Russo et al. BMC Pediatrics (2017) 17:21
DOI 10.1186/s12887-016-0756-x

RESEARCH ARTICLE

Open Access

What drives attitude towards telemedicine
among families of pediatric patients? A
surveyLuisa Russo, Ilaria Campagna, Beatrice Ferretti, Eleonora Agricola, Elisabetta Pandolfi, Emanuela Carloni,
Angelo D’Ambrosio, Francesco Gesualdo* and Alberto E. Tozzi

Abstract
Background: Telemedicine has been recognized as a way to improve accessibility, quality, and efficiency of care. In viewof the introduction of new telemedicine services, we conducted a survey through a self-administered questionnaire
among families of children attending the Bambino Gesù Children’s Hospital IRCCS, a tertiary care children’s hospital
located in Rome, Italy.
Methods: We investigated sociodemographic data, clinical information, technological profile, attitude towards
telemedicine, perceived advantages of telemedicine, fears regarding telemedicine, willingness to use a smartphone app
providing telemedicine services and willingness to use a televisit service. Through logistic regression, we explored theeffect of sociodemographic and clinical variables and technological profile on willingness of using a telemedicine app
and a televisit service.
Results: We enrolled a total of 751 families. Most patients had a high technological profile, 81% had at least one accounton a social network. Whatsapp was the most popular messaging service (76%). Seventy-two percent of patients would
use an app for telemedicine services and 65% would perform a televisit. Owning a tablet was associated with bothoutcome variables - respectively: OR 2.216, 95% CI 1.358–3.616 (app) and OR 2.117, 95% CI 1.415–3.168 (televisit). Kind of
hospitalization, diagnosis of a chronic disease, disease severity and distance from the health care center were notassociated with the outcome variables.
Conclusion: Families of pediatric patients with different clinical problems are keen to embark in telemedicine programs,
independently from severity of disease or chronicity, and of distance from the hospital.

Background
Once limited to delivering health care to patients in remoteareas, telemedicine has been recognized as a way to improve accessibility, quality, and efficiency of care [1]. As amatter of fact, telemedicine has been adopted by a numberof different medical specialties: cardiology [2–4], neurology[5, 6], surgery [7–9], dermatology [10–13], ophthalmology[14–17], radiology [18, 19]. In pediatrics, telemedicine has awide range of potential applications [20].
In Italy, telemedicine services dedicated to the pediatricpopulation are not common and are not always included
in reimbursement policies, despite Internet connection* Correspondence: f.gesualdo@gmail.com
Telemedicine Unit, Bambino Gesù Children’s Hospital IRCCS, Piazza S. Onofrio
4, 00165 Rome, Italy

being widespread among the population [21] and a variety
of technical solutions being available on the market.
The Bambino Gesù Children’s Hospital IRCCS, a tertiary care academic hospital located in Rome, Italy, dedicated to pediatric patients with a wide range of healthneeds, is planning an enhancement of the existing telemedicine projects and an implementation of new services.
In order to innovate processes through telemedicine
services, needs and expectations of the target publicshould be matched with the availability of technologic
solutions and with feasibility of expected interventions.
The aim of our study was to identify needs and expectations of families of children regarding the use of telemedicine services and to investigate their technologicaland Internet profile, prior to development and implementation of specific telemedicine services.

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Russo et al. BMC Pediatrics (2017) 17:21

Methods
Study design and population

This is a cross-sectional study. We conducted a survey,
from September 2014 to January 2015, on a random sampleof parents of children, aged 0–18 years, admitted to theBambino Gesù Children’s Hospital IRCCS, Rome, Italy,
both as outpatients and as inpatients, for acute or chronic
diseases. The Bambino Gesù Children’s Hospital is a tertiary care academic hospital, with 607 inpatient-beds.
Participants were consecutively recruited on different
weekdays by trained research nurses. Specifically, inpatientswere recruited among those admitted in the Department ofPediatrics on Mondays and Tuesdays; patients admitted to
Day Hospitals and outpatients were recruited on Wednesdays and Thursdays. Eligibility criteria included having achild aged 0–18 years, signing an informed consent andspeaking Italian.
The study was approved by the Bambino Gesù Children’s Hospital’s ethical committee.
Questionnaire

