When Howard County, Maryland, launched a telemedicine initiative in five elementary schools, it aimed to improve access to healthcare for students, reduce illness-related absences and improve student educational outcomes.

Inadvertently, it also encouraged local pediatric practices not included in the initial rollout to test and adopt telemedicine for themselves.

In 2014, the county decided to leverage its recent investment in broadband to offer telemedicine services in selected schools. To launch the program quickly, the county partnered with CareClix and the University of Maryland Medical Center, a sister state agency that could finalize contracts in a matter of months, according to Sharon Hobson, the school-based wellness centers program administrator for the Howard County Health Department.

“The local government and school system were looking for ways to improve performance in certain elementary schools and thought that increasing attendance by offering school-based wellness centers would help increase achievement regardless of race or economic background,” said Hobson.

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Local physicians found out about the program at a hospital meeting, said Scott Strahlman, M.D., chief of pediatrics at Columbia Medical Practice, a multispecialty group with 30 providers.

Scott Strahlman, M.D.

“In our opinion, they weren’t thinking through all the angles when they decided to outsource medical care to the University of Maryland,” he said. “Community pediatricians—some more loudly than others—objected to patients living and going to school in their county receiving advice from academic physicians in Baltimore.”

Others were less concerned with the distance but objected to patient displacement.

“I found it to be problematic that a third party medical center was going to be seeing my patients when I could see my patients,” said Ken Klebanow, M.D., founder of Kenneth M. Klebanow & Associates, a 16-provider pediatric practice. “Other providers were equally concerned about service being offered with no consultation with us. We told the schools we wanted to participate.”

Integrating physician practices

The next school year, the program invited any pediatric practice that had children already enrolled in one of the five schools to participate. “We had more interest than we could accommodate,” Hobson said.

Each practice had to purchase its own high-definition camera, noise-canceling headphones and laptop and attend a training session at the county health department.

In 2015-2016, nine community pediatric practices participated in the telemedicine program. Licensing fees and connections were covered by a grant obtained by the county. The practices each saw their own patients at the schools, while students who did not have relationships with any of the participating providers saw physicians at Howard County General Hospital.

Ken Klebanow, M.D.

The pediatric practices bill private insurance for the patients they see through telemedicine. Visits for students seen by Howard County General Hospital physicians are covered by general county funds.

“Some people were concerned about payment for these visits, but all Maryland insurers have paid us,” Klebanow said.

If the child attends a school with telemedicine availability and protocols determine that a telemedicine visit is appropriate, the school nurse contacts their pediatric practice. Strahlman was pleased to see that the program allowed children to receive care from a physician they had seen before and had access to their medical records.

“The nurses can take temperature, weight and blood pressure and operate the equipment to give us digital looks and listens,” said Strahlman, noting that school nurses can also be authorized to run quick strep tests.

Parents save an hour or more in travel time and missed work, he added. In many cases, children can be given a dose of ibuprofen and sent back to class. A teacher’s concern about potential pink eye may be diagnosed as a benign case of allergies.

“Even when we diagnose strep or pink eye through telemedicine and the kid has to go home and start on an antibiotic, that’s already waiting at the pharmacy," Strahlman said. "It’s very efficient."

Grant money runs out

Overall, the school program has seen steady growth. During the first six months of the initiative, beginning in January 2015, 94 students used the service. In the next school year, physicians saw 150 students. Last year (2016-2017), 217 students connected to physicians through telemedicine in the schools, Hobson said.

However, seven of the practices dropped out of the program after the grant money for their licensing fees ran out. Those with just one or two children in participating schools weren’t willing to pay the $125 monthly fee. Currently, Strahlman and Klebanow have 210 students signed up among eight schools, but both doctors see the program as an investment in the future of medical care.

“You have to grab the future or get pushed into the past,” Klebanow said. “The number of children we see will grow as the program expands into other schools. The next level will happen when parents have equipment.”

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Meanwhile, funding for school telemedicine programs around the country could be jeopardized if the Senate’s healthcare bill gets enough votes to pass. Medicaid cuts could mean less support for rural school systems using telehealth to provide children access to physicians and specialists, according to a Politico report.

But Maryland’s program has provided a jumping-off point for the practices to expand telehealth services outside of the school environment. Klebanow said his practice will provide follow-up services for hyperactivity disorder, behavioral health and lactation. Columbia Medical Practice is looking at a pilot partnership with CareFirst BCBS.

“It’s not as comprehensive as the system we’re using in the school—no nurses or digital equipment—but it will be useful for pink eye and certain follow-ups,” Strahlman said.