Using an iPad to Remotely Assess Seriously Ill Kids

TOPTENAndrea Cruz (Texas Children’s) and Michelle Macy (Michigan) presented the best PEM-related articles of 2016 at AAP this past October. If you weren’t one of the tens of thousands of people in the room that day, we’re going to be counting them down in no particular order over the next few weeks. 

#10: Reliability of Telemedicine in the Assessment of Seriously Ill Children

Siew L, Hsiao A, McCarthy P, Agrawal A, Lee E, Chen L. Pediatrics. 2016.

Unmet needs addressed

Telemedicine has the potential to bridge the distance between the provider and the patient, expand access to specialized care, and would make it feasible to evaluate ill children remotely. But PEM is different than dermatology and hospital medicine, which both have shown promise in using telemedicine. For PEM to integrate telemedicine into widespread practice, it’s important to know if telemedicine is reliable enough to make clinical recommendations and decisions.


The study was prospective and done in an urban tertiary care pediatric ED with 35,000 annual visits. The study compared telemedicine observations to bedside observations in assessing two specific PEM populations: febrile children 2-36 months old and children 2 months to 18 years in respiratory distress. Patients were excluded if they were thought to be “clinically too unstable.” Authors used inter-rater reliability to determine if telemedicine observations were significantly different than bedside assessments.

Bedside and telemedicine observers completed their Yale Observation Scales (for febrile patients) or Respiratory Observation Checklists (for respiratory patients) at the same time and were blinded to each other’s assessments.

The telemedicine was done using FaceTime on an Apple iPad with an assistant holding the iPad and controlling the distance and camera angles. The observer could ask for different angles and views.

Main Results

The study found excellent agreement on both febrile children and children in respiratory distress between telemedicine and bedside observations (kappa > 0.8). This suggests that both bedside observation and telemedicine came to similar conclusions when it came to these two populations of sick children.

How did this make our Top Ten?

  • This means that fever and respiratory distress—both common conditions seen in children—may be assessed remotely by clinicians with pediatric expertise.
  • The use of iPads means that the technology is both accessible and (relatively) affordable.
  • There is lower agreement between bedside and telemedicine observation for intercostal retractions. Perhaps this was due to camera and Wi-Fi limitations.
  • Integration of telemedicine into routine PEM practice would require use of platforms that would seamlessly link into the electronic health record in a way that preserves patient confidentiality.
Andrea Cruz MD MPH

Andrea Cruz MD MPH

Associate Professor of Pediatrics in Emergency Medicine and Infectious Diseases at Baylor College of Medicine
Andrea is the PECARN site PI for Texas Children’s Hospital and runs the Data Center for the Pediatric Emergency Medicine Collaborative Research Committee.
Andrea Cruz MD MPH
Andrea Cruz MD MPH

Andrea Cruz MD MPH

Andrea is the PECARN site PI for Texas Children’s Hospital and runs the Data Center for the Pediatric Emergency Medicine Collaborative Research Committee.