BACKGROUND

«Telemedicine» was born from the combination of new communication technologies with the traditional modes of personal medical examination, thus configuring a new service; it can thus contribute to improving the quality of health care, enable the usability of treatment, diagnostic services, medical advice at a distance, and allow the constant monitoring of vital parameters, to reduce the risk of the onset of complications in people at risk. The key concept is precisely that of «distance», which is the very essence of Telemedicine. Moreover, this discipline fosters multidisciplinary confrontation and better continuity between different hospital activities, thanks to innovative technologies, which facilitate a continuous computerized exchange of data, texts, communications (in voice and on-screen) and digital images, leading to net savings in terms of personal (and family) costs incurred by the patient and his or her caregivers and in terms of health and social costs incurred (including psychological ones) by the bureaucratic machine of the public sector of Health Care. Telemedicine is then the future and is an important innovation in the exercise of the medical ars because it makes it possible to support new paths of diagnosis and treatment through the digitization of clinical data and the provision of professional services that can be carried out remotely with appropriate digital technologies.¹

Historical and legal profiles

Historically, the development of Telemedicine can be associated with the evolution of demographic dynamics and the consequent change in the health needs of the population, which registers an increasing share of the elderly and chronic diseases, since the early years of mechanical and electronic applications in healthcare; however, recently, applications in other clinical areas as well, such as COVID-19 emergency management and precisely pediatrics, have enabled new assessments in terms of economic and welfare impact, opening the door to a new way of experiencing the morbid condition, especially when it is chronic and disabling. Telemedicine, however, also means taking care and attention to the legal profiles related to service delivery, the transmission of sensitive data and the rights/obligations arising from the fiduciary relationship with the health professional. And therefore, services are tailored to the case, based on specific needs, according to precise terminologies (often mistakenly confused): a) we speak of «teleconsultation» when the health act is put in place that intervenes in connection with the patient, who interacts remotely with the health professional, either for reasons of support or prescription of therapy or assistance on therapy and symptoms, or between professionals concerning a team or professional confrontation on a specific issue; b) we speak of «telehealth» when assistance is put in place in a general sense, and the consultation is aimed at the management of the therapeutic relationship or organizational relationship.²

Telemedicine tools and their various applications

The literature^3-5 documents that services offered and deliverable with the use of telemedicine systems have the following characteristics: 

1. “Synchronous (real-time) and asynchronous (delayed) messaging”, by which the user can interact with the professional, team, or health facility by exchanging short messages. 
2. “Televisit” (real-time interaction), with which the user can make a medical examination with the individual professional or the team, and hand over the documentation before the appointment unless the health care service to be performed does not require physical contact.
3. “Telemonitoring” (deferred monitoring), whereby the user is monitored over a certain period for scheduled functions (e.g., cardiac reveal plus, for analysis of potential arrhythmic episodes);
4. “Teleconsultation” (real-time interaction between professionals and the user for therapy or management of the health issue), with which the user or the professional can interact to perform the service, including because of a complex assessment involving the intervention of two or more professionals, whether it is to schedule specialized care, therapy, or rehabilitation intervention.
5. “Remote coaching” (real-time interaction between professionals and user to teach knowledge and management of the health care issue), whereby the user or professional can interact to schedule the lesson related to the health care service, including because of a complex assessment involving the intervention of two or more professionals, to facilitate the user in learning what is needed.
6. “Teleassistance / Psychological telesupport” (real-time interaction between user and professional in the psychological field), with which the user or professional can interact to carry out the psychological and/or psychiatric service, also because of a complex assessment involving the intervention of two or more professionals.

It is possible then, in this way, an exchange of clinical information, interaction and collaboration between patients and professionals, mentoring and rehabilitation activities, and psychological support therapy administered online. Telephone contact with the patient then allows for dialogue, organizational nursing triage to direct in the most appropriate course of care, and health education, precisely because contact makes it possible to maintain the human relationship, always personalized and to help the patient become independent and more aware. 

Applied telemedicine

Telemedicine experiences have been implemented in many healthcare sectors and for specific medical issues. Recurring themes in the literature concern aspects of complex patient management, critical social and economic issues, the most recurrent and naturally impactful diseases such as metabolic, cardiac, neurological, genetic, immunological, and oncological disorders, to psychological and psychiatric issues. 

