RANDOMIZED TRIALS IN EPIDEMIOLOGY

Comparison of Telemedicine to Traditional Face-to-Face Care for Children with Special Needs: A Quasiexperimental Study

Mary Hooshmand, PhD, MS, RN, and Cynthia Foronda, PhD, RN, CNE, CHSE, ANEF

School of Nursing and Health Studies, University of Miami, Coral Gables, Florida.

Abstract Background: Services for Children with Special Healthcare

Needs (CSHCN) have been challenging in terms of cost and

access to appropriate healthcare services.

Objectives: The objectives of this study were to examine cost,

caring, and family-centered care in relationship to pediatric

specialty services integrating telemedicine visits compared to

traditional face-to-face visits only for (CSHCN) in rural, re-

mote, and medically underserved areas.

Methods: This study used a prospective, quasiexperimental

research design with 222 parents or legal guardians of

CSHCN receiving pediatric specialty care. The traditional

group (n = 110) included families receiving face-to-face pe-

diatric specialty care and the telemedicine group (n = 112)

included families who had telemedicine visits along with

traditional face-to-face pediatric specialty care.

Results: Results indicated no significant differences in family

costs when the telemedicine group was compared to tradi-

tional face-to-face care. When the telemedicine group was

asked to anticipate costs if telemedicine was not available,

there were significant differences found across all variables,

including travel miles, cost of travel, missed work hours,

wages lost, child care cost, lodging cost, other costs, and total

family cost (p < 0.001). There were no differences in the

families’ perceptions of care as caring. Parents/guardians

perceived the system of care as significantly more family-

centered when using telemedicine (p = 0.003).

Conclusions: The results of this study underscore the im-

portance of facilitating access to pediatric specialty care by

use of telemedicine. We endorse efforts to increase healthcare

access and decrease cost for CSHCN by expanding tele-

medicine and shaping health policy accordingly.

Keywords: telemedicine, pediatrics, telehealth, technology

Background

F ifteen percent of children in the United States have

special healthcare needs.1 Children with Special

Healthcare Needs (CSHCN) are defined as ‘‘those who

have or are at increased risk for a chronic physical,

developmental, behavioral, or emotional condition and who

also require health and related services of a type or amount

beyond that required by children generally.’’2 CSHCN and

their families face multiple challenges, including cost and

access to pediatric specialty care.3 Families carry the burden

of treatment expenses, travel expenses, and lost time from

work.4 Furthermore, geographic barriers and insurance

hurdles complicate the ability to access a pediatric specialty

provider.5

Telemedicine may hold promise as a solution for CSHCN

and their family members. Telemedicine involves the use

of interactive communication systems with high resolu-

tion, interactive videoconference equipment with audio and

video capabilities, diagnostic cameras, and clinical assess-

ment equipment, including otoscopes, opthalmoscopes,

and digital stethoscopes.6–9 Recent studies have suggested

that telemedicine has been associated with reducing cost and

travel time for families of children requiring pediatric spe-

cialty services.4,10,11 The objective of this study was to ex-

amine cost, caring, and family-centered care (FCC) from the

family perspective in relationship to pediatric specialty ser-

vices integrating telemedicine visits compared to traditional

face-to-face visits only for CSHCN in rural, remote, and

medically underserved areas.

Materials and Methods The study used a prospective, quasiexperimental research

design. Based on an effect size of 0.42, alpha of 0.05, and

power of 0.80, the estimated sample size was calculated to be

89 per group totaling 178 subjects. The study sample included

parents or legal guardians of CSHCN enrolled in the Florida

Department of Health Children’s Medical Services (CMS),

the Title V Program, in the Southeast Region of Florida. This

program assures pediatric specialty care and care coordina-

tion for CSHCN across Florida whose families have household

DOI: 10.1089/tmj.2017.0116 ª M A R Y A N N L I E B E R T , I N C . � VOL. 24 NO. 6 � JUNE 2018 TELEMEDICINE and e-HEALTH 433

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incomes <200% of the Federal Poverty Level (FPL). Pediatric

specialty services provided by telemedicine were determined

by needs in the local community and availability of specialty

providers. Families had the choice of telemedicine or tradi-

tional care for identified pediatric specialty clinics such as

neurology and nutrition. A telemedicine visit included syn-

chronous visits using Polycom� equipment, in which the

specialty provider (neurologist or pediatric nutritionist) was at

a distance clinical site examining and interacting with the

CSHCN and their parent/guardian at the remote site through

the use of telemedicine equipment. A Registered Nurse (RN) or

Advanced Registered Nurse Practitioner (ARNP) was onsite

with the CSHCN and family at the remote site for both tradi-

tional and telemedicine visits. The RN or ARNP completed

initial assessments, reinforced the information, and was re-

sponsible for assuring that this information was provided to

the primary care provider and medical home.