After signing in an informed consent, participants wereinvited to fill in a self-administered questionnaire evaluating the attitude towards telemedicine applications (seeAdditional file 1). Specifically, the questionnaire collected
information about:– socio-demographic data (age, sex, nationality, regionof residence, postal code, education level,
employment);– child’s data: sex, age, number of the child’s hospital
admissions during last year, number of visits byfamily pediatrician during last year;– technological profile: availability of technologicaldevices among smartphone, personal computer(PC), tablet, smartTV (i.e. a television set withintegrated Internet and Web 2.0 features);availability of a blog or of a social media accountamong Facebook, Twitter, LinkedIn, Instagram,
Google+; use of messaging software among
Whatsapp, Skype, Facebook Messager; use of video
calls; use of smartphone apps; use of smartphone
apps for health; search of health information on theInternet;– telemedicine attitude, measured on a 5-point Visual
Analog Scale (VAS): perceived usefulness of the following services: an app allowing communication
with other parents of children with the same disease;a diary for recording the child’s health status; an app
for scheduling medical visits; telemonitoring; a service for transmitting telemonitoring data to a doctor;
a service for consulting a doctor in case of emergency; reminders for medical visits; a service providing transmission of health data from the hospital;

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reminder for therapy; newsletter on healthpromotion;– perceived advantages of telemedicine (measured on
a 5-point VAS scale): time saving; cost saving; empowerment of patients; empowerment of families;– fears regarding telemedicine (measured on a 5-point
VAS scale): lack of trust regarding the use of monitoring devices without the presence of a physician;privacy; difficulty in using technological devices.
Moreover, we asked if the participant would use (Yes/No question):– an app providing telemedicine services;– a televisit service (defined as synchronousvideoconference encounter between the provider
and family/patient).
We extracted disease diagnosis and disease severity
from patients’ electronic health record. A disease was defined as “chronic” according to the definition adopted by
the Medical Subject Heading (MesH) database [22]. Disease severity was categorized on the basis of the American
Society of Anesthesiologists (ASA) classification: I) normal
healthy patient; II) patient with mild systemic disease; III)patient with severe systemic disease; IV) patient with severe systemic disease that is a constant threat to life.
Analysis

We described sociodemographic variables, and prevalence
for each item as mean and standard deviation (SD), medianand range or proportions and 95% confidence intervals(CI), as appropriate. Proportions were calculated excluding
missing values.
In the descriptive analysis, the participants’ technological profile was classified as follows:– availability of technological equipment: low (0–1
device); medium (2 devices); high (3–4 devices);– availability of blog/social network accounts: low (noaccount); medium (1–2 accounts); high (3–6
accounts);– use of messaging services: low (0–1 service);
medium (2 services); high (3 services).
At the univariate analysis, we studied through logistic
regression the association of sociodemographic variables
and variables regarding telemedicine-attitude with two
different outcomes: 1) interest in using a televisit service,2) interest in using a telemedicine app. Here follows alist of the exposure variables which were studied at theunivariate analysis: respondent’s age (continuous), sex,
education level (university degree or lower), employment(employed/not employed), living in the Rome province,

Russo et al. BMC Pediatrics (2017) 17:21

hospital admission in the past year, visit by the family
pediatrician in the past year, ASA category (1–2 vs 3–4),
being a foreigner, child’s age, child’s sex, availability oftechnological devices (yes/no for each item), blog or social network account (yes/no for each item) and use of
messaging services (yes/no for each item), use of videocalls (yes/no), having ever used an app, having ever used
an app for health.
The multivariable analysis was performed through logistic regression, including the following as independent variables: type of hospital admission (inpatients, outpatients,
or day hospital), having a chronic disease, ASA category
and living within the Rome province, plus variables that
resulted associated with the outcome with a p < 0.2. The p
threshold <0.2 is commonly used as a compromise between including in the multivariate model all variables
and selecting only those associated at the p < 0.05 level.
Using the p value <0.2 should allow to include in the final
model also those variables that, at the univariate analysis,
are marginally associated with the outcome because of aconfounding effect.
We calculated that 600 interviews would have been sufficient to estimate proportions with a precision of +/- 4%,with a confidence level of 95%, and an expected proportionof families who would use a telemedicine service of 50%.

Results
Sociodemographic and clinical characteristics

A total of 751 families were enrolled: 257 outpatients,
248 Day-hospital patients and 246 inpatients.
Characteristics of families included in the study are
shown in Table 1.
The majority of responding parents were females(70.2%) and had a mean age of 39.9 (SD 8.1). The large
majority of respondents had a high level of education(50% had a high school diploma, 31% had a university
degree). In a high proportion of enrolled families (75%),
the child had a chronic disease.
Nearly one third of families had accessed the hospital
5 or more times in the past 12 months and 35% of themhad visited the family pediatrician in the same period.