Applied telemedicine (I): The complex management of the surgical and problematic patient

The tools used in telemedicine with surgical^6-7 and complex^8-9 patients were in particular video telephony (to obtain interim results and history), wearable devices (tablets), remote videotaping of clinical data, and post-visit survey (for satisfaction index), demonstrating that post-hospital follow-up by telematics in pediatric surgery provides a cost-effective alternative that saves time for patients and improves the quality of service and hospital care.¹⁰ Telerobotics then represents a well-established reality, which allows for reducing postoperative complications and improving the quality of patient recovery,¹¹, as well as telemedicine applied to home hospitalizations, which can improve the quality, efficiency, and effectiveness of care.¹²

Applied telemedicine (II): the critical social and economic issues

The issues related to this topic mainly refer to ancillary patient services such as the use of technology during patient transport,¹³ patient management during hospital discharge,¹⁴ and caregiver management of the patient during admission to the neonatal intensive care unit, ¹⁵ and any other clinical issues that have a social impact, such as tobacco addiction and misbehaviour to the detriment of the child,¹⁶ alcohol and substance abuse,¹⁷ pregnancy and the entire postpartum period,^18-20 chronic pain management,²¹ and vaccine immunization. ²² Each of these issues, in the literature, has been addressed through the use of telemedicine tools, such as broadband audio-video transmissions, messaging, video telephony, and teleconsultation, demonstrating the clear and positive impact on service quality, user satisfaction, and even unnecessary economic health care costs.²³ 

Applied telemedicine (III): the metabolic disorders

The issues related to the subject under review mainly relate to obesity,^24-25 diabetes,^26-27 celiac disease,²⁸ and thyroid dysfunction,²⁹ demonstrating that the use of videophone, wearable devices (tablets), remote videotaping, and post-visit questionnaires increase user and family member satisfaction, as well as the quality, efficiency, and effectiveness of the service provided, especially in terms of increased understanding and knowledge of the clinical phenomenon.

Applied telemedicine (IV): the cardiac disorders

Recurring themes include the premature risk of death from arrhythmic disorders and cardiac arrest,³⁰ congenital heart disorders,^31-32 and cardiovascular risk,³³ and even in these hypotheses, the importance of using telemedicine tools such as video telephony, tablets, and teleconsultation emerges to ensure the efficiency and effectiveness of health care intervention for better user satisfaction. 

Applied telemedicine (V): the neurologic disorders

Telemedicine systems such as messaging, video telephony, and teleconsultation, also find particular application in disorders of neurological origin, such as migraines,³⁴ brain trauma,³⁵ epilepsy,³⁶ and neurodevelopment in general,³⁷ as well as in pediatric neurodegenerative forms,³⁸ demonstrating as in previous cases the positive impact on patients and the health care system, in terms of improved quality, services, and subjective satisfaction.

Applied telemedicine (VI): other medical conditions

Telemedicine, according to the literature, also has applications in other disorders, such as genetic diseases,³⁹ oncological diseases⁴⁰ and the palliative care pathway,⁴¹ sepsis and systemic infections,⁴² inflammatory states of the gastrointestinal tract,⁴³ cystic fibrosis⁴⁴ juvenile rheumatoid arthritis,⁴⁵ allergies and asthma,⁴⁶ up to dermatological,⁴⁷ otolaryngological⁴⁸ and sensory⁴⁹ diseases, always with the same aims of positively impacting patients and the health care system, in terms of improving quality, services and subjective satisfaction.

Applied telemedicine (VII): the psychological and psychiatric conditions

Again, telemedicine systems, such as messaging, video telephony, and teleconsultation, have found wide application in the clinical hypotheses of autism^50-51 and many other psychological and psychiatric disorders, such as psychological trauma resulting from early exposure to drugs or sexual misconduct,⁵² obsessive-compulsive disorder⁵³ attention deficit hyperactivity disorder (ADHD),⁵⁴ gestational depression,⁵⁵ anxiety and depressive states^56-57 although results are mixed, ICT, ⁵⁸ and behavioral disorders, ⁵⁹ to positively impact patients and the health care system, in terms of improving quality, services, and subjective satisfaction.

This paper aims to verify the state of the art of telemedicine applied to Neonatology and Pediatrics healthcare facilities.

