Developing a Newborn Resuscitation Telemedicine Program: A Follow-Up Study Comparing Two Technologies

Abstract

Background: Early work has demonstrated that newborn resuscitation telemedicine programs (NRTPs) are feasible and improve the quality of high-risk newborn resuscitations in community settings. Research evaluating the telemedicine technology requirements for NRTPs is limited.

Objective: To compare the quality and reliability of two telemedicine technologies for providing NRTP consults. We hypothesized that the InTouch Lite Version 2 (ITH Lite) would provide a higher-quality user experience and superior reliability when compared with a wired telemedicine cart.

Methods: From December 1, 2015 to August 31, 2017, providers completed electronic surveys assessing technology performance after each NRTP consult and incident reporting/resolution was monitored. Survey questions assessed the overall, audio, and video quality using a 1–5 Likert scale. Reliability was assessed based on the ability to connect on first-attempt, unplanned disconnections, and the frequency and impact of reported incidents.

Results: During the study period, 118 NRTP consults were performed (n = 25 wired cart; n = 93 ITH Lite) and 155 surveys were completed (n = 26 wired cart; n = 129 ITH Lite). Overall and video quality were similar between the two technologies, but audio quality (mean ± standard deviation) was superior using the ITH Lite (4.61 ± 0.72 vs. 4.08 ± 1.13, p < 0.01). Ability to connect on first attempt was improved with the ITH Lite (96% vs. 73%, p < 0.01). Fewer incidents were reported per activation (0.5:1 vs. 0.9:1) and more incidents were proactively resolved using the ITH Lite (93% vs. 68%, p < 0.01).

Conclusion: The ITH Lite demonstrated improved audio quality and reliability when compared with a wired cart. Organizations should consider connection reliability and audio/video quality when selecting a NRTP technology.

Introduction

Approximately 10% of all newborn infants will require assistance at birth, and 1% of newborns require significant resuscitative interventions.^1,2 In a rural setting, neonatal resuscitations are typically attended by general pediatricians or family practitioners. While clinicians may have completed Neonatal Resuscitation Program training, knowledge and technical skills decline within 4–6 months if not used regularly.^3–5 Maintaining high proficiency in the face of low volumes presents inevitable challenges for rural providers. Telemedicine serves as a mechanism to address barriers in access to subspecialty care, support neonatal resuscitation in remote sites, and improve care for critically ill outborn neonates.

While earlier work demonstrated the feasibility and acceptance of newborn resuscitation telemedicine programs (NRTPs), the technical requirements for providing this type of telemedicine service are not fully understood.^6,7 The emergent nature of the neonatal consult (assessments and interventions occur at 30–60 s intervals), the need for high-quality video and audio to provide remote-guided care for a small patient (birth weight as low as 0.5 kg), and the small workspace surrounded by a large local care team are unique characteristics that should be considered when selecting a NRTP technology.⁶ Studies evaluating the technical requirements for NRTPs are limited. A recent study demonstrated that a wired telemedicine cart performed better than a consumer-grade wireless tablet; however, cart size and limited mobility hindered its ability to fully meet NRTP requirements.⁶ Therefore, a gap remains in identifying an optimal telemedicine technology for NRTPs.

The objective of this retrospective study was to compare the effectiveness of two telemedicine technologies used to provide NRTP consults. We hypothesized that the InTouch Health^® Lite Version 2 telemedicine device (ITH Lite) would provide a higher-quality user experience and superior reliability when compared with a wired telemedicine cart.

Materials and Methods

In 2013, Mayo Clinic began offering telemedicine consults to community hospitals within the Mayo Clinic Health System (MCHS) to provide remote-guided care during high-risk neonatal resuscitations. Board-certified neonatologists at the level IV neonatal intensive care unit at Mayo Clinic Hospital in Rochester, Minnesota provided these consults to hospitals located 40–125 miles away. There were six participating sites during the preintervention period, which expanded to 10 sites during the postintervention period. Community hospital staffing models differed by site, ranging from hospitals with a level II nursery and in-house pediatric hospitalists, to hospitals with a level I nursery staffed by family medicine physicians who take calls from home.

When a NRTP consult was needed, hospital staff followed the standard workflow as previously described.⁶ The teleneonatologist used a codec on campus (preintervention only), desktop on campus, laptop at home, or an iPad/iPhone to establish the real-time video connection with the community hospital.⁶ The telemedicine technology used in the community hospital was either a wired telemedicine cart or a wireless telemedicine system (ITH Lite), depending on the intervention period.

