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SYSTEMATIC REVIEW
published: 17 March 2021
doi: 10.3389/fped.2021.630365
Frontiers in Pediatrics | www.frontiersin.org 1March 2021 | Volume 9 | Article 630365
Edited by:
Mark Lo,
University of Washington,
United States
Reviewed by:
Alexis Rybak,
Assistance Publique Hopitaux De
Paris, France
Mark Graeme Coulthard,
Children’s Health
Queensland, Australia
*Correspondence:
Louise Tully
louisetully@rcsi.com
Specialty section:
This article was submitted to
General Pediatrics and Pediatric
Emergency Care,
a section of the journal
Frontiers in Pediatrics
Received: 17 November 2020
Accepted: 19 February 2021
Published: 17 March 2021
Citation:
Tully L, Case L, Arthurs N, Sorensen J,
Marcin JP and O’Malley G (2021)
Barriers and Facilitators for
Implementing Paediatric Telemedicine:
Rapid Review of User Perspectives.
Front. Pediatr. 9:630365.
doi: 10.3389/fped.2021.630365
Barriers and Facilitators for
Implementing Paediatric
Telemedicine: Rapid Review of User
Perspectives
Louise Tully 1
*, Lucinda Case 2, Niamh Arthurs 2, Jan Sorensen 3, James P. Marcin4and
Grace O’Malley 1,2
1Obesity Research and Care Group, School of Physiotherapy, RCSI University of Medicine and Health Sciences, Dublin,
Ireland, 2W82GO Child and Adolescent Weight Management Service, Children’s Health Ireland at Temple Street, Dublin,
Ireland, 3Healthcare Outcomes Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland, 4Department of
Pediatrics, University of California Davis School of Medicine, Sacramento, CA, United States
Background: COVID-19 has brought to the fore an urgent need for secure information
and communication technology (ICT) supported healthcare delivery, as the pertinence
of infection control and social distancing continues. Telemedicine for paediatric care
warrants special consideration around logistics, consent and assent, child welfare and
communication that may differ to adult services. There is no systematic evidence
synthesis available that outlines the implementation issues for incorporating telemedicine
to paediatric services generally, or how users perceive these issues.
Methods: We conducted a rapid mixed-methods evidence synthesis to identify barriers,
facilitators, and documented stakeholder experiences of implementing paediatric
telemedicine, to inform the pandemic response. A systematic search was undertaken
by a research librarian in MEDLINE for relevant studies. All identified records were
blind double-screened by two reviewers. Implementation-related data were extracted,
and studies quality appraised using the Mixed-Methods Appraisal Tool. Qualitative
findings were analysed thematically and then mapped to the Consolidated Framework
for Implementation Research. Quantitative findings about barriers and facilitators for
implementation were narratively synthesised.
Results: We identified 27 eligible studies (19 quantitative; 5 mixed-methods, 3
qualitative). Important challenges highlighted from the perspective of the healthcare
providers included issues with ICT proficiency, lack of confidence in the quality/reliability
of the technology, connectivity issues, concerns around legal issues, increased
administrative burden and/or fear of inability to conduct thorough examinations with
reliance on subjective descriptions. Facilitators included clear dissemination of the
aims of ICT services, involvement of staff throughout planning and implementation,
sufficient training, and cultivation of telemedicine champions. Families often expressed
preference for in-person visits but those who had tried tele-consultations, lived
far from clinics, or perceived increased convenience with technology considered
telemedicine more favourably. Concerns from parents included the responsibility
of describing their child’s condition in the absence of an in-person examination.
Tully et al. Review: Implementation of Paediatric Telemedicine
Discussion: Healthcare providers and families who have experienced tele-consultations
generally report high satisfaction and usability for such services. The use of ICT to facilitate
paediatric healthcare consultations is feasible for certain clinical encounters and can work
well with appropriate planning and quality facilities in place.
Keywords: telemedicine, telehealth, e-health, digital health, paediatrics, implementation
INTRODUCTION
Telemedicine is an umbrella term for the use of information
and communication technologies (ICTs) to facilitate remote
consultations and deliver healthcare using computers and
smart devices such as smart phones and tablet computers.
Whilst the potential applications of telemedicine are all-
encompassing, particularly in remote and underserved regions or
for populations living with medical conditions for whom travel
to healthcare appointments may be particularly burdensome,
the emergence of the COVID-19 pandemic has significantly
emphasised the need for secure ICT-supported healthcare. For
healthcare delivery in particular, a need for safe alternatives to
in-person care has rapidly come to the fore. During periods
of rapid transmission of the virus, emergency department
visits have sharply declined (1,2) and routine screening and
consultations have been virtually non-existent in many regions
for long periods since the COVID-19 pandemic (3–5). This
has resulted in a rapid and widespread increase in use of
telemedicine and expansion of electronic healthcare to meet
demand (6). It is likely that the need for infection control
and social distancing measures will continue and may increase
throughout the influenza and respiratory syncytial virus seasons.
Reliable, secure, high-quality telemedicine will be vital for
the continuation of healthcare services, particularly for those
most vulnerable.
Telemedicine for paediatric care warrants special
consideration around logistics, consent and assent, child
welfare and communication issues that may differ to adult
services (Figure 1) (7). There is no systematic evidence
synthesis available that outlines the implementation issues for
incorporating telemedicine to paediatric services generally, or
how users perceive these issues. We sought to identify factors
that affect the establishment of virtual paediatric care in order
to inform and equip those that need to urgently implement
telemedicine (8), and assist paediatric service delivery in the
longer term. Indeed, as noted by Ross et al. implementation does
not stop with “go live” and therefore this review also informs
those that have already implemented telemedicine (9). We
aimed to achieve this by synthesising scientific studies that have
documented barriers, facilitators, user attitudes and experiences
of implementing paediatric telemedicine.