Recruitment of participants was conducted through letters

to those families who received pediatric specialty care at the

identified CMS telemedicine clinic and traditional face-to face

specialty clinical sites in the previous 3 months. Flyers also

were posted in the CMS clinical sites participating in the study.

The letters were sent by the respective clinical site advising

families of the study and inviting them to participate. Letters

and recruitment flyers also were distributed at the respective

clinical sites. Families were invited to contact the principal

investigator and research assistant to learn more about the

study. The letters included a form as well as a self-addressed,

stamped envelope to be returned to the clinical site giving

permission for the research team to contact the family. If

parents were interested in participating in the study, the

principal investigator or research assistant contacted them

and reviewed the inclusion and exclusion criteria to assure

they met the criteria for enrollment. Face-to-face appoint-

ments were then scheduled for those determined eligible to

enroll in the study.

Before enrollment in the study, participants were advised of

the study goals to examine the system of care for CSHCN from

the perspectives of families as it relates to cost, caring, and

family-centered care. They received written and verbal in-

formation and instructions from the principal investigator or

research assistant, which included information about the type

of data being collected and the procedure for data collection.

Participants were asked to provide *1 h of their time to

complete the questionnaire booklet on one occasion. Partici-

pants were advised that they could withdraw consent at any

point in time and that the care their CSHCN receives through

CMS would not be compromised by their decision to withdraw

from the study.

Inclusion criteria for this research project included: (1) the

parent/guardian of a CSHCN enrolled in CMS for 1 year or

greater, (2) the CSHCN received pediatric specialty care at CMS

clinic within 1 year of data collection, (3) the telemedicine

group included only parent/guardian of a CSHCN who had

received greater than two visits utilizing telemedicine tech-

nology within 90 days, (4) the traditional face-to-face group

included only parent/guardian of a CSHCN who had received

two or more CMS clinic visits with the most recent clinic visit

within 90 days, and (5) the ability of the parent/guardian to

read and/or speak English.

A convenience sample was used, which comprised two

subject groups: families receiving traditional face-to-face

pediatric specialty care and families who have received

telemedicine visits along with traditional face-to-face pedi-

atric specialty care. The sample was recruited from participants

in the nutrition and neurology clinics, all of which had both

traditional and telemedicine components. The neurology sub-

group included CSHCN with neurologic diagnoses requiring

pediatric neurology specialty care while the nutrition subgroup

included CSHCN with wide ranging diagnoses requiring pedi-

atric nutrition services. Traditional care was provided either at

the remote CMS clinical site or through travel to the tertiary

center (children’s hospital, university-based or medical center

clinical/hospital site, or private office).

The protocol was approved by the Institutional Review

Board of the Florida Department of Health and the University

of Miami. Each participant completing the questionnaire

booklet received a letter thanking them and a gift card for

Publix valued at $20 as appreciation for their time.

INSTRUMENTS Three instruments were used to measure the outcome var-

iables of cost, caring, and family-centered care (Fig. 1). The

three instruments were packaged into one booklet with in-

structions for parents/guardians to complete.

The Family Cost Survey was developed specifically for this

research project. This survey included questions about travel,

transportation, loss of wages, child care, food, and lodging costs

related to the CSHCN’s visit to the CMS clinical site. The survey

also included questions regarding the anticipated cost to the

parent/guardian for clinical visits with specialists if tele-

medicine was not available. This ‘‘telemedicine not available’’

component was incorporated into the cost survey as access to

pediatric specialty care in these remote sites frequently requires

either travel to pediatric tertiary facilities at a distance or ex-

tensive waits for limited appointments in the remote clinical

sites. The cost survey questions were checked for reading level

and were graded at the Flesch–Kincaid 5.0 grade level.