Preintervention Technology

From December 1, 2015 to October 15, 2016, community hospitals used a wired telemedicine cart equipped with a high-definition Vidyo^® coder/decoder (CODEC) running enterprise-standard, Health Insurance Portability and Accountability Act-compliant videoconferencing software (Table 1; Fig. 1A, B). The cart included a pan–tilt–zoom camera that could be controlled by the teleneonatologist and a microphone–speaker set. The fixed camera height was 72″.

Table 1.

Comparison of the Product Features for the Wired Telemedicine Cart and the ITH Lite

	WIRED TELEMEDICINE CART	INTOUCH HEALTH® LITE V2
Compliance-based user access controlsa	No	Yes
Telemedicine cart	Rubbermaid Cart Model M38	InTouch Lite V2
Cart features	External: Inputs required for use as a single solution	Built-in: Product designed to function as a single solution
Video	Camera: Single Camera, Logitech CC3000e Conference Cam, 10 × zoom Video: Vidyo® HD40B CODEC, 720p, 30 fps Display: Samsung 21.5″ LED, up to 1080p	Camera: Dual Camera System, 26 × zoom Video: 640 × 480 resolution. 24-bit color Display: 15″ LCD, 1024 × 768px
Camera height	Fixed height 72″	Adjustable height Minimum: 59.4″ Maximum: 79.4″
Audio	Microphone: Omnidirectional, full duplex Speaker: Wideband audio supporting stereo mode	Microphone: Mono, directional and binaural, omnidirectional Speaker: Two 60W Mono
Wireless	Not approved for wireless use in our organization	Yes
Proactive monitoring	N/A	Device pinged every 2 min
Proactive support	Biweekly device checks performed by the organization	24 × 7 × 365, performed by InTouch TAC
Support model	M–F 8AM–5PM Provided by a combination of multiple departments within the organization and multiple vendors depending on reported issue.	24 × 7 × 365 Defined support model with escalation processes between InTouch TAC and Mayo Clinic IT
Single product technical specification	No, technical specifications needed for each component	Yes

^aDefined as user access based upon physician's state medical license, hospital privileging/credentialing, and facility access to the NRTP service.

CODEC, coder/decoder; N/A, not applicable; NRTP, newborn resuscitation telemedicine program; TAC, Technical Assistance Center.

Fig. 1.

Newborn resuscitation technology program preintervention technology. (A) Wired telemedicine cart equipped with hardware CODEC, pan–tilt–zoom camera, and microphone–speaker set. (B) Wired telemedicine cart in the delivery room during a simulated newborn resuscitation. Published with permission of the participants; used with permission of the Mayo Clinic. CODEC, coder/decoder.

Prepositioned network jacks were activated in all rooms, where an NRTP consult was likely to occur. Before the consult, the cart was connected to the network jack and powered on. Network bandwidth >3 megabits per second with low latency (<50 ms) was generally available from the wired infrastructure. There was limited monitoring of the cart which included biweekly test calls to check that it was powered on, charged, and on network. All users within the Connected Care Vidyo tenancy could access the wired telemedicine carts.

Postintervention Technology

On October 18, 2016, the technology used by the community hospitals was transitioned to a wireless telemedicine product, the ITH Lite (Table 1; Fig. 2A, B). InTouch Health Provider Access Software, Mayo Clinic user authentication, Mayo Clinic wireless network, and the InTouch cloud-based telehealth network were utilized during each consult. The ITH Lite has a dual camera system controllable by the teleneonatologist and directional echo-cancelling microphone with two speakers. The adjustable camera height ranges from 59.4 to 79.4″.⁸

Fig. 2.

Newborn resuscitation technology program postintervention technology. (A) ITH Lite with high-resolution pan–tilt–zoom camera, directional audio, and height extension capabilities. (B) ITH Lite in delivery room during a simulated newborn resuscitation. ITH Lite, InTouch Health Lite Version 2 device. Published with permission of the participants; used with permission of the Mayo Clinic.

The device was always on and connected to the wireless network, which allowed for proactive monitoring and immediate use by the care team. User access was granted for providers who were licensed in the state and credentialed at the facility where the ITH Lite was located. Before service go live, the product was tested across all hospital locations where the device might be used. During the 30-day burn-in phase, support teams monitored device connectivity on the local network to ensure any issues were identified and resolved before patient care use.

