**3. Applications of telemedicine in child abuse**

sites have the expertise needed to evaluate this population. The physician, physician assistant, or AdvancedRegisteredNursePractitioner,themedicalproviderofrecord,islocatedatthehubsite while a registered nurse and social worker engage with the child at the remote site during the medicalevaluation.Computerintegrationallowsforthestorageofimagestakenbyeitherthehub or remote site. A telemedicine exam follows the same general protocol as a traditional face-toface medical examination provided by the Child Protection Team. Thus, the medical evaluation includes the child's birth, past and current medical, developmental, and family history, an assessment of the child's behavior and social risk factors and obtaining photographs; all the components of a comprehensive abuse assessment. Examinations are utilized to assess physical

abuse, sexual abuse, and medical neglect cases.

106 Telemedicine

**Figure 1.** Florida Child Protection Team Map noting Main "Hub" Sites and telemedicine sites

The Child Protection Team (CPT) program at the University of Florida is a medically directed, multidisciplinary program based on the idea that child abuse and neglect involve complex issues and require the expertise of many professionals to protect children. It is one of twentyfour legislatively mandated teams of its kind throughout the state of Florida. The University of Florida Child Protection Team (UFCPT) is unique in that it serves a twelve county area in North Central Florida working in coordination with multiple community partners and localized Child Advocacy Centers (CAC) to provide CPT services in child-friendly settings. Established within the University of Florida College of Medicine, Department of Pediatrics

In addition to using telemedicine for real-time child medical evaluations, the technology can also be useful for peer review and consultation. Several Child Protection Teams in Florida also use the technology to conduct quarterly peer review of complex cases among the child abuse experts at various sites. The providers are able to present cases, share images of physical findings and participate in discussion simultaneously without delay. While these peer reviews are conducted in real-time, another application known as store and forward consultations, involves the transmission of still images from a practitioner to a data storage device which can then be retrieved by the expert medical professional and reviewed at a later time. The expert can then view the images remotely to give his/her opinion.

Live telemedicine consultations are another option for remote providers to access child abuse experts at a distance. Providers at remote sites where a patient presents with an allegation of abuse can connect with experts at a tertiary care center agreeing to provide the consultation. Live consultations have shown to reduce cost in other types of medical conditions by reducing the number of patients taken by aeromedical transport to larger medical centers [2]. The use of live consultation in sexual abuse examinations has been shown to improve a rural provider's accuracy in terms of findings and the completeness of the examination [3]. Berkowitz has suggested telemedicine could even be utilized to address underreporting of child abuse by children's primary care providers [4]. Primary care providers would be able to consult on a case with a child abuse expert prior to making a report to their state central register. Physicians may feel more comfortable consulting with an expert before reporting as some fear their suspicion may be wrong.

Live, simultaneously transmitted telemedicine exams are preferable compared to the store and forward application. While both methods accomplish the goal of having a child's injuries evaluated by an expert in the field of child abuse live examinations allow the medical provider access to information that can not be captured by a still image. During the live telemedicine evaluation the medical provider is able to observe the child's body language, interact with the child, observe the child's reactions to the physical examination, and is able to ask additional questions of the child and/or non offending caregiver if needed.

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 previously and have had positive results [5].