HOOSHMAND AND FORONDA

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Caring was measured using the Caring Professional Scale

(CPS), which includes two factor analytically derived sub-

scales, the compassionate healer, and the competent practi-

tioner.12 Items in the CPS are scored on a 5-point Likert scale.

Reliability of the scale has ranged from r = 0.74 to 0.96.12,13

While the CPS has not been applied to telemedicine, it has

been applied and tested with maternal–child health popula-

tions and particularly those who are vulnerable due to special

healthcare needs. This instrument has both theoretical and

empirical validity and is clinically relevant across healthcare

settings and populations (Swanson).

The Measure of Process of Care-20 (MPOC-20) Item Scale

(r = 0.63 to r = 0.92) was used to measure family-centered

care.14,15 Items in the MPOC-20 were scored on a 7-point

Likert scale with a range of 0–7. The MPOC-20 Scale has been

utilized widely to measure the domains of FCC and has es-

tablished reliability and validity across populations and, in

particular, among populations of families of CSHCN. The tool

also has been utilized across different professional groups,

including early education and health provider settings. For

these reasons, this tool was utilized in this study to measure

family centered care from the family perspective.

DATA COLLECTION AND DATA ANALYSIS Data collection occurred over a 6-month period. We re-

cruited families through mailings and onsite following

Fig. 1. Substruction of the study.

TELEMEDICINE FOR SPECIAL NEEDS CHILDREN

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pediatric specialty clinic visits. Families responding to the

initial recruitment letters and posters were screened for eli-

gibility; and if determined eligible for participation, were

scheduled for an appointment at the local CMS office. Families

also were invited to participate in the study during clinical

visits. All family participants completed the Family Demo-

graphic Data Form, Family Cost Survey, CPS, and MPOC-20

within 90 days following their pediatric specialty visit. It

was estimated that completion of these tools averaged 15

to 30 min.

Data were analyzed using the Predictive Analytic Software

(PASW), Version 18.0. The analyses included univariate sta-

tistics incorporating descriptive statistics and Analysis of

Variance (ANOVA). Descriptive statistics such as frequencies,

means, and standard deviations as well as t tests for contin-

uous variables and chi-squares (v2) for categorical variables

were calculated to compare the demographics of the two study

groups as well as for the outcome variables of family cost,

caring, and family-centered care. The two study groups

comprised parents whose CSHCN received pediatric specialty

care face-to-face and parents whose CSHCN received pediatric

specialty care via telemedicine. ANOVA’s were used to ex-

amine the individual dependent variables, caring, and family-

centered care between the two groups. If imbalances had been

found in one or more of the demographic variables, an Ana-

lysis of Covariance (ANCOVA) would have been conducted to

determine whether there were differences among the groups

when controlling for one or more of these variables or cov-

ariates.

Results SAMPLE

The study included a convenience sample of 222 parents or

legal guardians divided into two subject groups: (1) tradi-

tional group (n = 110) and (2) the telemedicine group

(n = 112). The majority of the surveys were completed within

30 days of the most recent clinic visit for both the traditional

(83.6% £30 days; 8.2% £60 days; 8.2% £90 days) and tele-

medicine (90.2% £30 days; 4.5% £60 days; 5.4% £90 days)

groups. Parents/guardians reported that the majority of the

CSHCN in both groups (traditional: n = 65, 59.5%; tele-

medicine: n = 76, 67.9%) had two or more reported health

conditions. The characteristics of the CSHCN are presented in

Table 1. There were no significant demographic differences

between the two groups.

RELIABILITY OF INSTRUMENTS The CPS demonstrated a Cronbach’s alpha reliability for

internal consistency for the total scale of r = 0.92 and r = 0.86

for each of the subscales. The MPOC-20 demonstrated reli-

ability for internal consistency for the subscales at a range of

r = 0.80 to r = 0.92 and the total scale reliability was r = 0.95.

The correlation between the CPS and the MPOC-20 was r = 0.62;

and correlations between subscales ranged from r = 0.40 to

r = 0.68 (all significant at p < 0.001). These correlations sug-

gested that while the two measures shared a similar underlying

construct, there remained unique differences between caring

and family centeredness.

COST

Traditional versus telemedicine. We examined for differences

in cost to parents/guardians when care was provided through

traditional face-to-face visits compared with telemedicine.