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Table 1 Sociodemographic and clinical characteristics
Number

Percent

Female

522

70.16

Male

222

29.84

Respondent’s sex

Respondent’s age≤ 35 years

228

30.89

36–45 years

327

44.31

≥ 46 years

183

24.80

Foreign nationality

86

11.70

High school diploma or university degree

594

81.00

University degree

230

31.38

Employed

484

67.22

Living in the municipality of Rome

271

39.45

Living in the province of Rome

414

60.26

Living in Lazio Region

524

76.27

Female

367

49.80

Male

370

50.20

< 1 years

118

15.71

1–5 years

232

30.89

Child’s sex

Child’s age

6–10 years

199

26.50

11–17 years

164

21.84

≥ 18 years

38

5.06

Never

131

17.90

Up to 4 times

407

55.60

5 or more times

194

26.50

< 1 years

62

57.41

1–5 years

196

86.96

Frequency of hospital visits during last year

At least 1 hospital visit in the last year by age

6–10 years

171

87.24

11–17 years

141

87.04

≥ 18 years

31

81.58

Visits to the pediatrician during last year

Technological profile

Never

66

9.48

The technological profile of the respondents is reported
in Table 2.
All respondents had at least one device allowing connection to the Internet. A high proportion of respondents had a computer (73%), a smartphone (67%) or atablet (50%). Fifteen percent had a SmartTV. Moreover,more than one third of respondents had more than 3 or
4 devices connected to the web.
A high proportion of respondents (81%) had at least
one account on a social network or a blog. As expected,
the most popular social network was Facebook (75%),

Up to 4 times

383

55.03

5 or more times

247

35.49

At least 1 visit with family pediatrician during last year by age< 1 years

90

89.11

1–5 years

213

97.26

6–10 years

172

92.47

11–17 years

135

87.66

≥ 18 years

20

55.56

Chronic disease

561

74.70

Russo et al. BMC Pediatrics (2017) 17:21

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Table 1 Sociodemographic and clinical characteristics(Continued)

Telemedicine attitude

Disease severity (ASA)
Lev. 1

208

27.73

Lev. 2

227

30.27

Lev. 3265

35.33

Lev. 450

6.67

followed by Google + (27%), Twitter (17%) and LinkedIn(15%). Notably, 14% of respondents had a blog. Regarding the use of messaging services, Whatsapp was themost popular service used (76%), followed by Facebook
Messenger (59%) and Skype (34%).
Half respondents used videocall services. A large proportion (72%) had used a smartphone app and one quarter
had used a smartphone app with health-related contents.
Table 2 Technological profile
Number

Percent

Smartphone

501

66.71

PC

548

72.97

Tablet378

50.33

Smart TV

114

15.20

Low (0–1 device)

236

31.47

Medium (2 devices)

235

31.33

High (3–4 devices)

279

37.20

Blog

89

13.78

Facebook account

553

75.03

Technological equipment

Twitter account

131

17.77

LinkedIn account

112

15.20

Instagram account

83

11.28

Google + account

199

27.00

Multivariable analysis

Social network profile
Low (no account)

122

19.09

Medium (1–2 accounts)

368

57.59

High (3–6 accounts)

149

23.32

WhatsApp

564

75.60

Skype

251

33.69

Facebook

442

59.25

Low (0–1 messaging service)

309

41.48

Medium (2 messaging services)

263

35.30

High (3 messaging services)

