Objective Despite the emergence of telemedicine as an important model for healthcare delivery, there is a lack of evidence-based telemedicine guidelines, especially for resource-limited settings. We sought to develop and evaluate a guideline for a pediatric telemedicine and medication delivery service (TMDS).

Methods A prospective cohort study was conducted at a TMDS in Haiti; children ≤10 years were enrolled. Among non-severe cases, paired virtual and in-person exams were conducted at the call center and household; severe cases were referred to the hospital. The primary outcome was the performance of the virtual exam compared to the in-person exam (reference standard).

Findings A total of 391 cases were enrolled. Among 320 cases with paired exams, no general World Health Organization (WHO) danger signs were identified at the household; problem-specific danger signs were identified in 6 cases (2%). Cohen’s kappa for the designation of mild cases was 0.78 (95%CI 0.69-0.87). Among components of the virtual exam, the sensitivity and specificity of a reported fever were 91% (87%-96%) and 69% (62%-74%), respectively; the sensitivity and specificity of ‘fast breathing’ were 47% (21%-72%) and 89% (85%-94%), respectively. Kappa for dehydration assessments indicated moderate congruence (0.69; 95%CI 0.41-0.98). At 10 days, 95% (273) of the 287 cases reached were better/recovered.

Conclusion This study, and resulting guideline, represents a formative step towards an evidence-based pediatric telemedicine guideline built on WHO clinical principles. In-person exams for select cases were important to address limitations with virtual exams and identify cases for escalation.

The authors have declared no competing interest.

NCT03943654

This research was supported by a National Institutes of Health grant to EJN [DP5OD019893] as well as internal support from the Emerging Pathogens Institute (EJN), the Departments of Pediatrics (EJN), the Department of Environmental and Global Health (EJN), the Department of Emergency Medicine (KEF/TKB) at the University of Florida, and the Children’s Miracle Network. These funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

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The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

The University of Florida Institutional Review Board gave ethical approval for this work (IRB201802920). Additionally the Comite National de Bioethique in Port-au-Prince Haiti gave ethical approval for this work (1819-51).

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All data produced in the present study are available upon reasonable request to the authors.