There were no significant differences in costs between the

groups based on mode of care provision. Total family out-of-

pocket costs for one clinical visit (traditional, M = $53.10,

SD = 58.62; telemedicine, M = $54.15, SD = 67.63) were also

similar across both groups. This is attributed to the fact that

both the traditional and telemedicine clinics were located in

their home communities.

Telemedicine versus telemedicine not available. Table 2 illus-

trates the results examining the differences in costs to parents/

guardians in the telemedicine group when their CSHCN re-

ceived pediatric specialty care at their local CMS clinical

site through telemedicine compared with the projected

costs if telemedicine was not available locally. There were

significant differences found across all other family cost

variables, including travel miles, cost of travel, missed work

hours, wages lost, child care cost, lodging cost, other costs,

and total family cost. Family members were reported to

have missed work 40.2% of the time for a telemedicine visit

compared with 58.9% had telemedicine not been available.

Parents/guardians reported lodging needs 5.4% of the time

for telemedicine, but 24.1% of the time if telemedicine was

not available. Total family out-of-pocket costs reported

were significantly higher when telemedicine was not

available.

CARING The CPS was used to determine if differences existed in

parents’/guardians’ perception of the care their CSHCN re-

ceived as caring. The results demonstrate no significant

differences between the groups in their perceptions of pro-

viders as caring (Table 3). The traditional and telemedicine

groups were further compared to examine for differences

between groups. Clinic type (nutrition or neurology) had no

interaction effect on perception of caring F (1, 218) = 0.099,

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Table 1. Characteristics of Children with Special Healthcare Needs

CHILDREN CHARACTERISTICS

TRADITIONAL TOTAL

(N = 110), M (SD)

TRADITIONAL NUTRITION (N = 53), M (SD)

TRADITIONAL NEUROLOGY

(N = 57), M (SD)

TELEMEDICINE TOTAL

(N = 112), M (SD)

TELEMEDICINE NUTRITION (N = 58), M (SD)

TELEMEDICINE NEUROLOGY

(N = 54), M (SD)

Age (in years) 9.8 (5.1) 9.3 (5.1) 10.3 (5.1) 9.97 (5.4) 10.7 (5.6) 9.1 (5.1)

Length of time CMS enrolled (in months) 68.1 (51.1) 67.6 (52.8) 68.6 (50.0) 60.7 (50.9) 56.3 (52.7) 65.6 (48.9)

Number of reported health conditions 2.6 (1.9) 3.0 (2.2) 2.3 (1.5) 2.5 (1.4) 2.4 (1.4) 2.6 (1.4)

Number of times seen by a specialist

at CMS clinic in past year

5.7 (5.4) 6.3 (6.5) 5.2 (4.2) 6.0 (4.5) 6.2 (3.9) 5.7 (5.1)

Number of times seen by a specialist

using telemedicine in past year

NA NA NA 2.7 (1.3) 2.8 (1.3) 2.6 (1.3)

Race

White 24 (21.8) 7 (13.2) 17 (29.8) 23 (20.5) 7 (12.1) 16 (29.6)

Hispanic 29 (26.4) 15 (28.3) 14 (24.6) 28 (25.0) 13 (22.4) 15 (27.8)

Black 34 (30.9) 19 (35.8) 15 (26.3) 46 (41.1) 29 (50.0) 17 (31.5)

Black (Haitian) 12 (10.9) 6 (11.3) 6 (10.5) 8 (7.1) 3 (5.2) 5 (9.3)

Native American 1 (0.9) 1 (1.9) 0 (0.0) 1 (0.9) 1 (1.7) 0 (0.0)

Multiracial 8 (7.3) 3 (5.7) 5 (8.8) 5 (4.5) 4 (6.9) 1 (1.9)

Asian/PI 2 (1.8) 2 (3.8) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)

Other 0 (0.0) 0 (0.0) 0 (0.0) 1 (0.9) 1 (1.7) 0 (0.0)

Health insurance

No 5 (4.5) 2 (3.8) 3 (5.3) 4 (3.6) 1 (1.7) 3 (5.6)

Yes 105 (95.5) 51 (96.2) 54 (94.7) 108 (96.4) 57 (98.3) 51 (94.4)

Health coveragea

Medicaid 87 (79.1) 42 (79.2) 45 (78.9) 93 (83.8) 50 (86.2) 43 (81.1)