173

23.22

359

49.93

Ever used a smartphone app

530

71.91

Ever used a smartphone app for health

172

24.47

Use of instant messaging services

Video calls

A total of 476 (65%) would do a televisit for the problem
that caused the hospital access, while 85 (12%) would
not; 515 (72%) would use an app, while only 23 (3%)
would not. In both cases, one quarter of patients
responded “I do not know”: 173 (24%) regarding the
televisit, 181 (25%) regarding the app.
Table 3 shows perceived usefulness of specific telemedicine functions and perceived advantages of telemedicine services (the 5 point Lickert scale is presented
in a synthetic format in order to overcome excessive
granularity of data).
Most respondents considered most of the functionsof telemedicine, as investigated by our questionnaire,as moderately important or very important. Amongthe most appreciated potential functions of telemedicine were those concerning communication with thehospital: transmission of health data from the hospital(moderately/very important according to 93%), consultation of a doctor in case of emergency (moderately/very important according to 90%), scheduling of
medical visits (moderately/very important according
to 90%).
Concerning the advantages of telemedicine, most respondents thought that time saving was moderately/very
important (88%), followed by cost saving (85%).
Finally, we asked those that had responded “No” or “I
do not know” to both outcome questions (interest in televisits or health app) on their fears regarding telemedicine. Lack of trust towards telemedicine tools was themost addressed concern (30% considered it as moderately/very important), followed by fear of excessive responsibilities for the family (28%). Surprisingly, fear for
privacy was not a strong concern (57% considered it oflittle importance or not important at all).

The multivariable analysis (see Tables 4 and 5) showedthat willingness of performing a televisit was associatedwith the following outcomes: owning a PC (OR 1.61,
95% CI 1.02–2.542), owning a tablet (OR 2.117, 95% CI
1.415–3.168), having a LinkedIn account (OR 2.329, 95%
CI 1.151–4.714), having the habit of performing videocalls (OR 1.865, 95% CI 1.138–3.057). On the other
hand, the availability for the use of an app dedicated totelemedicine was associated with owning a PC (OR2.835, 95% CI 1.68–4.784), owning a tablet (OR 2.216,
95% CI 1.358–3.616) and having already used an app for
health (OR 2.689, 95% CI 1.323–5.465). Owning a Twitter account was negatively associated with willing to use
an app (OR 0.448, 95% CI 0.208–0.963). Notably, distance from the hospital was not associated either withwillingness to perform a televisit or to use an app.

Russo et al. BMC Pediatrics (2017) 17:21

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Table 3 Attitude towards telemedicine and perceived advantages
None/A bit
N

Sufficient%N

Moderate/Much%

N%

Attitude towards telemedicine - perceived usefulness of:
An app allowing communication with other parents of children

124

18

167

25

389

57

A diary for recording the child’s health status

67

9

122

17

541

74

An app for scheduling medical visits

15

2

62

8

663

90

A service for televisits

147

20

137

19

452

61

A telemonitoring service

98

13

117

16

513

70

A service for transmitting telemonitoring data to the doctor

56

8

95

13

589

80

A service for consulting a doctor in case of emergency

22

297

52

7

669

90

Reminders for medical visits

28

4

77

10

637

86

A service providing transmission of health data from the hospital

16

2

38

5

689

93

Reminders for therapy

110

15

107

15

519

71

A newsletter on health promotion

38

5

64

9

639

86

Time saving

21

3

68

9

645

88

Cost saving

29

4

81

11

622

85

Empowerment of patients

60

8

121

17

545

75

Empowerment of families

54

7

125

17

551

75

Perceived advantages of telemedicine

Table 4 Multivariable analysis – dependent variable: willingness
to use an app for health issued by the hospital

Discussion
The decision leading to the creation and implementationof an innovation should be moved by the combinationof three cornerstones: feasibility, viability, and desirability [23]. The development of a telemedicine projectOR

95% CI

p

Male

1.64

0.926–2.889

0.09

Graduated

1.28

0.737–2.225

0.38

Table 5 Multivariable analysis – dependent variable: willingness
to use a televisit service

