**4. Establishing a telemedicine program**

#### **4.1. Equipment**

Telemedicine requires very specific equipment, software, and network capability. The UFCPT's current network is Secure Integrated Services Digital Network operating at 384kbps transmission speed. A Tandberg Intern was previously used and the Polycom Practitioner Cart is now located at the remote sites (Figure 2 and 3). The hub site also requires a Polycom Practitioner Cart with integrated computer and software. Second Opinion Professional is the current software being used. An AMD General Exam Camera with 50X magnification and a Welsh-Allyn or Leisgang colposcope is used to capture physical findings. The Florida Depart‐ ment of Health Information Technology personnel provide technical support to the CPT Telemedicine program statewide. Consultation with IT support familiar with telemedicine should be initiated in the very early stages of planning.

**Figure 3.** Side-by-side view of both hub site (left) and remote site (right).

In establishing a telemedicine program several key partners should be involved in this process outside of the obvious medical staffing needs. The pilot telemedicine project in Florida found that a key to successful establishment of a telemedicine program is a complete understanding and "buy-in" from the local agencies. An essential part of the planning process is involving these professionals early through a community meeting. This group should include, but is not limited to, hub site medical personnel, local child protective services personnel, local law enforcement investigating crimes involving children, state or district attorney involved in prosecution, local health department and hospital personnel, and the local Child Advocacy Center. The community meeting should explore the benefits of telemedicine to the children being served and the professionals involved in the investigative process. The local community members can assist in identifying viable remote site locations in the area and those best located to serve the greatest number of children. Early on, it is expected that this introduction of technology may meet with some reluctance. Providing documentation of successful programs

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The performance of a telemedicine exam requires a minimum of two medical professionals who have specific child abuse training and training in conducting telemedicine examinations; the medical provider of record (physician, physician assistant, or ARNP) and a registered nurse. The University of Florida Child Protection Team also has a social worker present during the medical evaluation. This individual has usually already conducted a thorough forensic interview with the child prior to the medical examination unless due to the child's young age/

and caregiver and victim testimonials are often helpful in allaying concerns.

**4.2. Community support**

**4.3. Staffing needs**

**Figure 2.** Polycom Practitioner Cart with side-by-side simultaneous view of hub site provider (left) and injury being captured (right) by AMD General Exam Camera with 50x magnification.

**Figure 3.** Side-by-side view of both hub site (left) and remote site (right).

### **4.2. Community support**

Although Florida was the first state to use telemedicine, child abuse professionals throughout the United States have utilized this technology. The Southwest Alabama Abuse Network, Support for Health Involved Professionals in Children's Safety Centers (SHIPS) network, The University of Utah Child Advocacy Centers, and University of California-Davis also rely on the application of telemedicine to provide assessments and conduct reviews in child abuse cases [5]. These and other programs utilize the various telemedicine applications described

Telemedicine requires very specific equipment, software, and network capability. The UFCPT's current network is Secure Integrated Services Digital Network operating at 384kbps transmission speed. A Tandberg Intern was previously used and the Polycom Practitioner Cart is now located at the remote sites (Figure 2 and 3). The hub site also requires a Polycom Practitioner Cart with integrated computer and software. Second Opinion Professional is the current software being used. An AMD General Exam Camera with 50X magnification and a Welsh-Allyn or Leisgang colposcope is used to capture physical findings. The Florida Depart‐ ment of Health Information Technology personnel provide technical support to the CPT Telemedicine program statewide. Consultation with IT support familiar with telemedicine

**Figure 2.** Polycom Practitioner Cart with side-by-side simultaneous view of hub site provider (left) and injury being

previously and have had positive results [5].

**4.1. Equipment**

108 Telemedicine

**4. Establishing a telemedicine program**

should be initiated in the very early stages of planning.

captured (right) by AMD General Exam Camera with 50x magnification.

In establishing a telemedicine program several key partners should be involved in this process outside of the obvious medical staffing needs. The pilot telemedicine project in Florida found that a key to successful establishment of a telemedicine program is a complete understanding and "buy-in" from the local agencies. An essential part of the planning process is involving these professionals early through a community meeting. This group should include, but is not limited to, hub site medical personnel, local child protective services personnel, local law enforcement investigating crimes involving children, state or district attorney involved in prosecution, local health department and hospital personnel, and the local Child Advocacy Center. The community meeting should explore the benefits of telemedicine to the children being served and the professionals involved in the investigative process. The local community members can assist in identifying viable remote site locations in the area and those best located to serve the greatest number of children. Early on, it is expected that this introduction of technology may meet with some reluctance. Providing documentation of successful programs and caregiver and victim testimonials are often helpful in allaying concerns.