Title XXI 17 (15.5) 8 (15.1) 9 (15.8) 14 (12.6) 7 (12.1) 7 (13.2)

Safety net 6 (5.4) 3 (5.7) 3 (5.3) 4 (3.6) 1 (1.7) 3 (5.7)

Uninsured past yeara

No 92 (83.6) 45 (84.9) 47 (82.5) 96 (86.5) 52 (89.7) 44 (83.0)

Yes 18 (16.4) 8 (15.1) 10 (17.5) 15 (13.5) 6 (10.3) 9 (17.0)

Most recent clinic

£30 days 92 (83.6) 45 (84.9) 47 (82.5) 101 (90.2) 52 (89.7) 49 (90.7)

31 £60 days 9 (8.2) 4 (7.5) 5 (8.8) 5 (4.5) 2 (3.4) 3 (5.6)

61 £90 days 9 (8.2) 4 (7.5) 5 (8.8) 6 (5.4) 4 (6.9) 2 (3.7)

Number of reported health conditionsa

One 44 (40.4) 17 (32.7) 27 (47.4) 36 (32.1) 21 (36.2) 15 (27.8)

Two 14 (12.8) 5 (9.6) 9 (15.8) 29 (25.9) 15 (25.9) 14 (25.9)

Three 18 (16.5) 11 (21.2) 7 (12.3 18 (16.1) 7 (12.1) 11 (20.4)

‡Four 33 (30.2) 19 (36.4) 14 (24.6) 29 (25.9) 15 (25.8) 14 (26.0)

continued /

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p = 0.753. Results indicated that there were no significant

differences in perception of system of care and specifically

the healthcare providers as caring F (1, 220) =1.31, p = 0.253.

This result was consistent in the competent practitioner and

compassionate healer subscales.

FAMILY-CENTERED CARE There were significant differences in parents’/guardians’

perception of the system of care as family-centered between

the traditional and telemedicine groups (Table 4). The MPOC-

20 demonstrated higher mean scores across the total scale and

all subscales for the telemedicine group compared with the

traditional group. The most significant difference between the

groups was for the Coordinated and Comprehensive Care

Subscale ( p = 0.001). The lowest scores on the subscale for

both groups was Providing General Information, and the

highest scores were on the Respectful and Supportive Care

Subscale. Again, the groups were examined for group differ-

ences by clinic type and determined that clinic type (nutrition

or neurology) had no interaction effect on the group percep-

tion of the system of care as family-centered.

Discussion This research study expands our knowledge and under-

standing of family costs/burdens and family perceptions of

pediatric specialty care with telemedicine compared with

traditional face-to-face care. Frequently, families have limited

choices when seeking specialty providers for their CSHCN, as

the required specialists may only be available at a distance

posing further hardship or ultimately the choice to not to seek

specialty care. Notably, there was no difference between tel-

emedicine and traditional groups in respect to the costs. This

finding supports the fact that telemedicine, when offered in

communities, can be cost neutral from the perspective of the

care recipients. Findings indicated that costs and financial

burdens for families were anticipated to significantly increase

if telemedicine for pediatric specialty care was not available in

their local communities. If telemedicine was not available,

Table 1. Characteristics of Children with Special Healthcare Needs continued

CHILDREN CHARACTERISTICS

TRADITIONAL TOTAL

(N = 110), M (SD)

TRADITIONAL NUTRITION (N = 53), M (SD)

TRADITIONAL NEUROLOGY

(N = 57), M (SD)

TELEMEDICINE TOTAL

(N = 112), M (SD)

TELEMEDICINE NUTRITION (N = 58), M (SD)

TELEMEDICINE NEUROLOGY

(N = 54), M (SD)

Specific health conditions reported (primary presenting)a

Premature 1 (0.9) 0 (0.0) 1 (1.8) 0 (0.0) 0 (0.0) 0 (0.0)

Pulmonary 12 (11.0) 12 (22.6) 0 (0.0) 7 (6.3) 4 (6.9) 3 (5.6)

Neurological 29 (26.6) 6 (11.5) 23 (40.4) 22 (19.6) 3 (5.2) 19 (35.2)

Autism 4 (3.7) 2 (6.8) 2 (3.5) 3 (2.7) 2 (3.4) 1 (1.9)

