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    Best tech for Pediatrics: 2014

    In case you missed my presentation at the American Academy of Pediatrics National Conference last month, here’s a recap of my most favorite tech for the pediatric office.

    I recently had the good fortune to present a forum on medical office technologies (“Must-Have Gadgets, Gizmos, and Technology for the Pediatric Office”) at the American Academy of Pediatrics (AAP) National Conference and Exhibition in beautiful San Diego. Given at the request of the AAP’s Section on Advances in Technology and Therapeutics, several pediatrician colleagues and I did a “show and tell” on a wide spectrum of gadgets and gizmos to a receptive audience of 80 pediatricians.

    The room was at capacity, and unfortunately we could not accommodate all the pediatricians who wanted to attend. Even a reporter from Contemporary Pediatrics had to be physically removed when she attempted to “crash” the session. Although I have been writing about office tech since the world was young, I have rarely had the opportunity to answer questions and receive feedback directly from pediatricians. Let’s take a look at what devices the pediatricians favored and review some of the hot topics discussed at the forum.

    Advantages (and disadvantages) of being “high tech”

    I began the presentation with a brief overview of how integrating office technology can improve pediatric practice. Pediatricians have limited time and much to do at any health supervision or ill visit. Our gadgets can improve patient care by expediting our screens, providing accurate office-based diagnostic tests, and providing new treatment options.

    There may be a few disadvantages to the “high-tech office.” First, our technology is often expensive, and we need to be able to determine if the technology is a worthwhile investment and to have the cash reserves sufficient to purchase a new device. Once acquired, we also need to learn when not to “trust” the information our technology provides us. Often this means validating the technology by comparing results to those produced by our previous “low-tech” tests. Some devices may not be appropriate for our patient population (in-office lead tests, for example), or may complicate existing workflow (otoacoustic emissions [OAE] hearing screeners and photoscreeners).

    Screening pediatric patients

    A recent article in the Morbidity and Mortality Weekly Report indicated that pediatricians could be doing a better job at screening children for preventable diseases.1 According to the article:

    • Approximately 50% of infants who failed their newborn hearing screening did not have follow-up testing.
    • Approximately 80% of children aged 10 to 47 months did not have a formal screen for developmental delays.
    • Two-thirds (67%) of children who met criteria for screening at 1 and 2 years of age were not tested for lead poisoning.
    • Approximately 1 in 5 (22%) children aged 5 years never had his/her vision checked by a doctor or other healthcare provider.
    • Approximately 1 in 4 (24%) clinic visits for preventive care made by 3- to 17-year-olds had no documentation of blood pressure measurements.
     

    At the forum “screening technology” station, several of my favorite technologies were presented and discussed. I’ve long been a fan of the Child Health and Development Interactive System (CHADIS; Total Child Health; Baltimore, Maryland) online service that enables parents to complete age-appropriate questionnaire and screening tools in advance of an office visit. At the time of the visit itself, the CHADIS documentation is recalled electronically and results pasted into the electronic health record (EHR) well-visit note after they are reviewed with the parent. Most pediatricians at the forum were aware of CHADIS, but were reluctant to enroll in the service because they assumed it was too expensive or too difficult to use. After CHADIS was demonstrated and discussed, many pediatricians at the forum said they planned to consider adopting the service.

    We also demonstrated 2 hearing screening devices: the Welch Allyn (Skaneateles Falls, New York), OAE Hearing Screener and the Maico Diagnostics (Eden Prairie, Minnesota) Ero-Scan Screener Plus. Both were discussed in a recent Peds V2.0 article. The Ero-Scan Plus with printer is less expensive than its competition, selling for $4300 with disposable ear tips that cost about 30 cents each. In contrast, the Welch Allyn device sells for $500 more at $4834, and the ear tips are 3 times as expensive at $1 each. However, complicating the purchasing decision is that Maico offers no extended warranty, but Welch Allyn offers up to a 2-year extended warranty. The cost of repairing an OAE screener out of warranty could easily exceed $500 (my personal experience with previous Ero-Scan devices). Doing 100 screens per month, the cost difference for ear tips between the Maico and Welch Allyn screeners would exceed $800 dollars per year! Also, keep in mind that based on a reimbursement rate of $10 per test and 100 tests per month, either device would generate $12,000 per year, covering the cost of acquisition more than twofold, and perhaps making the difference in acquisition price and the cost of supplies less significant. The conclusion from this mental exercise is that cost considerations may influence the decision regarding the acquisition of any new device when alternatives are available.