#### **4.3. Staffing needs**

The performance of a telemedicine exam requires a minimum of two medical professionals who have specific child abuse training and training in conducting telemedicine examinations; the medical provider of record (physician, physician assistant, or ARNP) and a registered nurse. The University of Florida Child Protection Team also has a social worker present during the medical evaluation. This individual has usually already conducted a thorough forensic interview with the child prior to the medical examination unless due to the child's young age/ development this was not feasible. The social worker's presence during the exam helps to make the child comfortable and also provides continuity for the child while at the clinic or Child Advocacy Center. In addition, the social worker operates the hand held camera that captures the images in order to allow the registered nurse to act as the medical provider's "hands" during the examination. All images and video are available to the medical provider simulta‐ neously. All personnel located at the remote site act under the direction of the medical provider. The history provided to the social worker is relayed to the medical provider via telephone before the exam begins. Prior to the child's examination the registered nurse will explain to the child and family how the exam will be conducted and provide an opportunity for questions to be asked. Families and the child most often want to be reassured that the examination is confidential and cannot be observed by an outside party. The personnel explain that the examination is conducted over secure telecommunications lines and that only the examiner at the hub site is being transmitted the encounter. The child and caregiver are shown the telemedicine equipment and explained that the utilization of the equipment avoids lengthy travel and provide them access to an expert more easily. The child's medical history is gathered from the caregiver accompanying the child to the appointment, if available. The caregiver is asked to leave the room when the examiner obtains history from the child specific to the alleged abuse. Following the medical history, the child is asked whom if any of the individuals that accompanied them to the appointment would they prefer to remain with them during the medical examination. The UFCPT program has found that often with adolescents they prefer to be examined alone.

additional testing or dispensing of medication is necessary. Any child suspected to have

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For the other medical specialties utilizing telemedicine, when the examination is completed and the hub and remote sites disconnect the encounter has also ended. However, for child abuse cases when the medical provider's assessment reveals abuse, there may be criminal and civil court action. Some skepticism about the quality of the photographs that would ultimately need to be presented as evidence in court has been voiced from time to time. To date, since the Florida program's inception in 1998, there have been no legal challenges in court to the thousands of telemedicine images captured by Florida Child Protection Teams. The CPT telemedicine examinations and photos have been utilized hundreds of times in successful

A 4 11/12 year old male was evaluated on 2/18/2011 via telemedicine for concerns of physical abuse due to multiple bruises. This was the fourth time in 17 months that Child Protective Services (CPS) referred him for concerns of physical abuse. There were multiple prior reports for this family including verified reports for family violence and physical injury. The child resided with his mother, four half-siblings and his stepfather. His mother reported that his older sibling (age 10) caused the injuries. The child did not disclose the true etiology of his injuries until this visit when he reported that he was punched, kicked, beaten, and dragged by his mother's paramour and hit by his mother. Physical examination revealed over 40 bruises on multiple body planes. According to a systematic review of bruising in childhood, bruises concerning for physical abuse include those located away from bony prominences, are located on the face, back, buttocks and abdomen, and are multiple occurring in clusters [6]. Please note the following images were taken using the previous Tandberg Intern. UFCPT began using the Polycom Practitioner Cart August 2012 and images for a case study were not yet available. There is much improved quality of the still images captured using the new equipment

After a thorough law enforcement investigation, his sibling disclosed that he and this child were instructed by their mother to lie and state that the injuries resulted from fights between them. Additionally,itwasrevealedthatthischildwasspecificallytargetedbyhismother.Shebeathim, burned him with cigarette lighters, cut his hands, locked him outside their home in the cold and rain, and forced him to remain in a dark closet for hours. In June 2012, his mother pled guilty to 9 felonies, including six counts of child abuse. She was sentenced to 20 years. His stepfather pled

Prior to the criminal case, a Dependency Trial successfully terminated the mother and stepfa‐ ther's parental rights to each of their children. The telemedicine images were accepted into evidence and were an invaluable component of the child abuse medical professional's expert

guilty to 4 felonies, including one count of child abuse. He was sentenced to 5 years.

sustained serious injuries is referred to the nearest Pediatric Emergency Department.

**4.5. Legal consideration**

**5. Case study**

testimony.

criminal prosecutions and dependency trials.