Behavioral 7 (6.4) 1 (1.9) 6 (10.5) 5 (4.5) 3 (5.2) 2 (3.7)

Genetics 13 (11.9) 6 (11.5) 7 (12.3) 16 (14.3) 6 (10.3) 10 (18.5)

Immunodeficiency 0 (0.0) 0 (0.0) 0 (0.0) 8 (7.1) 7 (12.1) 1 (1.9)

Cerebral palsy 14 (12.8) 7 (13.5) 7 (12.3) 9 (8.0) 2 (3.4) 7 (13.0)

Obesity 2 (1.8) 2 (3.8) 0 (0.0) 15 (13.4) 15 (25.9) 0 (0.0)

Endocrine/metabolic 6 (5.5) 6 (11.5) 0 (0.0) 11 (9.8) 11 (19.0) 0 (0.0)

Hematology/oncology 1 (0.9) 1 (1.9) 0 (0.0) 1 (0.9) 0 (0.0) 1 (1.9)

Cardiac 5 (4.6) 4 (7.7) 1 (1.8) 5 (4.5) 2 (3.4) 3 (5.6)

Developmental 6 (5.5) 2 (3.8) 4 (7.0) 6 (5.4) 2 (3.4) 4 (7.4)

Other 9 (8.3) 3 (5.8) 6 (10.5) 4 (3.6) 1 (1.7) 3 (5.6)

aOf total participants, one parent/guardian in the telemedicine neurology group did not report information relating to insurance type and insurance/uninsured status.

One parent/guardian in the traditional neurology group did not report health conditions of their CSHCN. One parent/guardian in the traditional nutrition group did not

report the number of health conditions.

CMS, Children’s Medical Services; CSHCN, children with special healthcare needs; NA, not applicable; PI, Pacific Islander.

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there was a fourfold anticipated increase in total family costs

averaging $197.24 per visit or $1,183.44 for an average of six

pediatric specialty visits per year. The most significant in-

creases in costs were noted in travel costs with mean costs

increasing from $17.88 to $ 90.28 per visit and the total family

out-of-pocket costs increasing from a mean of $54.15 to

$197.24. Travel miles increased from a mean of 32.25 to 155.45.

Families reported a loss of work hours from 45% to 66% with

a mean loss of wages from $28.06 to $69.48 if telemedicine

was not available. These additional anticipated costs and travel

result in additional hardship as well as impacting weekly in-

comes for these families with incomes <200% of the FPL.

Results of this study indicated that there were no significant

differences in parents’/guardians’ perceptions of the system of

care and healthcare providers as caring when care was de-

livered integrating telemedicine compared with traditional

face-to-face care. Furthermore, parents/guardians perceived

the system of care as significantly more family-centered across

all domains of family-centered care with the telemedicine

subgroup. These results strengthen the argument that pro-

viders can convey caring and family-centered care success-

fully while integrating telemedicine into systems of care. This

finding is similar to previous research.16 In a randomized

controlled trial evaluating care coordination through tradi-

tional means, telephone only, and telephone and video tele-

health together, all three groups demonstrated high levels of

FCC. This may be a reflection of nursing, but the key similarity

is that with various forms of telehealth and telemedicine, FCC

can be maintained at high levels.

The results of cost savings in our study are similar to pre-

vious studies.4,10,11 Prior research has suggested that the use

of telemedicine decreased family members’ cost, travel dis-

tance, and missed time from work. Our study substantiates and

strengthens these findings indicating that telemedicine can

significantly reduce family costs and burdens in providing

much needed access to healthcare for vulnerable popula-

tions.4,10,11 However, previous research regarding telemedicine

and perceptions of human connections or caring in respect

to families of CSHCN or other populations was not located.

