Table 3.

Potential Facilitators to Pediatric Emergency Telemedicine Programs in Development

DOMAIN	SPECIFIC RECOMMENDATION
Selection of spoke hospitals	When choosing spoke hospitals to include in a network, program administrators should first consider ease of implementation. They should begin with sites that are likely to be the most straightforward (e.g., sister hospital with a shared electronic health record.) Once they have worked out logistical and administrative hurdles, then they should expand and begin to select sites based on need.
Cultivation of clinical champions	Program administrators should cultivate clinical champions at both the hub and spoke sites. In addition, there tends to be a great deal of emphasis on the identification of physician champions. It is equally important to cultivate nurse champions who set up equipment and coordinate the consultations.
Physician engagement with technology	Lack of comfort with equipment is a major reason why physicians elect not to use telemedicine and instead opt for a phone consult. To improve their comfort level, encourage physicians to engage with the technology as much as possible outside of consults. For example, offer educational programming via telemedicine and do frequent testing of equipment.
Obtaining buy-in from spoke sites	In cases where spoke hospitals must be convinced that a pediatric emergency telemedicine program is worth the effort, bundle a pediatric emergency telemedicine program with a menu of other service lines or programs. For example, program administrators can offer pediatric emergency telemedicine among other offerings where spoke sites already see value (e.g., telestroke).
Obtaining buy-in from hub physicians	Hub site physicians may view consults as additional work, and this can inhibit buy-in. Program administrators can incentivize physicians to provide consults by removing other responsibilities/allowing telemedicine consults to replace another time-consuming activity. For example, administrators can remove the requirement that physicians drive to do a remote clinic once a month.
Improving volume	Spoke sites may fail to initiate consults if they are unclear regarding the proper use of telemedicine. If volume is low, program administrators can provide education to spoke hospitals regarding when exactly to use telemedicine. They should provide specific instructions and examples of when a consult should be initiated.To improve volume, closed systems can impose a health system-wide rule that any phone consult be rolled over into telemedicine.
Common platform for telemedicine within hub site	To improve efficiency, program administrators should have all telemedicine programs within the hospital under one umbrella. A common platform not specific to service line provides economies of scale.