#### **4.4. The medical evaluation**

The child abuse medical evaluation includes a complete physical examination. Height and weight are measured and if the child is 2 years old or younger, a head circumference is obtained. The child's face is photographed for identification. Afterwards, in older children and adolescents, the nurse proceeds to examine the child from the head to the feet. The nurse will comment on body and oral hygiene and any unusual odors in addition to cutaneous manifes‐ tations of abuse. In younger children, examination of the heart and lungs may precede eye and ear examination due to the child's inherent fear and stranger anxiety. Any noted marks, scars, or bruises are identified, measured and photographed. If there are allegations of sexual abuse, then a thorough anogenital exam is also performed. Depending on the age of the child, various positions are used to view the anogenital area. For younger females, frog leg supine position is often used to view the genitalia. Labial separation and/or traction are used to examine the urethra, hymen, fossa navicularis, and posterior fourchette. The knee-chest supine or lateral decubitus positions may be used to view the anus. Boys may be examined in similar positions. Adolescent females are often examined in the lithotomy position. When hymenal injury is detected, to confirm the findings, the nurse can run the hymenal edge with a cotton swab or position the child into knee chest prone, which enables the best view of the posterior hymen. Photographs of the anogenital exam are also obtained, especially any pertinent findings. For acute sexual assaults a forensic evidence kit is completed and given to the accompanying law enforcement officer. Site-specific cultures and/or nucleic acid amplification tests, or any other laboratory tests are obtained as per CPT protocol. The medical provider may determine that additional testing or dispensing of medication is necessary. Any child suspected to have sustained serious injuries is referred to the nearest Pediatric Emergency Department.

#### **4.5. Legal consideration**

development this was not feasible. The social worker's presence during the exam helps to make the child comfortable and also provides continuity for the child while at the clinic or Child Advocacy Center. In addition, the social worker operates the hand held camera that captures the images in order to allow the registered nurse to act as the medical provider's "hands" during the examination. All images and video are available to the medical provider simulta‐ neously. All personnel located at the remote site act under the direction of the medical provider. The history provided to the social worker is relayed to the medical provider via telephone before the exam begins. Prior to the child's examination the registered nurse will explain to the child and family how the exam will be conducted and provide an opportunity for questions to be asked. Families and the child most often want to be reassured that the examination is confidential and cannot be observed by an outside party. The personnel explain that the examination is conducted over secure telecommunications lines and that only the examiner at the hub site is being transmitted the encounter. The child and caregiver are shown the telemedicine equipment and explained that the utilization of the equipment avoids lengthy travel and provide them access to an expert more easily. The child's medical history is gathered from the caregiver accompanying the child to the appointment, if available. The caregiver is asked to leave the room when the examiner obtains history from the child specific to the alleged abuse. Following the medical history, the child is asked whom if any of the individuals that accompanied them to the appointment would they prefer to remain with them during the medical examination. The UFCPT program has found that often with adolescents they prefer

The child abuse medical evaluation includes a complete physical examination. Height and weight are measured and if the child is 2 years old or younger, a head circumference is obtained. The child's face is photographed for identification. Afterwards, in older children and adolescents, the nurse proceeds to examine the child from the head to the feet. The nurse will comment on body and oral hygiene and any unusual odors in addition to cutaneous manifes‐ tations of abuse. In younger children, examination of the heart and lungs may precede eye and ear examination due to the child's inherent fear and stranger anxiety. Any noted marks, scars, or bruises are identified, measured and photographed. If there are allegations of sexual abuse, then a thorough anogenital exam is also performed. Depending on the age of the child, various positions are used to view the anogenital area. For younger females, frog leg supine position is often used to view the genitalia. Labial separation and/or traction are used to examine the urethra, hymen, fossa navicularis, and posterior fourchette. The knee-chest supine or lateral decubitus positions may be used to view the anus. Boys may be examined in similar positions. Adolescent females are often examined in the lithotomy position. When hymenal injury is detected, to confirm the findings, the nurse can run the hymenal edge with a cotton swab or position the child into knee chest prone, which enables the best view of the posterior hymen. Photographs of the anogenital exam are also obtained, especially any pertinent findings. For acute sexual assaults a forensic evidence kit is completed and given to the accompanying law enforcement officer. Site-specific cultures and/or nucleic acid amplification tests, or any other laboratory tests are obtained as per CPT protocol. The medical provider may determine that

to be examined alone.

110 Telemedicine

**4.4. The medical evaluation**

For the other medical specialties utilizing telemedicine, when the examination is completed and the hub and remote sites disconnect the encounter has also ended. However, for child abuse cases when the medical provider's assessment reveals abuse, there may be criminal and civil court action. Some skepticism about the quality of the photographs that would ultimately need to be presented as evidence in court has been voiced from time to time. To date, since the Florida program's inception in 1998, there have been no legal challenges in court to the thousands of telemedicine images captured by Florida Child Protection Teams. The CPT telemedicine examinations and photos have been utilized hundreds of times in successful criminal prosecutions and dependency trials.