Technology Implementation

For both technologies, the implementation services team conducted on-site training of the local care teams and teleneonatologists. When training was complete, teams performed a series of simulated consults in various clinical settings (i.e., labor and delivery room, newborn nursery, and operating room). Simulated consults gave providers an opportunity to experience the clinical workflow and telemedicine technology before implementation.

Pre- and Postintervention Data Collection

Electronic surveys were sent to the teleneonatologist and local team leader after each telemedicine interaction. Each study period lasted 10 months, with the preintervention period, including surveys collected from December 1, 2015 to October 15, 2016, and postintervention period from October 18, 2016 to August 31, 2017. The surveys assessed overall, audio, and video quality using a 1–5 Likert scale (1 = very poor, 5 = excellent). Ability to connect on first attempt and ability to maintain a connection were used to evaluate reliability. Secondary analysis included whether the device type used by the teleneonatologist impacted quality and reliability. The survey also allowed for qualitative data collection, where providers could offer comments about their experience during the consult.

Incident Reporting and Resolution

During the preintervention period, an Excel file was used for incident management and tracking by the Mayo Clinic Center for Connected Care liaison team. ServiceNow™ and Salesforce.com Service were used by Mayo Clinic and InTouch Health for incident management and tracking during postintervention. Incidents were divided into two categories: (1) those identified and resolved proactively that did not impact patient care and (2) those identified at the point of care during a clinical consult with a patient. Proactive monitoring included incidents identified during real-time vendor monitoring of the devices, training sessions, daily support device checks, clinical simulation, and physician on-call preparation activities. Point-of-care incidents were defined as incidents identified by a provider during a patient encounter. It is important to note not all incidents identified at the point of care resulted in a complete failure to conduct a consult. Incident tracking combined with the vendor's ability to measure device uptime allowed determination of product availability. Product availability was defined as the ability to complete a consult, regardless of audio/video quality.

The Mayo Clinic Institutional Review Board approved this study.

Statistical Analysis

Continuous variables were summarized by using mean (standard deviation) as appropriate. Frequency counts and percentages were used to summarize categorical variables. Comparison of continuous variables was conducted using the Wilcoxon rank-sum and two-sided t test as appropriate. For testing associations between categorical variables, chi-square test or Fisher's exact test was used. The Kruskal–Wallis test was used to compare device type and its effect on overall, audio, and video quality. A two-tailed p-value <0.05 was considered statistically significant. Statistical analysis was performed by using JMP software version 13.0.0 (SAS Institute, Inc.) and Excel 2010 (Microsoft Corp.).

Results

During the study period, a total of 155 surveys were completed. Nineteen of the 25 (76%) telemedicine consults during the preintervention period had survey data. Of the completed surveys (n = 26), 11 (42%) were completed by the MCHS local provider, and 15 (58%) were completed by the teleneonatologist. Comparatively, 89 of the 93 (96%) consults during the postintervention period had survey data. Of the 129 surveys completed, the local provider completed 55 (43%) surveys, and the teleneonatologist completed 74 (57%) surveys.

User satisfaction for overall, audio, and video quality was compared for the two NRTP technologies (Table 2). Overall quality and video quality ratings were not significantly different between the technologies. However, the mean audio quality rating was significantly higher for the ITH Lite compared with the wired telemedicine cart [4.61 (0.72) vs. 4.08 (1.13), p < 0.01].

Table 2.

Comparison of the Quality and Reliability for the Wired Telemedicine Cart and the InTouch Lite V2

	WIRED CART (n = 26)	INTOUCH LITE V2 (n = 129)	p
Quality (mean ± SD)a
Overall quality	4.42 ± 0.76	4.53 ± 0.82	NS
Audio quality	4.08 ± 1.13	4.61 ± 0.72	<0.01
Video quality	4.69 ± 0.47	4.62 ± 0.64	NS
Reliability
Successful connection on first attempt	73%	96%	<0.01
Connection lost or dropped	4%	8%	NS

^aBased on survey results using a 1–5 Likert scale (1 = very poor, 5 = excellent).

NS, not significant; SD, standard deviation.