Abbreviations: HCP, Healthcare Professional; ICT, Information and
Communication Technology; MMAT, Mixed-Methods Appraisal Tool; CFIR,
Consolidated Framework for Implementation Research.
METHODS
We conducted a rapid systematic review (10,11), using a
concurrent mixed-methods evidence synthesis methodology
(12). This review was registered on PROSPERO (registration
number CRD42020184115).
A search strategy was developed and run in the MEDLINE
database by a research librarian (Supplementary Image 1).
We included any study examining aspects of implementing
telemedicine for paediatric care, published in English
between 2005 and 2020. This included studies whereby the
technology facilitated paediatric consultations for patients
and their caring adults. Studies were included if they assessed
telemedicine undertaken in a clinical setting by healthcare
professionals (HCPs) including physicians, surgeons, allied
health professionals and nurses. References of relevant articles
were also reviewed for eligibility. Full inclusion and exclusion
criteria are available in the Supplementary Table 1.
All titles/abstracts and all potentially eligible full texts were
screened by two of the three reviewers (LT and LC/NA).
The reviewers discussed all conflicts and a consensus decision
was made regarding inclusion. Data (study and participant
characteristics, methods, findings consistent with the aims of
this review) were extracted to Microsoft Excel and the Mixed-
Methods Appraisal Tool (MMAT) (13) was used to assess
the quality of included studies and risk of bias at outcome
level. A randomly selected 20% portion of the extraction
and assessment were independently verified (by LC/NA) to
ensure quality.
Qualitative findings were coded (by LT) and analysed by
the analytical themes identified from the developed code
structure. We used thematic analysis, with guidance from
Thomas and Harden (14). This process involves adding
descriptive codes to the data and combining these to categorise
the findings into themes using an iterative process. The
identified barriers and facilitators were mapped to the constructs
within the Consolidated Framework for Implementation
Research (CFIR) (15), which involved categorising findings
according to whether they are intervention-, individual-,
setting- or process-specific (Table 1). Quantitative findings were
summarised narratively.
RESULTS
Eligible Studies
We identified 207 records in total from database searching
and one additional title while scanning the references
of the articles (Figure 2). Title and abstract screening
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Tully et al. Review: Implementation of Paediatric Telemedicine
TABLE 1 | Summary of barriers and facilitators for implementation of telemedicine assessed qualitatively.
CFIR construct Barriers/challenges Facilitators
Intervention characteristics:
Source
Evidence strength and quality
Relative advantage
Adaptability
Trialability
Complexity
Design quality and packaging
Cost
• Lack of buy-in for need
• Perception of additional work, complex,
onerous
• Uncertainty legality/credentialing
• Fear of litigation
• Lack of insurance coverage
• Lack of confidence in the technology to be
reliable
• Fear of embarrassment (unreliable technology)
• Outsider implementing programmes out-with
perceived needs
• Perceived convenience, time & money savings
for families
• Perceived opportunity for learning
• Straight-forward technology
• “Plan B” protocols e.g., photos to
complement poor video image
Outer setting:
Patient needs and resources
Cosmopolitanism
Peer pressure
External policies and incentives
• Misaligned incentives: loss of patients =loss of
earnings
• Perception that management get to “fly the flag”
at any cost to staff
• Trust in providers ensures privacy
Inner setting:
Structural characteristics
Networks and communication
Culture
Implementation climate
Readiness for implementation
• Implementation climate: perception of being
tested or monitored
• Fear of being replaced
• Insufficient time/staff
• Inadequate/no compensation
• Paternalistic tone of remote colleagues
• Clear dissemination of telemedicine aims to all
users
• Reallocating administrative tasks away from
those expected to use technology
• Ability to offer wider services and thus better
care
• Calm and supportive tone among remote
specialists
• Equipment that fit into the environment
• Strengthened relationships with outside teams
Individual characteristics:
Knowledge and beliefs about the
intervention
Self-efficacy
Individual stage of change
Individual identification with the
organisation
Other personal attributes
• Lack of familiarity between clinician and family
• Lack of proficiency with technology
• Working alone at home preventing interaction
with colleagues
• Reliance on subjective descriptions by parents
& non-medical factors
• Having the option (for families)
• Values: valuing effective care over
reimbursement
• Acknowledgement of cognitive bias which
may influence decision-making
Process:
Planning
Engaging
Executing
Reflecting and evaluating
• Unclear aims goals of telemedicine service-
inappropriate use
• Early comprehensive training, including
communication training
• Communication of the value of telemedicine—
“selling it”
• Allocated team time for debrief/reflecting with
colleagues
• Clarity on when to use telemedicine
• Champions for telemedicine (for each
discipline)
• Accessible technical support
• Appropriate triaging and referrals
• Designating a suitable area for
tele-consultations
• Thorough planning and involvement of end
users at all stages of planning
and implementation
excluded 110 records, while full text screening excluded
71. We identified 27 eligible studies; 19 quantitative studies
(16 quantitative descriptive, two RCTs and one non-
randomised trial); five mixed-methods studies, and three
qualitative studies. All studies and their characteristics
are listed in Supplementary Table 2. There was initially
86.4% agreement on screening decisions between reviewers
(179/207 decisions), which increased to 100% agreement
after discussion.