    The Welch Allyn Spot Vision Screener and the Plusoptix (Atlanta, Georgia) S12 Mobile Screener were presented and compared. Pediatricians liked the ability to screen young children for amblyopia, but were intimidated by the price of these devices ($7000 plus). They were pleased to learn that the screening is now being covered by most insurance companies, even Medicaid, at a rate of $35 per test. Because this is a screening that pediatricians will perform frequently, the devices are likely to pay for themselves within several months to a year’s time, depending on screening volume. A pediatrician could consider paying for these devices with a low-interest practice credit card and use the points to purchase other office equipment.

    We also demonstrated a new smartphone-based photoscreener called GoCheck Kids (Gobiquity; Aliso Viejo, California). There is no up-front cost to purchase this photoscreener because the practice shares one-half of the test reimbursement with the manufacturer. I’ve been trialing the device in the office and it is very easy to use because children of all ages are already used to posing for their parents’ smartphones. According to a study published earlier this year, the GoCheck Kids smartphone application has comparable specificity and sensitivity in detecting children with risk factors for amblyopia compared with the Plusoptix and Spot photoscreeners.2

     

     

    We also demonstrated the Welch Allyn Connex Vital Signs Monitor, which is a portable $2000 device that can be used for quickly obtaining vital signs including blood pressure on pediatric patients. Most pediatricians liked the device, but thought that traditional manual blood pressure cuffs and thermometers were more than adequate for taking vitals in most pediatric offices.

    Lastly, pediatricians rotating through the screening station were also intrigued by the only in-office lead screening device on the market, the LeadCare II from Magellan Diagnostics (North Billerica, Massachusetts), which is reasonably priced ($2500) and accurate compared to reference labs. Test supplies cost less than $10 per test. The test kit lists for $395 on Amazon.com with free shipping—an opportunity to use those credit card points! Tests can be performed either on a finger-stick sample or venous specimen, and results are available in minutes. For most practices, lead screening is a “send-out” test. By performing tests in the office, physicians can reassure parents that their children pass the screen at the time of the office visit, and practices do not need to call parents or mail out letters when test results become available.

    Diagnostic and treatment options

    Our second workstation featured several devices both familiar and unfamiliar to the forum participants. Many pediatricians said that they use the Vios Pro compressor and LC Sprint Nebulizer System from Pari (Midlothian, Virginia) that we demonstrated, which enable pediatricians to provide a nebulizer treatment to kids with asthma in about 10 minutes.

    However, most of the attendees were not familiar with the Veinlite (Sugar Land, Texas) devices that use LED lights to help staff identify veins for phlebotomy and intravenous catheter insertion, but were convinced by the demonstration that these could prove helpful for offices where blood drawing is done regularly.

    Pediatricians who were not familiar with the Masimo (Irvine, California) Pronto-7 system touch-screen pulse oximeter were intrigued by its ability to talk the user through a measurement and its ability to screen older children for anemia as it displays a hemoglobin measurement (see “Pulse oximetry: The fifth vital sign,” October 2014).

    The Becton Dickinson (Franklin Lakes, New Jersey) BD Veritor System also was presented and discussed. This is a high-tech digital immunoassay for the rapid identification of children with respiratory syncytial virus (RSV), influenza, and group A streptococcal (GAS) infections. The manufacturer boasts that its Veritor GAS, RSV, and influenza A and B tests are more accurate than the rapid tests pediatricians are accustomed to using. The system employs a cassette system and an optical reader to provide results in less than 5 minutes.

    Pediatricians were also keenly interested in the CryoProbe (Mount Pleasant, South Carolina) system that uses nitrous oxide cartridges to freeze warts. In my experience, the nitrous oxide spray is less painful compared with liquid nitrogen, yet equally effective. The Cryoprobe system sells for about $3000, and a box of 24 cartridges (8 grams) sells for $150. The device comes with several tips to precisely control the area of the freeze.