The teleneonatologist was able to connect on first attempt more reliably with the ITH Lite compared with the wired telemedicine cart (96% vs. 73% of consults, p < 0.01; Table 1). The percentage of consults complicated by unplanned disconnections was not significantly different between the technologies.

Teleneonatologists provided NRTP consults using various devices from either the hospital or their home. The impact of device type used by the teleneonatologist on overall, audio, and video quality and reliability was assessed. Device type had no significant effect on quality or unplanned disconnections for the wired telemedicine cart or the ITH Lite (data not shown). However, with the wired cart, the device type used by the teleneonatologist significantly impacted the ability to successfully connect on first attempt. Specifically, the desktop on campus (100%) and laptop at home (100%) were superior to the CODEC on campus (50%) or the iPhone/iPad (0%), (p = 0.05).

Qualitative comments from the surveys were summarized to gain a deeper understanding of the favorable characteristics and limitations of each technology (Tables 3 and 4). For the wired telemedicine cart, the advantages primarily related to improved access to subspecialists and better resource allocation. Technology limitations included dropped audio, poor quality of audio when multiple team members were present, poor image quality with a camera that was difficult to use, and a cart that was difficult to position. For the ITH Lite, the advantages included enhanced technology performance, a fast and sustainable connection, and improved ability to perform remote-guided procedures. Limitations of the technology included audio volume being too low for the resuscitation setting, dropped audio with some delay and compromised clarity, and poor image quality.

Table 3.

Summary of Qualitative Survey Comments and Exemplar Quotes for the Wired Telemedicine Cart

THEME	EXEMPLAR QUOTE
Advantages
Access to subspecialist	“Very useful; a must-have equipment at all level I or II nurseries.” (OHP)
	“Excellent service for providers in periphery with limited neonatal exposure.” (OHP)
Better allocation of resources	“Glad that the baby stayed locally. Without telemedicine, the evaluation would have been difficult to perform.” (Neo)
Audio/video quality	“Audio was awesome and we could see the provider very well.” (OHP)
	“Great clarity to the point I could monitor the glidescope monitor and help with airway visualization and intubation.” (Neo)
Limitations
Audio
Dropped audio	“The audio still breaks up at times, so we need to repeat our information and recommendations.” (Neo)
	“The audio again kept cutting out and making echo noises when anyone talked.” (OHP)
Difficulty when multiple team members present	“When the resuscitation area has multiple conversations, it's hard to hear clearly and know who a question is being asked to - Rochester Neo vs. a local team member.” (Neo)
	“It was a busy delivery room which caused the sound to be intermittently interrupted making conversation difficult.” (Neo)
Delays	“My audio was also delayed from my image on their end which was a bit distracting.” (Neo)
	“The sound was not glitchy, but was delayed.” (OHP)
Video
Poor image quality	“Image degradation with panning and zooming.” (OHP)
	“The video was very good, but when trying to zoom in on the scalp defect, the image quality was still a bit pixelated…the smaller details (presence of dimple or fluid leak) was difficult to appreciate.” (Neo)
	“Video feed froze once during the resuscitation.” (Neo)
Difficult to use	“I couldn't figure out how to move the camera so ^local provider just held the baby up.” (Neo)
Cart size	“The team had to reposition the cart so I could see the infant. The team clearly had to work around the cart.” (Neo)
	“Camera position still makes it a bit hard to see the baby. I'm still looking through people to get a peek of the baby.” (Neo)
Connectivity	“The wireless connection seemed to be a bit unstable with low quality.” (Neo)

^Substitution of “neonatologist” or “spoke-site” for de-identification.

Neo, teleneonatologist; OHP, outside hospital provider.

Table 4.