Quality Appraisal
The full quality appraisal results, as presented according to the
MMAT items, can be seen in Supplementary Table 3. To briefly
summarise the quality of included studies, most quantitative
descriptive studies (which represented 16/27, 59% of the included
studies) were generally moderate to low quality. The primary
reason for low scores was ambiguity or low quality relating
to the instrument used for assessing attitudes/experiences
among participants (i.e., the tool used, its development, validity
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Tully et al. Review: Implementation of Paediatric Telemedicine
FIGURE 2 | PRISMA flow diagram.
or reliability, appropriateness within the specific setting), in
addition to unclear reporting of response rates or whether
the samples surveyed were representative. Three trials (16–18)
were of high quality. However, the study by Cady et al. (16)
only assessed the outcomes of interest for this review as open-
ended feedback post-intervention. The mixed-methods studies
consisted of two high quality papers and three lower quality. One
study scored low based on an unclear research question and thus
inability to assess whether the design was best placed to answer
it, while two scored low due to insufficient detail presented for
assessment of the qualitative components. The three qualitative
studies were generally of high quality.
Qualitative Synthesis
The themes identified from the qualitative and mixed-methods
data are described below. Table 1 summarises the barriers and
facilitators for implementation of telemedicine as presented
within these themes, according to the domains of the
CFIR framework.
Buy-In
Several issues were described relating to participant buy-in for
the use of telemedicine as an alternative for in-person paediatric
care, or as a tool for accessing specialist care remotely. Among
HCPs, buy-in to the benefits of and need for telemedicine was
an important facilitator for its uptake and use (19), and there was
apprehension expressed by some providers about its introduction
to paediatric services (20). Uscher-Pines et al. reported that HCPs
believed that video conferencing was being proposed for cases
whereby a “phone call would suffice,” adding additional work
and unnecessary complexity (19). Other barriers were related
to the perception that they were being tested or monitored, or
that it would increase the potential for having their decisions
questioned (19,20), specifically whereby the telemedicine service
was between a remote site and a specialist hub. Participants in
one study (20) proposed increased reassurance to staff that these
were not the aims of the telemedicine service, in order to increase
uptake and buy-in (21).
If providers suspected that the use of telemedicine would be
onerous, complex or that the technology would be unreliable,
they were less likely to use it according to one study (21).
Initiating care through telemedicine without previous familiarity
of a family/case was also cited as a concern among providers
(22). Participants suggested various strategies for facilitating buy-
in including early comprehensive training in the technology
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Tully et al. Review: Implementation of Paediatric Telemedicine
to increase comfort with its use, accommodating time for
implementation by redirecting other time-consuming tasks away
from busy providers (19), and communicating the value and
potential benefits widely to potential users in advance (19,
23). Some patients and families had reservations about tele-
consultations with unfamiliar clinicians, or those with whom they
did not have a relationship. Choice between telemedicine and
face-to-face care was a suggested facilitator for buy-in among
families (24).
“I would like to think that this is something that is going to be a part
of the care, not is going to become the norm. So that would bother
me, because I think it’s still important to be able to have that option
to come in and have your child seen, vs. ‘Oh, I think if we just do
a conference call we’re fine.’ I don’t. . . I’d like to see, you know—I
don’t know. That would just be a concern of mine” (24).
Financial, Regulatory, and Legal Considerations
Concerns were raised by HCPs across multiple studies around
the legality of care using telemedicine. One study reported that
providers had serious reservations about telemedicine due to
their inability to assess risk in paediatric patients the same way
they could during an in-person visit, in addition to the risk of a
misdiagnosis, resulting in a fear of litigation arising from its use
(22). This fear influenced HCPs’ decisions made via telemedicine.
“Everything was documented since I had more concern in this
work about lawsuits. The documentation was very detailed and
meticulous. There were those I would return to after a few hours...
the inability to examine closely certainly influenced, and it is
difficult to make decisions in this consultation. I did not feel
confident enough to make decisions. . . ” (22).
The issue of credentialing, the process of ensuring legitimacy
of care through the medium of telemedicine, was discussed in
detail and described as onerous and time-consuming (19). A
variety of interpretations of the need for specific credentialing
for telemedicine was reported across different sites, which varied
from this being a barrier for uptake due to local laws, to some sites
concluding that no additional credentialing was necessary (19).
Karlsudd et al. reported that, where families waived their
right to confidentiality, it facilitated a more open exchange
of information and allowed for efficiency in terms of multi-
disciplinary care (25). From the perspective of the patient/family,
parents had little concern related to privacy, though did report
hoping it was well-managed by the healthcare organisation (24).
Uptake of telemedicine among families was found to depend
heavily on whether insurance companies were willing to
reimburse care by this means (24). One study found that the
administrative time spent organising billing for telemedicine was
reported to be too time consuming, and that lack of insurance
coverage in addition to inadequate reimbursement for tele-
consultations were perceived to be major barriers for the long-
term sustainability of telemedicine (19).
Relative Advantages vs. Opportunity Costs
The advantages of telemedicine for patients and families were
widely recognised to include time saved by avoiding travelling
to appointments (25), with the consequential effect of reduced
absenteeism from school for patients and work for parents/carers
(24,26), reducing stress and burden for families (19,24). This
was reported to result in financial savings for families also,
related to travel and associated expenses (26). Some observed
benefits went much further than convenience however, with
the implementation of telemedicine allowing for access to
appropriate and timely specialist care for children far beyond
what had previously been available, particularly in remote areas
(19,20,24,26). HCPs who participated in one study expressed
relief at the enhanced capacity that telemedicine allowed for (26).