    Several pediatricians were critical of the low-cost Firefly DE500 Digital Video Otoscope (Firefly Global; Belmont, Massachusetts). In the exhibit hall at the conference, the vendor had no problems demonstrating how easily the $350 device could view and display the ear canal and tympanic membrane on a computer screen. Many who had had experience with the device, however, said that it was very difficult to get an adequate image when used with a less-than-cooperative child.

    Lastly our pediatrician “teaching assistants” demonstrated several popular Bionix (Toledo, Ohio) products. These included the ShotBlocker, which can reduce the pain associated with injections; the Igloo Wound Irrigation System; and the company’s Lighted Ear Curette that can assist pediatricians in removing impacted cerumen that can obstruct the view of the tympanic membrane.
     

     

     

    Mobile devices and applications

    Our last station featured several mobile applications and devices. One of my favorite mobile devices is the Zamzee (HopeLab; Redwood City, California), a fitness tracker for kids that has proven effective in motivating kids to exercise. This device will be discussed in detail in a future Peds v2.0 article.

    Also popular among our pediatrician audience was the Masimo iSp02 consumer pulse oximeter that connects to either an iOS or Android phone or tablet. The device sells for $130 on Amazon.com and gives parents of children with asthma the ability to record pulse oximeter readings if their child has an exacerbation. Having the ability to measure oxygen saturation at home can alert parents that the child needs to be seen by their pediatrician. Like the professional Masimo pulse oximeters, the consumer device can display readings when a child is moving or in low-perfusion situations. The iSp02 pulse oximeter is just 1 example of many devices that connect to smartphones or tablets to display and record physiologic measurements. Their use can be of benefit in monitoring children with chronic medical conditions.

    I pointed out to our audience that smartphones, introduced just a few short years ago in 2007, have changed the way patients and parents occupy their time while in the waiting and exam rooms. Smartphones also can directly improve care because many parents use their devices to capture pictures of rashes or record videos of behaviors (such as tics) that concern them.

    I shared with our audience that I rely on just a few mobile applications on my own smartphone and tablet. To quickly research an illness, I favor both UpToDate and Medscape. To perform most of my routine calculations, my favorite application is Pedi QuikCalc. This application provides several tools such as a pound-to-kilogram conversion tool, percent weight-loss tool, a bilirubin level risk calculator, and an intravenous infusion rate calculator. It also provides medication dosages of most common pediatric medications based on the inputted weight. By using Pedi QuikCalc, it’s not necessary to switch between several different applications. I also demonstrated Scoliometer HD that turns your smart device into a scoliometer for quantifying scoliosis, and the many high-resolution image applications from DrawMD that can help pediatricians explain a variety of medical conditions to parents.

    And in the end . . .

    In our closing review and discussion session, I highlighted some technologies that are in the works, including needle-free injection systems, pain-free phlebotomy systems, microneedle patch immunizations, more intelligent stethoscopes, and even a medical “tricorder” (yes, as in Star Trek) that can help expedite diagnosis.

    Even after reporting on office gadgets and gizmos for more than a quarter century, I am convinced that the best is yet to come.

     

    I would like to thank the following pediatricians for their help with the “Gadgets and Gizmos’"session: Kevin Hodges MD; Naveen Mehrotra, MD; Larry W. Desch, MD; Eugenia Marcus, MD; and Manuel Vides, MD. I also would like to express my appreciation to Teresa McNulty, Content Channel Director at Contemporary Pediatrics, for attempting to attend and report on the forum for our readers!

     

    REFERENCES

    1. Frieden TR; Centers for Disease Control and Prevention (CDC). Use of selected clinical preventive services to improve the health of infants, children, and adolescents—United States, 1999-2011. MMWR Morb Mortal Wkly Rep. 2014; 63(Suppl 2):1-107.

    2. Arnold RW, Armitage MD. Performance of four new photoscreeners on pediatric patients with high risk amblyopia. J Pediatr Ophthalmol Strabismus. 2014;51(1):46-52.



     

    Andrew J Schuman, MD, FAAP
    Dr Schuman, section editor for Peds v2.0, is clinical assistant professor of Pediatrics, Geisel School of Medicine at Dartmouth, ...

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