Summary of Qualitative Survey Comments and Exemplar Quotes for the ITH Lite V2

THEME	EXEMPLAR QUOTE
Advantages
Enhanced technology performance	“The InTouch device worked so smoothly and in part validated our hopes that this would be a significant enhancement to our service.” (Neo)
	“The new InTouch Health is very advanced and best one I have ever worked with.” (OHP)
Access to subspecialist	“Absolutely loved it! It was great knowing you had the backup of a specialist.” (OHP).
	“Worked great. Had ^neonatologist on the line before the infant was born.” (OHP)
Video	“Even from across the room I was able to zoom in and see the baby well.” (Neo)
Reliability	“The connection was so fast.” (OHP)
	“They pushed me from the postpartum room to the NICU. The video froze once but the connection did not drop. Impressive!” (Neo)
Remote guided procedures	“Consultant was able to view patient clearly and assist with guidance of the chest tube insertion.” (OHP)
	“The telemedicine connection was very helpful with evaluating this infant for the possible need for therapeutic hypothermia.” (OHP)
Limitations
Audio
Volume too low	“Initially the volume was very quiet. The nurse was able to turn up the volume to its highest capacity… but it was still a little too quiet with all of the additional noises in the OR.” (OHP)
Dropped audio	“I received frequent ‘audio lost’ and ‘connection failure’ messages. The audio dropped during the consult which was disruptive…” (OHP)
	“There were a couple of times when audio went out for just a few seconds. Resolved quickly and not a big impact on total service.” (OHP)
Delay and poor clarity	“Needed to use regular telephone and telemedicine initially as audio was not clear.” (OHP)
	“There was a delay in seeing neonatologist's lips move and then hearing what she was saying.” (OHP)
Video
Poor image quality	“Occasionally the video image became a bit pixelated with an image quality that was poorer than I've come to expect with the ITH technology.” (Neo)
	“Difficult to view any of the monitors or baby; everything was pixelated.” (Neo)
Difficulty focusing	“The ^neonatologist had some trouble focusing the video to get a clear image of the baby.” (OHP)
Connectivity	“Connection was dropped once spontaneously and once related to user error.” (Neo)

^Substitution of “neonatologist” or “spoke-site” for deidentification.

Analysis of incident reporting and resolution revealed product availability was 96% (24/25) with the wired telemedicine cart and 99% (92/93) with the ITH Lite (p = 0.3). Twenty-two incidents were reported for the preintervention technology and 43 for the postintervention technology. While product availability was not different between the two technologies, the ratio of incidents to activations was 0.9:1 during the preintervention period and 0.5:1 for the postintervention period. During the preintervention period, 68% (15/22) of the incidents were proactively resolved compared with 93% (40/43) in the postintervention period (p < 0.01). Consequently, the percentage of point-of-care incidents was significantly higher with the wired telemedicine cart (7/22) compared with the ITH Lite (3/43), (32% vs. 7%, p < 0.01).

Discussion

In this study, we hypothesized that a wireless telemedicine system (ITH Lite) would provide a higher-quality user experience and superior reliability when compared with a wired telemedicine cart for providing NRTP consults. We found the ITH Lite increased audio quality and first-attempt connection reliability, but overall quality, video quality, and unplanned disconnections were unchanged between the two technologies.

The technological base of any telehealth program is connectivity.⁹ Given the emergent and critical nature of NRTP consults, a highly reliable telemedicine technology is crucial. Furthermore, the ability to sustain the connection is important because these consults can last up to 4 h (median, 45 min) for neonates delivered extremely preterm.^6,7 This study demonstrated first-attempt connection reliability was improved with the ITH Lite, but unplanned disconnections were similar between the two devices. While quantitative data did not suggest differences in dropped connections, qualitative data for the wired cart included comments about delays in connecting and descriptions of the connection being “unstable with low quality.”

Improved connection reliability with the ITH Lite is further supported by fewer reported incidents, a greater percentage of incidents resolved proactively, and fewer incidents impacting clinical care. Qualitative data showed providers were impressed with the fast connection and stability of the connection with the ITH Lite (even while moving the cart from a Labor and Delivery room to the nursery).

Communication is fundamental to a successful newborn resuscitation, and may be even more critical when separated by time and space such as that experienced in the NRTP environment. To provide high-quality care during neonatal resuscitations, the team needs to share information and communicate intentions and plan of care.^6,10 For these reasons, exceptional audio quality is imperative during NRTP consults. Audio quality was superior with the ITH Lite compared with the wired cart. Although audio quality was significantly improved, users still commented on issues with audio volume, delay, and clarity that were disruptive to the consult.

Similarly, video quality during a newborn resuscitation is important for a successful NRTP consult. Video must provide variation in visual expansion such that the teleneonatologist can obtain a wide view of the local team to maintain situational awareness. The technology must also be able to focus on a newborn to evaluate for millimeters of chest rise or allow remote-guided procedures such as umbilical catheter placement.⁶ Both the wired cart and ITH Lite had mean video quality scores that were “very good” to “excellent.”