The same study found that rural families saw the ability to
connect with tele-psychiatry and its benefits as an opportunity
to become active members of their community again. Families
expressed a sense of hope as a direct result of the implementation
of this service, with a suggestion that this could even contribute
to the stability of rural communities. For children with chronic
illnesses, it was reported that telemedicine was viewed by families
as offering the potential to streamline access to multi-disciplinary
care and also reduce the risk of cancellation of appointments due
to illness.
“There are times when she’s too weak to get up, and I’ve had to
cancel appointments. Instead of cancelling, I would have loved to
have had the ability to say, ‘Hey, she can’t get up today. I don’t want
to cancel. Here you know, let’s video-conference and discuss what’s
going on’.. . ” (24).
Ray et al. also reported that families expressed feeling that
telemedicine would allow for reassurance and reduced anxiety
about a child’s condition between in-person hospital visits,
and could also allow for more logical/efficient scheduling for
healthcare, one example given being a screening/triage system to
assess need for an in-person visit, and therefore increase the value
of in-person care (24).
Change Management
In contrast, however, telemedicine was widely reported to be
additional work on a practical level from the perspective of HCPs,
and in particular its implementation tended to involve what staff
perceived as excess paperwork/administrative tasks (19,20,27).
This was compounded in cases by ICT illiteracy resulting in
tasks being completed manually by those not proficient with the
software (27). Some HCPs added that using telemedicine, which
often meant working out of their own homes, was sometimes
isolating and that the inability to run cases, issues and ideas
past colleagues in the clinical environment was a drawback
(22). In some cases, these issues were expressed with frustration
that this work came without additional compensation, although
other providers acknowledged feeling that the ability to provide
effective care was more valuable than reimbursement (19).
On a more profound level, providers also expressed concerns
around the broader pathways associated with implementation of
telemedicine, whereby offering a one-time consultation would
not be a solution to patients for whom there was a dearth
of access options (26). Participants in another study expressed
apprehension around misaligned incentives also, within a
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Tully et al. Review: Implementation of Paediatric Telemedicine
jurisdiction whereby healthcare provision is often for-profit, and
therefore losing patients equated to loss of earnings/income and
so, introducing telemedicine for remote care was not always in
the interests of everyone involved (19). Haimi et al. on the other
hand found that in some cases providers did not view saving
money for the healthcare service/system to be a priority when
considering the use of telemedicine (22).
Impact on Quality of Care
The use of telemedicine was reported to both positively influence,
and at times hinder clinical decision-making among providers.
The support of specialist input to satellite healthcare providers
for instance, was found to instil confidence and reassurance in
the ability of local providers to give appropriate care (20,26). In
some cases however, the fear of having their clinical judgement
questioned or having a decision overturned as a result of using the
telemedicine service was a barrier to uptake of the service (19).
Some clinicians discussed how telemedicine could not replace
in-person consultations with families, and this was a source
of apprehension about its use. Others were reassured that
video allowed for an opportunity to provide care rather than
nothing/only a phone call, despite being seen as inferior to
in-person care (22). Among those who were less confident in
their ability to make judgements via telemedicine, the worry
of children’s inability to express symptoms, in addition to
frustration at being unable to gather sufficient information whilst
under time pressure given the acute nature of paediatrics, was
described as being a primary source of worry. Many participants
discussed their need to rely on subjective descriptions provided
by parents (22). This was echoed by parents in another study
who felt under pressure to provide accurate descriptions of
their child’s condition and feared they would not convey all the
necessary information, which increased their anxiety about the
process (24).
“I suppose the fact that they can’t really see him, I guess, and if I can’t
really say for sure what’s wrong with him. . . if I couldn’t explain
what’s going on with him, I might make it sound not as bad as it
actually is or I might make it sound worse” (24).
In contrast, other parents saw telemedicine as an opportunity
for better access to care and timely diagnoses (24), though
from a provider perspective, some talked about the conflict
of “good service vs. proper medicine,” whereby they felt the
need to oblige parents who misused the telemedicine service for
convenience (22).
Healthcare providers interviewed by Haimi et al. discussed
the non-medical factors they relied on to help guide decisions
where needed, and these included parents’ tone of voice,
perceived health literacy of the parent and their perceived ability
to make shared decisions with the family. Some participants
acknowledged the need for awareness of their own cognitive
biases that may affect judgement in such circumstances, an
example of this being the perception of a family’s socioeconomic
status, which participants cited as one factor considered when
making decisions using telemedicine (22). The same study found
that younger physicians, and those who had studied medicine in
less “conservative or patriarchal” cultures tended to be better able
and more open to shared decision-making with families.
Reliability and Usability of Technology
Issues with the usability and complexity of the technical
platforms for facilitating telemedicine were widespread across
studies. Their quality, reliability and the proficiency of clinical
users were major factors in determining its acceptance and
uptake among staff (19,22,27,28), and some families
(24). Participants discussed connectivity issues reducing their
utilisation of telemedicine (27), with long setup times, audio-
visual issues (21,22), and “background fears” of something going
wrong constantly affecting the quality of a consultation (20).
Some clinicians described feeling embarrassed by these issues,
which were often beyond their control. This issue was not unique
to older studies, with the issue observed in those published up
to 2018.
“Equipment can be hard to use and it looks like you don’t know
what you are doing to the person on the other end. It is an ongoing
challenge to keep people competent when volume is low” (19).