METHODOLOGY

We searched in Pubmed until March 30, 2023, for meta-analyses, clinical trials and randomized controlled trials, using the keyword “telemedicine”, selecting 8,523 useful results. Based on the inclusive criteria, such as telemedicine, preterm, infant, and pediatric, 54 publications were selected, to which an additional 3 systematic reviews and 5 books were added. Simple reviews, opinion contributions, or publications in popular volumes were excluded because they were irrelevant or redundant for this paper, and publications that did not present results or statistical samples but only research protocols and proposals, those that did not specifically address the topic of investigation, those with contradictory data, unreliable data, or otherwise with a deficient research design. The search was not limited to English-language articles. No limit was placed on the year of publication, covering the time window from 1996 to the present period. Figure 1

RESULTS

In the literature Table 1, new communication technologies applied to traditional modes of personal medical examination configure a new way of performing health care service, to help improve the quality of care, and the satisfaction of the user and his or her family and achieve a net benefit in social and economic terms.⁶⁰ 

In Neonatology and Pediatrics, in particular, there has been an increase in the last decade, especially in Italy, of these activities, having felt the need for new dimensions of care, especially for pathological conditions that lend themselves well to telematic and remote consultations (via messaging, televisit, telemonitoring, coaching and telehealth), especially in terms of follow-up.⁶¹ In particular, thanks to the 20-year experience of the Italian Society of Telemedicine (SIT), it has been possible to spread the use and importance of telemedicine in health care, with emphasis on the lack of digital skills on the part of professional staff; in particular, in the pediatric setting: «[…] for large-scale development of telemedicine on a large scale, it is necessary to create confidence in the services it can offer and to promote its acceptance by health care professionals and patients. by health care professionals and patients. In this context, patient information on the use of telemedicine, the benefits that can be derived from it, and the training of health professionals and patients in the use of the new tools. professionals and patients in the use of the new technologies are key aspects. […] For the present and future of digital health care, there is a need for professionals’ skills growth and a continuous learning approach throughout their professional lives. Therefore, information and training actions are important to ensure the necessary professionalism and knowledge of the tools, as well as a good understanding of the interactive context in which they are used. In addition, medical skills can be integrated with those of different professional figures (engineers, physicists, statisticians, and mathematicians) to give rise to a new category of health professionals responsible for building new semiotics, identifying criteria for predictive models to be integrated into clinical practice, standardizing clinical and research databases, defining the boundaries of social networks and new communication technologies within health services”.⁶² 

DISCUSSION AND LIMITATIONS

Technology, over the past three decades, has been able to guarantee high performance in terms of efficiency, effectiveness and cost-effectiveness, and digital skills undoubtedly represent the central theme of innovation in the national health service, and not only in the pediatric theme, both for the system-country and for all the actors involved: patients, physicians, technicians, IT specialists and managers. It is clear, however, that, as in any other health and care pathway, training tools are at the heart of innovation, and for the current present and the imminent future (of digital health care), exponential growth in professionals’ skills and a continuous learning approach throughout professional life is required. Progress, therefore, positively impacts both the system country and individuals, but it must be aided with continuous training and information actions to ensure the necessary professionalism and knowledge of the tools, as well as a good understanding of the interactive context in which they are used continuously and functionally for public and private health objectives. And while, on the one hand, information follows communication and social channels, training must be concerned above all with educational profiles, both concerning new technical and technological knowledge and concerning the practical part, that is, new information acquisition equipment and data transmission technologies. Therefore, it is essential that learning becomes a systematic action and not just an extemporaneous proposal aimed at the short-term goal. In pediatrics, the focus must be more maintained at a higher level, as patients are by their nature considered «fragile»; to date, however, there are several implementation limitations to the active regime of telemedicine in pediatrics and neonatology: a) the lack of technical knowledge of the instruments used for applied telemedicine;⁶³ b) the costs of supporting, operating and maintaining the material instrumental network; c) the subjective cognitive distortions of the user and/or his or her family, related to the complication or uselessness of the new technologies compared to traditional methods of health consultation and delivery; d) the non-applicability of the new technological measures related to telemedicine in the hypothesis of medical examination that requires physical contact or other physical modality; e) a good part of the published studies have structural errors in the construction phase of the research design, effectively vitiating the final result, as happens in the hypotheses of reduced or insufficient population sample with respect to representativeness, conflict of interest with respect to the hypotheses of publicity of the specific IT tool devised and used by the research team, and approval questionnaires of dubious statistical usefulness. These reported limitations, however, should not discourage the hypothesis that technology can be used constructively and functionally to foster a better approach to the issue, to achieve the social and economic benefit, for the individual user and the entire community. 

CONCLUSION 

Significant evidence emerges concerning the importance of using new information technology in the service of medicine, albeit with several practical criticalities, to ensure efficiency, effectiveness, and quality of health service, both in social and economic contexts, for Neonatology and Pediatrics departments.

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