Employed

0.68

0.383–1.189

0.17

OR

95% CIp

Living in the Rome province

1.44

0.902–2.288

0.13

Graduated

1.03

0.652–1.633

0.89

Foreign nationality

0.95

0.43–2.085

0.89

Employed

1.06

0.685–1.623

0.81

Smartphone

1.82

0.238–13.894

0.57

Living in the Rome province

1.2

0.814–1.77

0.36

PC

2.84

1.68–4.784<0.001

Foreign nationality

0.66

0.34–1.292

0.23

Tablet2.22

1.358–3.616<0.001PC

1.61

1.02–2.542

0.04

Smart TV

0.96

0.455–2.015

0.91

Tablet2.12

1.415–3.168<0.001

Blog

0.86

0.422–1.75

0.68

Smart TV

0.97

0.54–1.752

0.93

Facebook account

1.31

0.628–2.744

0.47

Facebook account

1.5

0.817–2.756

0.19

Twitter account

0.45

0.208–0.963

0.04

Twitter account

0.75

0.399–1.403

0.37

LinkedIn account

1.99

0.841–4.684

0.12LinkedIn account

2.33

1.151–4.714

0.02

Instagram account

1.3

0.522–3.234

0.57

Instagram account

0.85

0.43–1.671

0.63

Google + account

1.81

0.963–3.402

0.07

Google + account

1.22

0.745–1.999

0.43

Whatsapp

0.94

0.499–1.768

0.85

Whatsapp

0.98

0.575–1.665

0.94

Skype

0.84

0.431–1.655

0.62

Skype

0.96

0.556–1.654

0.88

Facebook

0.84

0.429–1.656

0.62Facebook

0.88

0.511–1.519

0.65Video calls

1.77

0.981–3.204

0.06

Videocalls

1.87

1.138–3.057

0.01Ever used an app

1.69

0.928–3.086

0.09Ever used an app

1.29

0.768–2.151

0.34Ever used an app for health2.69

1.323–5.465

0.01Ever used an app for health

1.55

0.912–2.628

0.11

Russo et al. BMC Pediatrics (2017) 17:21

would benefit from the application of such principles.
With the present study, we explored the last item: what
the public - in our case, families of children attending atertiary care children’s hospital - desires and expects.
Our results show a notable interest towards telemedicine: a large proportion of families were keen on the ideaof using an app issued by the hospital and more than ahalf were willing to do a televisit. Willingness to use telemedicine services was transversal among participating
families, and was not influenced by kind of hospitalization,
presence of a chronic disease, disease severity and distancefrom the health care center. Such characteristic suggeststhat the creation of a telemedicine service can be oriented
towards all kinds of patients, with no need of focusing on
specific subgroups.
Attitude to the use of technologies for health management has previously been explored in adult patients. Most
published studies have focused on specific patient populations and investigated heterogeneous items, with variable
results. Interest towards telemedicine has been detectedamong cancer patients [24] and patients affected withchronic lung diseases [25], although, in some cases, the attitude towards the use of new technologies was low. In alarge survey, patients affected with depression and thosewith a high risk of cerebrovascular disease reported amoderate interest in phone, email and Internet based services, while interest in social media based services was
lower. In these two groups, sociodemographic variables
were not predictive of interest in telemedicine [26].
On the other hand, the pediatric context is particularly
favorable for telemedicine services: parents and patientsare young and familiar with new technologies. This is confirmed by our findings: most participants had a high leveltechnological profile, both in terms of availability oftechnological tools and in terms of used functions, including videocalls, messaging services and social networks.
Such profile, together with the elevated cultural level ofour population, represents a fertile environment for thedevelopment and the spreading of telemedicine services.
Regarding the interest towards telemedicine of the surveyed population, our findings are in line with the resultsof most published surveys, reporting a positive attitude
and a strong interest towards telemedicine in the pediatriccontext. Great satisfaction was expressed towards a telemedicine service for child and adolescent mental health[27]. In a randomized controlled trial, families of obese
children showed a high level of satisfaction towards a telemedicine group intervention [28]. A survey conducted on
patients’ families regarding the teleconsultation service
provided at the Royal Children’s Hospital in Melbourne
showed a high level of satisfaction, most families declaringthat they had received the same standard of care as in aface-to-face consultation [29]. Families are interested intelemedicine-based follow up of their children after a visit

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at the emergency department [30]. A positive perception
towards telemedicine, with a variable degree of preference
for face-to-face consultation was detected among familiesof children undergoing a genetic consultation [31] and ascreening for retinopathy of prematures [32].
In our study population, three quarters of patients wereaffected by a chronic disease, and had frequent contacts
both with the hospital and with their family pediatrician.
At the multivariate analysis, presence of a chronic illness
and disease severity were not associated with willingness
to use telemedicine services. Despite this lack of association, as a matter of fact, pediatric patients with chronic
diseases, often requiring frequent contacts with healthcare institutions, may benefit from televisits and telemonitoring, with a direct impact on costs, in particular those
associated with hospital readmission [33]. Enrolled families accounted cost saving as an interesting advantage ofthe implementation of telemedicine services.
Preferred telemedicine functions concerned communication with the hospital, in terms of logistics (data transmission, appointment scheduling) and clinical communication(distance communication in case of emergency).
Such functions may have an interesting impact on quality of life, which can be positively affected by telemedicine
services [33] through reducing the need of in-person visits(time saving was the most regarded item among the advantages of telemedicine in our population), speeding up
processes, empowering patients and strengthening their
feeling of security.
On the other hand, those who were less keen on theuse of telemedicine mainly did not trust the technologies
which would be involved in the provision of telemedicine services. Despite the overall high digital literacy of
the target population, issuing an app for health or a service of televisits warrants a strong program of education,
directed towards patients, patients’ families and healthcare professionals, in order to guarantee adequate use
and implementation.
Interestingly, owning a tablet was associated with bothstudy outcomes, showing that tablets may have a great
potential for the delivery of telemedicine services.
Due to their size allowing a mix of portability and good
image quality, tablets represent an ideal media for distancecommunication and for the use of apps dedicated tohealth care. Tablets have been widely used for telemedical
purposes, targeting both health care professionals [34–37]
and patients [38–40].
Our study has several strengths: first, the study population is large, thus increasing precision of estimates.
Moreover, we included clinical information in the survey, which allowed us to study the potential associationof telemedicine attitude and expectations with variables
such as severity of the disease and chronicity, whichhave been rarely taken into account in such studies.