Insufficient training on the telemedicine equipment/technology
was a reported source of technical problems in the same studies
where ICT illiteracy was a cited major barrier to uptake of
telemedicine (19,27). Other interviewees however noted that
confidence with the technology grew with increased use and
experience of tele-consultations (22). Some clinical staff made
suggestions for potential facilitators for smooth implementation,
including having the facility for families to send photos when
video quality was insufficient (22) and ensuring access to
all necessary medical records via the telemedicine software
(28). Participants also suggested investment in user-friendly
equipment that fit well with the existing clinic, in addition to
continued staff training (19,20), availability of technical support
(28), and frequent testing of the equipment by staff outside of
scheduled consultations (19). It should be noted that among
participants who found their telemedicine platform to work
well, improved communication between families and clinical
staff was reported, in addition to allowance for “genuine further
education” (25).
Integration to the Organisation
Healthcare providers described the implementation of
telemedicine as having allowed for streamlining of care
processes, which had a positive impact on care (20). Appropriate
triaging, appropriate referrals for telemedicine consultations and
practicalities such as having a suitable area for staff to carry out
tele-consultations comfortably were all cited as facilitators for its
use (28).
Where clinical staff reported feeling less satisfied with
the integration of telemedicine to the local workflow, these
issues tended to be around how expectations and logistics
had been managed (19). Participants conveyed dissonance
between management and staff, describing the impression that
telemedicine was implemented as a tick-box activity for the
organisation, without careful planning.
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Tully et al. Review: Implementation of Paediatric Telemedicine
“The [hub] hospital gets to wave the flag that they offer this
service, but the [hub] doc just has to work harder for no additional
compensation” (19).
Insufficient staff numbers with capacity to engage with patients
via telemedicine was a problem encountered by others (20,22),
which prevented use of the service.
Beyond individual settings, the implementation of
telemedicine was also described by some to facilitate
strengthening of relationships between clinical sites (19) and
disciplines (25), and where calm and supporting communication
was used for tele-support between sites, this facilitated acceptance
of this service (20). In contrast however, the use of overly
paternalistic tone of communication by remote specialists was a
barrier to engagement cited by satellite staff (20).
Suggestions for facilitating integration of telemedicine
services to existing organisations arising from these discussions
were common. Thorough planning with consideration for
each aspect of implementation, logistics and administration
as well as cultivation of clinical champions across the relevant
disciplines within the healthcare setting were suggested
(19). Additional suggestions included allocation of staff to
coordinate and support telemedicine and its various tasks
(20,28), involvement of frontline staff within the organisation
throughout the implementation process (20), a designated
clinician to accompany patients at remote facilities (28), and
additional support for ensuring follow-up and adherence to
patient recommendations arising from the tele-consultation
(26). Finally, need for clear dissemination of the purpose of
telemedicine to ensure appropriate use, and allocated time online
with peers for those working in isolation to reflect, debrief and
discuss their experiences were described (22).
Quantitative Synthesis
Attitudes to Telemedicine vs. Usual Care
Four studies assessed attitudes to telemedicine as an alternative
to in-person visits, among families who had not yet experienced
telemedicine and found high (95%, 151/159) (29) to moderately
high (58% 148/256; 57%, 588/1032) (30,31) preference for in-
person visits, despite openness to trying telemedicine (30,32).
For studies whereby telemedicine had been tested (18,33–37),
acceptability of tele-consultations ranged from 79 to 100%. Qubty
et al. also reported feedback that telemedicine is useful if the child
is doing well, otherwise face-to-face is preferable (34). Marconi
et al. examined physician tele-presence during an emergency
triage and found that 59% of parents and 83% of children would
prefer this type of visit (18).
Time/distance spent travelling to appointments (29–31),
perceived cost of in-person appointments (31), familiarity with
telemedicine (31), and number of missed work hours (38) were
all significantly correlated with positive attitudes to telemedicine.
Usability
Of the five studies that reported usability from the perspective of
HCPs, the majority found the technology easy to use (90%; 95%)
(20,39) or rated it highly (9.3/10.0; 4.2/5.0) (25,40). Zachariah
et al. reported all clinicians to be competent with independent use
of telemedicine following training on use of the equipment (35).
Among patients and families (n=1,032), one study found
participants to be comfortable communicating about medical
issues through email (69.9%, n=721), telephone (82.9%, n=
856), and video conferencing (52.9%, n=546) (31). Others
reported unanimous satisfaction and comfort with the experience
of using telemedicine (98%; 100%) (33,34), and high ratings for
user-friendliness of the telemedicine platform (4.8/5.0) (25).
Challenges Encountered
Table 2 presents the main barriers to initiating use of
telemedicine that were reported across six quantitative studies.
The challenges encountered with the use of telemedicine that
were reported quantitatively by seven studies are shown in
Table 3.
Participants within some studies offered suggestions for
improvements of telemedicine services. These included the need
for training and education (17%, 7/41; 100%, 7/7), and suggested
investment in higher quality equipment with higher resolution
imaging (7%, 3/41; 100%, 7/7) (35,41). Fefferman (40) reported
no negative feedback, while Brova et al. reported 39% (42/107) to
have experienced no significant implementation challenges. No
studies reported whether any adverse events related to the use
of telemedicine occurred and no detail was provided within the
included trials about whether this was monitored (16–18).
Perceived Benefits of Telemedicine
Table 4 outlines the perceived benefits of telemedicine. Time-
savings were cited across more studies than any other beneficial
factor, with eight papers reporting that it was mentioned. One
additional study (32) found that most respondents thought
that time-saving was moderately/very important (88%), followed
by cost-saving (85%) among those who had not yet tested
telemedicine.