Although earlier studies with patients, caregivers, and pro-

viders have suggested positive experiences and satisfaction

with telemedicine,6–8,16–20 to our knowledge, this study is the

first to date to examine the effects of parents’/guardians’

Table 2. Family Cost/Impact Comparison for Telemedicine Versus Telemedicine Not Available

FAMILY COST/IMPACT TELEMEDICINE TOTAL

(N = 112), M (SD) TELEMEDICINE NOT AVAILABLE

TOTAL (N = 112), M (SD) T P

Travel miles 32.25 (28.04) 155.45 (76.72) 16.33 <0.001

Travel cost (dollars) 17.88 (15.56) 90.28 (47.96) 15.12 <0.001

Work hours loss 2.33 (3.41) 5.30 (5.45) 7.11 <0.001

Wages loss (dollars) 28.06 (52.16) 69.48 (110.20) 5.61 <0.001

Child care cost (dollars) 3.92 (11.67) 8.73 (18.23) 3.30 <0.001

Lodging cost (dollars) 1.99 (14.56) 19.51 (48.35) 3.93 <0.001

Other costs (dollars) 2.15 (7.72) 10.01 (22.03) 3.98 <0.001

Total family cost (dollars) 54.15 (67.63) 197.24 (159.42) 10.71 <0.001

Table 3. Comparisons of Traditional Versus Telemedicine on Parental Perceptions of Provider Caring

MEASURE M (SD) F P

Caring (CPS total) 1.313 0.253

Possible range (15–225)

Traditional 69.33 (8.08)

Telemedicine 70.51 (7.21)

Compassionate healer 1.086 0.298

Possible range (8–40)

Traditional 36.44 (5.2)

Telemedicine 37.12 (4.43)

Competent practitioner 1.457 0.229

Possible range (7–35)

Traditional 32.86 (3.38)

Telemedicine 33.39 (3.15)

CPS, caring profession scale.

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perceptions of caring and family-centered care with tele-

medicine. As patient-centered and family-centered care is

increasingly noted as a priority in healthcare, these study

findings hold importance in the direction for telemedicine.

LIMITATIONS This study had limitations due to the quasiexperimental

design as well as a convenience sample drawn from parents/

guardians of CSHCN in Southeast Florida who met income

requirements less than 200% of the FPL, limiting this sample

to families from these socioeconomic strata. Subjects were not

randomly assigned. The overall sample comprised 79% mi-

norities, including 25.7% Hispanic, 45% black, and 9% Hai-

tian black, and unfortunately, inclusion criteria were limited

to English speaking patients. However, we consider the ethnic

diversity represented in this sample as a strength. In addition,

this study only included families attending neurology and

nutrition specialty clinics limiting generalizability.

Conclusions This study suggests that telemedicine can reduce family

costs, maintain caring behaviors on the part of healthcare

professionals, and promote family-centered systems of care.

Many people make the assumption that technology lessens the

interpersonal relationship in the healthcare setting. This study

challenges that mindset and provides evidence that the human

connection is not lost through the use of technology. We

endorse efforts to increase healthcare access and decrease cost

for CSHCN by expanding telemedicine and shaping health

policy accordingly.

Acknowledgments We acknowledge Donna Shalala, PhD, Kristen Swanson,

RN, PhD, FAAN, Victoria Mitrani, PhD, and Gail McCain, PhD,

RN, FAAN for their expertise and guidance with the study.

This study was partially supported by the Robert Wood

Johnson Executive Nurse Fellows Program FWA00002247.

Disclosure Statement No competing financial interests exist.

R E F E R E N C E S

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Table 4. Family-Centered Care: Measure of Processes of Care-20 Item Scale Results

MEASURE M (SD) F P

Family-centered care total

MPOC-20 total scale 8.96 0.003

Traditional 5.47 (1.29)

Telemedicine 5.96 (1.16)

Domains of family-centered care

Enabling and partnership 3.76 0.054

Traditional 5.77 (1.52)

Telemedicine 6.13 (1.20)

Providing general information 7.91 0.005

Traditional 4.65 (1.91)

Telemedicine 5.36 (1.89)

Providing specific information about child 6.05 0.015

Traditional 5.22 (1.83)

Telemedicine 5.79 (1.56)

Coordinated and comprehensive care 11.61 0.001

Traditional 5.73 (1.31)

Telemedicine 6.27 (1.03)

Respectful and supportive care 4.37 0.003

Traditional 6.05 – 1.05

Telemedicine 6.33 – 0.94

MPOC-20, Measure of Process of Care-20.

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Address correspondence to:

Mary Hooshmand, PhD, MS, RN

School of Nursing and Health Studies

University of Miami

5030 Brunson Dr.

Coral Gables, FL 33146

E-mail: [email protected]

Received: May 2, 2017

Revised: August 9, 2017

Accepted: August 9, 2017

Online Publication Date: December 21, 2017

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