Russo et al. BMC Pediatrics (2017) 17:21

Our study also has a number of limitations. First, we did
not acquire information on people declining to answer tothe questionnaire, thus the responding population might
be selected towards those more interested in telemedicine.
Secondarily, we investigated education level and employment as proxies for the socio-economic status of the enrolled families. To this regard, even though the estimationof the socio-economic status through these variable may
not be precise, our population might have been selected
towards those with a high level of education and employment, thus leading to an overestimation of technological
profiles and of the attitude towards telemedicine. However, confounding by socio-economic variables was taken
into account in the multivariable analysis. Thirdly, our results are likely influenced by the specific context (patients
attending a tertiary care pediatric hospital in central Italy),
and their generalizability to other settings may be limited.

Conclusion
Families of pediatric patients with different clinical problems are keen to embark in telemedicine programs, irrespective of severity of disease or chronicity, and of distancefrom the hospital. Technological profiles of these families
are largely sufficient to meet basic requirements for telemedicine services based on videocalls and dedicated apps.
Since the market offers many commercial solutions withdifferent levels of complexity for telemedicine programs,
the only determinant for implementation regards feasibility,
including presence of appropriate infrastructures in telemedicine hospital providers, and availability of personnel
for telemedicine services.
Additional file
Additional file 1: Questionnaire on the attitude towards telemedicine
among families of pediatric patients. (DOCX 25 kb)
Abbreviations
ASA: American Society of Anesthesiologists; CI: Confidence interval;
MesH: Medical subject heading; OR: Odds ratio; PC: Personal computer;
SD: Standard deviation; VAS: Visual analog scale
Acknowledgements
Not applicable.
Funding
The study was supported by internal fundings of the Bambino Gesù Children’s
Hospital dedicated to research.
Availability of data and materials
The datasets generated during and/or analysed during the current study are notpublicly available due to hospital research policy and lack of consent from thoseinterviewed. Aggregate analyses different from those presented in the article are
however available on reasonable request to the corresponding author.
Authors’ contributions
LR and IC conceived the study, participated in its design and drafted the article.
BF and EA participated in the logistic and in the conduction of the survey. EP
coordinated the study and participated to the drafting of the manuscript. EC

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performed the statistical analysis. ADA and FG contributed to the interpretationof data and critically revised the article. AET conceived the study and revised
the article. All authors read and approved the final manuscript.
Author’s information
LR, IC and BF are research nurses specialized in telemedicine. EA is a biologist
engaged in communication activities of the hospital’s Telemedicine Unit. EP is a
medical doctor specialized in hygiene, with experience in pediatric infectious
diseases and telemedicine policies. EC is a statistician and a data manager. ADA isa medical doctor with expertise in biostatistics, research methods and eHealth. FG
is a pediatrician with expertise in pediatrics, eHealth and telemedicine research.
AET is a pediatrician and epidemiologist leading the Telemedicine Unit of theBambino Gesù Children’s Hospital, engaged in eHealth and innovation in
Pediatrics.
Competing interests
The authors declare that they have no competing interests.
Consent to publication
Not applicable.
Ethics approval and consent to participate
The study was approved by the Bambino Gesù Children’s Hospital EthicalCommittee (protocol N. 821_OPBG_2014). An informed consent toparticipation in the study was signed by parents at enrolment.
Received: 11 September 2015 Accepted: 7 December 2016

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