Satisfaction With the Telemedicine Service
Overall satisfaction with telemedicine was reported among six
studies that assessed the patient/family perspective (16,17,25,33,
34,36), with two of these as part of randomised controlled trials
(16,17). Coker et al. (17) found that parents reported significantly
higher satisfaction with a tele-referral system and with care
overall compared with usual care. Cady et al. (16) reported
significantly higher “adequacy of coordination of care” among
participants within the intervention group of a three armed
trial testing phone, video and usual care, compared to baseline.
No significant differences were observed between groups. Four
studies reported high satisfaction with telemedicine care received
(25,33,34,36).
HCPs’ satisfaction with telemedicine was reported
quantitatively by eight studies (20,25,35,36,39,40,42,43), with
generally high satisfaction ranging from 91-100% among those
whereby the telemedicine was used for communication with
patients/families (20,35,36,39). McConnochie (42) found that
46% were at least as confident of diagnoses made via telemedicine
as face-to-face. This increased to 83% among providers who had
carried out over 50 tele-consultations. High satisfaction with
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Tully et al. Review: Implementation of Paediatric Telemedicine
TABLE 2 | Reported barriers to initiating the use of telemedicine.
Author Perspective Barrier Frequency reported
Fieleke Healthcare provider Lack of need
Billing/reimbursement issues
Concerns about medico-legal
ramifications
Lack of trust in telemedicine accuracy
Lack of direct patient contact
Cost
Time constraints
Twice or more
Fang Healthcare provider Lack of clinical need 65·5% (36/55)
McCrossan Healthcare provider Insufficient training in relevant specialty 87% (13/15) of those using telemedicine
infrequently (37% in total, 13/35)
Inexperience with the equipment 31% (11/35), (73% in total, 11/15)
Seckeler Healthcare provider Patient privacy concerns 60% (27/46)
Cost of implementation 10% (4/46)
Ease of access in the catheterization
laboratory
10% (4/46)
Image quality 10% (4/46)
Time constraints 10% (4/46)
Trust of advisor (technology for
communication with mentors)
10% (4/46)
Russo Patient/family Lack of trust toward telemedicine tools 30%
Fear of excessive responsibilities for the
family
28% (of those who expressed non-interest
in telemedicine; n =unclear)
Marconi Patient/family Child too sick to take part Most common reason for declining to
participate; % not reported
technology for communication between professionals was also
reported (40,43). Karlsudd et al. reported greater satisfaction
among parents (4.8/5.0) than HCPs (3.9/5.0) (25).
DISCUSSION
Summary of Findings
We aimed to identify and describe the scientific literature
related to implementing telemedicine in paediatrics. This
study is essential as it informs and supports the response
of paediatric health services to the COVID-19 pandemic and
the efforts needed to maintain clinical services while adhering
to pandemic-response guidelines. We present a synthesis of
evidence for factors affecting implementation of paediatric
telemedicine from the perspectives of end-users, including HCPs
and patients/families. In addition, we map the findings to
the CFIR (Table 1) to facilitate systematic identification of
multi-level factors reported to influence implementation of
telemedicine in paediatrics. The use of CFIR provides readers
with a practical guide allowing stakeholders to apply relevant
findings to their own paediatric setting. Our review provides
an outline of the broad issues that have been identified within
a set of studies of variable quality, settings and clinic types,
informing actionable considerations for current implementation
plans whilst also providing evidence to inform further primary
research and focused evidence syntheses. This review also collates
evidence for both paediatric patient/family and HCP acceptance
of telemedicine for the first time.
The quantitative studies assessed demonstrate that among
those who have not yet tried telemedicine, there was a tendency
to favour in-person care, however among those who had
tested tele-consultations, acceptance and satisfaction was high,
increasing also with experience. Families who lived further away
from healthcare facilities, and who therefore had greater costs
(both monetary and opportunity costs) for attending in-person
appointments, were more open to tele-consultations. This is of
particular importance in paediatrics whereby both school and
workdays are potentially missed due to healthcare appointments.
Several barriers to uptake and challenges were identified
within the quantitative literature specific to paediatric care and
telemedicine generally, and scepticism about the reliability of
the technology was a key barrier expressed by both providers
and families. Telemedicine was perceived as inappropriate for
various types of examinations logistically, and often could
not replace in-person visits, while other common challenges
included connectivity and quality issues, specifically inadequate
audio/visual quality. Many of these issues were echoed by
the qualitative studies, where it was also clear that HCPs
experienced a great deal more practical issues and concerns
around the use of telemedicine than patients and their families,
who valued the convenience it allowed. Thorough planning
before implementation commencement and involving frontline
staff in order to identify practical concerns within a specific
setting and to increase buy-in, is a key finding. Investment
in quality, reliable technology that staff can trust to overcome
the communication considerations for working with families,
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Tully et al. Review: Implementation of Paediatric Telemedicine
TABLE 3 | Reported challenges encountered during use of telemedicine.