Complications with video quality for both technologies arose during technical maneuvers such as camera panning and zooming. The video image became pixillated, delayed, or froze during these maneuvers. The teleneonatologists also commented on occasional difficulty with camera focus, particularly with the ITH Lite. At other times, the video provided detailed visualization allowing the teleneonatologist to give pointed instructions. For example, one consultant said, “Even from across the room, I was able to zoom in and see the baby well.”

Several complex procedures were performed using the ITH Lite, which affirms “very good” or “excellent” video quality. Specifically, the teleneonatologist was able to guide community providers through thoracocentesis, chest tube insertion, umbilical line placement, and electrocardioversion. Additionally, video quality allowed the teleneonatologist to evaluate an infant for encephalopathy and need for therapeutic hypothermia. These examples, however, may represent the benefits of NRTPs rather than a superiority of one technology to the other.

Local providers found the wired telemedicine cart to be bulky and less maneuverable. They either had to work around the cart or the teleneonatologist's view of the infant was compromised due to obstruction by the local care team. Comparatively, qualitative data suggested that the ITH Lite was more maneuverable, particularly when moving from one location to another (e.g., operating room to nursery). Correct positioning of the ITH Lite within the workspace was still important, however, as positioning behind the warmer may limit visualization of the infant and monitors.

For an effective NRTP, the neonatologist needs to be available 24 h a day, 7 days a week as newborn emergencies are unpredictable. For accessibility purposes, neonatologists may need to establish the telemedicine connection using a variety of devices from different locations. Evaluation of whether device type used by the teleneonatologist impacted quality or reliability was important. Device type had an effect on first-attempt connection reliability for the wired cart, but not the ITH Lite. Connectivity was poorer when the teleneonatologist used the iPhone/iPad or the CODEC on-campus to connect to the wired cart. This may have been due to consults occurring over cellular networks or variation in the teleneonatologist's user interface depending on what device they used.

Telemedicine has been successfully used in pediatrics and has led to strong patient, caregiver, and provider satisfaction.¹¹ More specific to neonatology, telemedicine has improved the quality of care, transfer times, and initiation of outcome-driven interventions.^11–13 These benefits were echoed in the qualitative data for both the wired cart and ITH Lite in our study. An appreciation for access to a subspecialist, improved allocation of resources, enriched communication with family members, and supervision of infrequently performed procedures were recurrent themes. Overall, the importance of preserving the value gained from telemedicine consults while improving on technical performance was expressed.

This study is not without limitations. Given the retrospective observational study design, there is risk of recall bias. Also, despite both intervention periods lasting 10 months, there were more consults performed and surveys completed during the postintervention period. However, the local provider and teleneonatologist completion rates were equally represented across both pre- and postintervention periods.

Transitioning our NRTP technology from a wired cart to the ITH Lite significantly improved audio quality and first-attempt connection reliability. In addition, ITH Lite product availability was 99%, and improved incident reporting/resolution allowed 93% of incidents to be resolved proactively so patient care was not impacted. Nevertheless, certain deficiencies remain that need to be addressed to achieve our programmatic goals, including (1) seamless high-fidelity video that is maintained with panning/zooming and (2) improved form factor that allows the device to fit well in the care space and provides the teleneonatologist with views of the newborn, monitors, and X-ray images.

Telemedicine represents a rapidly developing platform in medicine to support underserved areas.¹⁴ NRTPs bring tertiary care resources to newborns with the greatest needs regardless of their birth location. While telemedicine has already demonstrated improved regionalization of perinatal care and a decrease in infant mortality,^11,15 continued research involving telemedicine within perinatal/neonatal medicine is needed.

Conclusion

For NRTP consults, this retrospective study demonstrated that the ITH Lite improved audio quality and ability to connect on first attempt when compared with a wired telemedicine cart. The device type used by the teleneonatologist impacted first-attempt connection reliability for the wired cart, but not the ITH Lite. Qualitative data collected for both devices demonstrated a desire for reliability of connection, dependable audio/video quality, and a technology that fits well in the care environment. Incident reporting revealed there were fewer incidents with the ITH Lite and these were more likely to be resolved proactively when compared with the wired telemedicine cart. Organizations should consider these qualities when selecting a technology for their NRTP.

Disclosure Statement

K.M., B.L.K., and T.S. have no conflicts of interest relevant to this article to disclose. J.L.F. has unrelated licensed intellectual property with InTouch Health.