Medical image sharing is a barrier to Pediatric Urology telemedicine in Western Pennsylvania: a project to enhance quality and access to care

Telemedicine has become an integral part of ambulatory encounters since the COVID-19 pandemic. Pediatric urology telemedicine encounters frequently involve radiologic imaging as part of the diagnostic evaluation and for postoperative surveillance. While regulatory, licensure, and payer hurdles have been overcome with recent legislation (CARES Act), obtaining outside imaging records by the time of the visit is a barrier yet to be overcome. The lack of outside medical information can lead to duplicate testing, extra visits, and potential medical error. This affects the value of telemedicine by increasing direct and opportunity costs and reducing the quality of encounters. To date, there is a paucity of quality metrics for telemedicine, as well as metrics for pediatric urology disease processes. At the UPMC Children’s Hospital of Pittsburgh division of pediatric urology, the staff of eight physicians and advanced practice providers have performed non-facilitated telemedicine visits since April 2020. Telemedicine represents 4.7% of the fiscal year 2021 pediatric urology outpatient encounters and three new patients are seen for every one return visit. Access to telemedicine appointments is faster than in-person visits, with an average of 5.6 days versus 6.5 days, making telemedicine visits an efficient option for children and their families. However, pre-visit imaging was missing for 45.6% of telemedicine visits, and imaging was non-viewable despite completion in 9% of children. The most affected diagnoses were urinary tract infection, voiding dysfunction, hematuria, and kidney stones. After better understanding the imaging capabilities and needs of the pediatric urology providers, a root cause analysis was conducted along with interviews to establish best practices for obtaining outside imaging at the University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh (CHP). This revealed the lack of medical image sharing via cloud-based servers and was chosen as the intervention for this quality improvement project. Outcomes chosen as metrics during the study period included patient access, rate of non-viewable imaging, and rate of duplicate appointments or testing. A smart aim was created to reduce the rate of non-viewable imaging from an average of 9% of appointments monthly to 0% by June 1, 2021. The problem and proposed intervention were presented to the CHP telemedicine steering committee and subsequently escalated to the University of Pittsburgh Medical Center (UPMC) telemedicine steering committee as critical stakeholders. Pediatric urology proposed a pilot of the new process for medical image sharing. Though the timeline is delayed, and the actual proposed process may be altered, the pilot in pediatric urology with three monthly PDSA cycles followed by incremental testing within the different CHP departments is still planned to understand individual barriers. Creation of such a process has a regulatory implication, as the 21st Century CURES act will mandate medical image sharing by health entities in the form and format requested as of October 6, 2022. Perhaps more importantly, medical image sharing is critical to ensure high value encounters for telemedicine patients and as a critical component of interoperability between health systems