Author Perspective Issues reported Frequency reported
Brova Healthcare provider Process concerns 39% (42/107)
Technology concerns 14% (15/107)
Fieleke Healthcare provider Poor image quality
Patient movement leading to blurred images
Inability to perform necessary examination/treatment
Billing/reimbursement issues
Twice or more
Hopper Patient/family Perception that telemedicine examination was insufficient 10% (1/10)
Child distracted/bothered by screen 10% (1/10)
McConnochie Healthcare provider (Reasons for incomplete visits)
Inability to perform necessary examination/ treatment
remotely
64% (51/79)
Further test or imaging needed 14% (11/79)
Child site or parent decision prevented clinician from seeing
child
4% (3/79)
Technical failure/inadequacy 17% (14/79)
(Reasons for cancelled/refused visits)
Designated clinicians for tele-consultations out of office
without cover
40% (96/243)
Practise indicated being too busy to accommodate tele-visit 19% (47/243)
Insurance did not cover telemedicine/no insurance 18% (43/243)
Visit requested too late 11% (27/243)
Administrative error/issue unrelated to the technology 3% (7/243)
Practise unable to complete visit within available time 2% (4/243)
Practise refused visit due to unpaid bill <1% (1/243)
(Reasons for abandoned visits)
Parent picked up child before information capture was
complete
25% (23/90)
Unable to acquire necessary information (e.g., child
uncooperative)
15% (14/90)
Administrative problem (e.g., unable to contact parent for
consent)
20% (18/90)
Technical problem 12% (11/90)
Problem was beyond capacity of model 10% (9/90)
Other (not specified) 18% (15/90)
Qubty Patient/family (from open feedback)
Sub-optimal audio/video
Connectivity issues due to capacity of home internet service
Not optimised for tablet PC
Insufficient troubleshooting resources for families
Telemedicine calendar not open early enough to find
available slots
Administrative burden
No sign interpreter
26% (13/51)
8% (4/51)
2% (1/51)
4% (2/51)
2% (1/51)
4% (2/51)
2% (1/51)
Seckeler Healthcare provider Encountered inadequate imaging to provide advice 42% (8/19)
Zachariah Healthcare provider Temporary disruptions in audio (sound distortion) and video
(image streaking) quality requiring widening bandwidth of the
internet provider.
86% (6/7)
in addition to appropriate reallocation of resources to allow
the service to run and comprehensive training are also
necessary. For paediatric care specifically, a key consideration
is the importance of triaging patients for the suitability
of telemedicine (e.g., whether a tele-medical consult might
expedite access to specialist care, whether a physical assessment
can feasibly be undertaken without physical examination or
whether physical rehabilitation can occur without therapeutic
handling). Secondly, the inability of children to describe and
express symptoms depending on age/development should be
considered and is of particular importance in situations where
child welfare may be at risk. Thirdly, with young children,
there can be difficulty in capturing images electronically,
which in addition to general anxiety among staff using
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Tully et al. Review: Implementation of Paediatric Telemedicine
TABLE 4 | Benefits of telemedicine as perceived by participants.
Benefit cited Study % (n)
Time savings Feffermana-
Fielekea-
Laib24% (5/21)
Qubtyb85% (4/51)
Seckeler 82% mentors (16/19);
65% (30/46) mentees
McConnochie 91% (207/227) (mean
saving 4·5 h; SD 2·2)
Cadyb1% (2/139)
Karlsuddc-
Increased efficiency Feffermana-
Fielekea-
Cadyb4% (5/139)
Convenience Feffermana-
Laib10% (2/21)
Qubty 100% (51/51)
Cadyb2% (3/139)
Lower cost Lai 10% (2/21)
Qubty 100% (51/51)
Increased
communication/
familiarity/
solidarity between
staff/services
Feffermana
Seckeler
Zachariah
Fang
Karlsuddc
–
82% (16/19) mentors
71% (5/7)
90% (84/93)
–
Improved
workflow/patient
management/protocols
Fefferman
Fielekea
Zachariah
Fang
Karlsuddc
100% (16/16)
–
86% (6/7)
85% (79/93)
–
Increased learning
opportunities
Feffermana
Fielekea
Zachariah
–
–
100% (7/7)
Improved enjoyment
of visits for paediatric
patients
Fielekea–
Reassurance (for
professional or
parent)
Lai
Cadyb
14% (3/21)
1% (1/139)
Reduced stress Qubtyb2% (1/51)
Cadyb1% (1/139)
Reduced risk of
infection
Cadyb1% (1/139)
aOpen-ended feedback, frequency not reported.
bOpen-ended feedback.
cPresented as average scores out of 5.0 (parents/staff): time savings (4.6/3.5); synergy
effects (4.6/3.4); increased quality of contact and information (4.5/3.5).
telemedicine, impacts decision making and can result in
additional caution.
Previous Literature
Many of our findings are consistent with those outlined by
reviews of telemedicine in broader populations, for many of
the aspects of implementing telemedicine generally (9,44).
Concerns about liability and reimbursement were also raised
in a review of statutes and regulations for telemedicine for
stroke care in the U.S. (45) and this was prominent with our
review, particularly among clinicians in the U.S.. Costs and
reimbursement issues were further highlighted by Helleman et al.
in a review of tele-care for amyotrophic lateral sclerosis (46),
who also reported evidence of perceived benefits that were closely
aligned with the findings of this review; continuity of care,
convenience, time-savings and reduced travel burden. Concerns
among clinicians about lack of opportunity to conduct a physical
examination and the resulting limitations on care were also
emphasised (46). Our review, however, is the first to synthesise
the evidence for barriers and facilitators for implementing
telemedicine in paediatric settings and highlights additional
considerations pertinent to paediatric care. For example, the
inability of younger children or those with communication
difficulties to describe their symptoms requires interpretation
by carers and HCPs. Such assessment and interpretation may
not be as easily conducted through tele-consultations. Secondly,
taking informed parental consent and child assent using tele-
consultations may be challenging. This adds additional pressure
to both parents/carers and clinicians to accurately assess the
level of risk associated with the child’s condition and act
accordingly, and may result in decreased confidence in the use
of the telemedicine medium for paediatric care compared with
adult care.
