of allergy rather than conjunctivitis. “We used to have to send them home on the chance that it was pinkeye,” said DeSimone. “Now we can keep them.”
Last year, the six Howard County schools conducted 150 telemedicine exams. Midway through this academic year, the total was 87. In 98 percent of the cases (excluding contagious illnesses and conditions that could not be treated through telemedicine), the students immediately returned to class.
Other school systems have reported similar results. Studies have also shown that telemedicine in schools reduces trips to the emergency room.
“Not having to pull my child out of school & take him to the pediatrician is a huge benefit,” one parent wrote in a survey about the Howard County program. “Saves time & money.”
In the future, Hobson said, she hopes that telemedicine in Howard County not only will be able to address acute health conditions — the sudden onset of symptoms — but also will help students manage chronic conditions such as asthma, attention-deficit hyperactivity disorder and obesity.
Schools in New York and South Carolina are using school telemedicine for mental health. It is being used for speech pathology in Michigan, and in New Mexico, an effort is underway to use school telemedicine in oral health.
The Medical University of South Carolina provides telemedicine services to 47 schools. James McElligott, the medical director for telehealth at the university’s hospital in Charleston, said he is most gratified by the work the hospital does with Pace Academy, a school for children with multiple disabilities.
In the past, many of those children had to endure minor ailments such as rashes and earaches because it was just too difficult to bring them to a doctor. Now, using telemedicine, the hospital can provide almost immediate relief.
Some doctors say they actually prefer telemedicine encounters to face-to-face exams with children. David Monroe, medical director of the children’s center at Howard County General, said the images provided by the telemedicine instruments are often better than those made by using conventional equipment on a squirming child. “It’s easier because you get this high-definition picture, which I never get otherwise,” Monroe said.

This article was produced by Stateline, an initiative of the Pew Charitable Trusts.

Using telemedicine for school children can decrease the number of days lost to sickness.

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