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Telemedicine improves care in child sexual assaults
Majority of rural practitioners improve their processes
Telemedicine has long been known to assist rural facilities in delivering more expert care in a number of specialties, but sexual assault examinations have not typically been among them. However, a new study in the journal Pediatrics shows that it can have dramatic results.1
The study looked at the effectiveness of consults performed at two rural northern California clinics linked by videoconference to experts with the UC Davis Children's Hospital Child and Adolescent Abuse Resource and Evaluation (CAARE) Center through the UC Davis Center for Health and Technology and its telemedicine program. One site was in Eureka in Humboldt County; the other was in Clearlake in Lake County.
UC Davis provided each study site with videoconferencing equipment, including a camera, a flat-screen television monitor, and a video camera connected to the site's colposcope (a lighted magnifying instrument that is used to examine the vagina and cervix). The CAARE Center expert in Sacramento video-conferenced with the community physician and the patient in the exam room at the study site. The expert provided guidance on all aspects of the examination by alternating between viewing the community physician and the patient in the exam room and the images captured by the colposcope.
In all, 42 child sexual assault cases were included in the study, which involved one male and 41 female patients ranging in age from seven months to 17 years. In 47% of the consults, the presence of the CAARE Center expert resulted in changes to the interview methods used. There were nine acute sexual assault telemedicine consults that resulted in improved collection of forensic evidence.
The presence of the expert also resulted in changes in the manner in which 35 — or 89% — of the consults used what is called the "multi-method technique," which involves using multiple, complimentary avenues for obtaining information about instances of sexual assault.
"The quality-of-care piece is this: Delivery of care becomes an educational program where our practitioners sit on one side of the monitor and assist the practitioner with the exam and with obtaining forensic medicine," explains Kristen Rogers, PhD, an assistant professor in the department of pediatrics working in CAARE, and one of the study's authors. "It's live assistance, so it increases the quality of care — which we've shown in our research. It's a higher level of care because you're getting the experts."
For instance, she says, a lot of rural practitioners are not expert in looking for injuries resulting from sexual assault. "Our experts coach them through the exam and say 'Look here,' or 'Manipulate this,'" Rogers explains. "We can look through the colposcope and see a magnified picture, and say, 'Now look at the bottom left corner; do you see that?' It's a great teaching mechanism."
This led to the aforementioned changes in the multi-method technique."These are techniques used by the experts that help visualize the injuries; these are what we assist them with," Rogers explains.
Evidence collection improved
Rogers argues that even improved collection of forensic evidence has quality implications. "It definitely impacts quality of care in terms of a holistic approach — looking at the whole child," she asserts. "It is a mechanism from which evidence is collected to help the whole milieu of obtaining sufficient evidence to prosecute the offender and keep them away from the community."
Not too long ago, Rogers recalls, a local practitioner was examining a child who had been raped and couldn't find any evidence. "Our practitioner said, 'Ask the child what happened,' and she said the man kept whispering in her ear throughout the assault," Rogers shares. "So, our practitioner suggested they swab her ear, and sure enough they got DNA and the guy pled out."
The CAARE experts also are invaluable in assisting with the medical history, Rogers continues. "Local practitioners are pretty good, but not as good as we are at asking questions about the assault — what happened, where, what the child was doing, and so forth," she explains. "It's harder for them because they do not do it all the time, but these questions are also important for gathering evidence. Oftentimes this helps get information about the actual assault — details leading up to it, during and after."
The way the questions are asked also is important in terms of a future trial, Rogers notes. "You can't lead the patient, because it won't hold up in court," she explains. "For example, 'He did this to you, didn't he?' rather than 'Who did this?'"
Care and sensitivity also are crucial, she adds — not just for the victim, but for the provider as well. "This is a very emotionally upsetting prospect that even the local practitioners go through, and to have the consultant 'with' them is very reassuring," Rogers notes. "It's very difficult for everybody."
[For more information, contact:
Kristen Rogers, PhD, department of pediatrics, UC Davis School of Medicine, Children's Hospital & CAARE Center, 2516 Stockton Boulevard, Sacramento, CA 95817. Phone: (916) 734-5647. Fax: (916) 456-2236. E-mail: firstname.lastname@example.org.]