Considerations and Future Research
In addition to the findings of this review, further considerations
for the context of urgent implementation of telemedicine as a
response to a global pandemic are needed. The absence of in-
person care may greatly infringe upon the ability of HCPs to
identify issues relating to child protection such as compliance
with immunisation schedules or evidence of potential harm,
particularly in regions whereby schools may close during the
COVID-19 pandemic and the opportunities to flag such issues
are greatly reduced. Concerns about assessment of risk were
highlighted within this review (22). However, the broader
assessment of risk within the context of child welfare in the home
is another role of the healthcare provider (47,48) and emphasises
the balance needed between maintaining care via telemedicine
while no alternative is available, while monitoring and evaluating
its feasibility as a long-term replacement for in-person care. Our
review also highlights the dearth of data related to the reporting
of adverse events in tele-medical interventions and future studies
should ensure such data is collected and reported.
In many cases the planning, staff consultations, time, and
funding necessary for gold standard implementation will simply
not be available, while additional necessities such as staff working
from their own homes and related privacy issues must also
be considered. From the perspective of families, the need for
quality technology and connectivity may contribute to issues of
inequity and could increase socioeconomic disparities. Recently
documented issues have emphasised security concerns however
(49) and particularly in Europe, compliance with General Data
Protection Regulations (GDPR) is the primary criterion for
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Tully et al. Review: Implementation of Paediatric Telemedicine
selecting appropriate platforms. Monitoring and evaluation of
implementation that occurs, over the course of the pandemic and
beyond, will offer insight into barriers and facilitators of rapid
implementation in the context of a pandemic. It is important
that well-designed process evaluations and assessments of user-
experiences are undertaken, with meaningful data captured in
order to inform future service design and optimise the capacity
for using telemedicine safely and effectively.
Strengths and Limitations
This study had several strengths and limitations due to its nature
as a rapid evidence synthesis. We searched one database due to
time constraints, in the interest of producing a review of the
key issues in a timely manner to be of maximum use. As a
result, we have not assessed the breadth of the available literature
on this topic for this review. Additionally, this review covers
a variety of studies, which are heterogeneous in terms of the
technology used, the clinical setting observed, a mix of high,
low and middle income countries, and having been undertaken
over a period of 15 years. Technological issues described by older
studies may no longer have relevance in countries where IT
infrastructure has rapidly evolved. However, many of the articles
identified for inclusion still produced insightful comparable data
on implementation. This article provides an overview of aspects
of implementation of paediatric telemedicine that future research
can build upon through carefully planned, robust and exhaustive
reviews with more tightly focussed inclusion criteria.
Our inclusion of multiple research methods however, allowed
for a comprehensive and rich overview of the factors involved
in paediatric telemedicine. We undertook steps to minimise
risks of bias, including double screening of records and
verification of quality appraisal and data extraction by additional
members of the review team. While the quality of the included
quantitative literature was not consistently high, this highlighted
a need for comprehensive feasibility studies that incorporate
implementation fully into their design.
Conclusion
To conclude, the use of telemedicine to facilitate and augment
paediatric healthcare consultations is feasible and, in many
cases, can work well with appropriate planning and quality
facilities in place. HCPs and families who have experienced
tele-consultations generally report high satisfaction and usability
for such services. However, telemedicine is not practical for
every clinical situation (such as cases where complex physical
examinations or specific physical therapies are needed or a parent
cannot articulate a child’s condition), and its implementation can
create an array of obstacles for healthcare workers in providing
care to their full potential. Well-designed studies, undertaken
throughout the implementation process are needed, in addition
to a comprehensive systematic review of academic databases and
grey literature, to establish the evidence base for user experiences
of implementing paediatric telemedicine. Notwithstanding, our
review will assist HCPs with the knowledge and information
necessary to optimise clinical care safely through telemedicine
in situations where normal clinical services are interrupted or
reduced. Further reviews with more refined and focused research
settings and exhaustive literature searches are warranted. A
visual summary of our findings and conclusions is available in
Supplementary Image 2.
DATA AVAILABILITY STATEMENT
The original contributions generated in the study are included
in the article/Supplementary Material, further inquiries can be
directed to the corresponding author.
AUTHOR CONTRIBUTIONS
GO’M, LT, and JS designed the study. LC, NA, and LT screened
abstracts, titles, and full texts. LT extracted data and completed
critical appraisal/risk of bias. LC and NA verified 20% of
extracted data and completed critical appraisal for 20% of
studies to ensure consistency. LT, GO’M, and JPM drafted and
finalised the manuscript with critical feedback from JS, NA, and
LC. All authors contributed to the article and approved the
submitted version.
FUNDING
This study was funded by the Royal College of Surgeons in
Ireland StAR programme (Grant No. 2151), and undertaken as
part of the Health Research Board (HRB) Structured Population
and Health Services Research Education (SPHeRE) training
programme (Grant No. SPHeRE/2013/1). The HRB supports
excellent research that improves people’s health, patient care, and
health service delivery.
ACKNOWLEDGMENTS
Special thanks to Andrew Simpson (Research Librarian, RCSI
University of Medicine and Health Sciences) for support with
database searching for this review.
SUPPLEMENTARY MATERIAL
The Supplementary Material for this article can be found
online at: https://www.frontiersin.org/articles/10.3389/fped.
2021.630365/full#supplementary-material
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Conflict of Interest: The authors declare that the research was conducted in the
absence of any commercial or financial relationships that could be construed as a
potential conflict of interest.
Copyright © 2021 Tully, Case, Arthurs, Sorensen, Marcin and O’Malley. This is an
open-access article distributed under the terms of the Creative Commons Attribution
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provided the original author(s) and the copyright owner(s) are credited and that the
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