Telemedicine Integrated in the Primary Care Medical Home:

When Virtual is Better than Reality

Kenneth McConnochie

Neil Herendeen

Nancy Wood

Division of General Pediatrics

Program Funding Acknowledgements• US Dept of Commerce Technology Opportunities Program• Robert Wood Johnson Local Initiative Funding Partners Program• Rochester Area Community Foundation• Maternal and Child Health Bureau R40 MC03605 • Agency for Healthcare Research and Quality R01 HS15165

DisclosureN. Herendeen, K. McConnochie and N. Wood hold equity positions in Tel-e-Atrics, Inc., a vendor of telemedicine equipment, hosting and support services

The Problem – Community Perspective

• Majority of US preschool children are in child care

• Acute illness more common among children in child care

• For parents using child care, a child’s illness accounts for 40% of work absence

• Over 50% of working mothers will miss work the next time one of their children is ill

Related Problem – Pediatrician’s Perspective

• Retail-based clinics (RBCs) appeal to families

• RBCs being developed by Wal-Mart, Targets, CVS, Walgreen and others

• RBCs have the capacity to address most minor acute illness episodes that generate 52% of office visits* for children < 15 years

• RBCs appeal to public and private payers

• RBCs threaten continuity of care

* 2004 National Ambulatory Medical Care Survey

A Solution: Health-e-Access

• Child care site - child with health problem, telehealth assistant

• Remote clinician site - physician or nurse practitioner

• Telehealth technology – broadband communications link, computer-driven digital sensors

How it works

• Health problem identified by child care or by parent

• Schedule a visit - page the telehealth clinician

• Telehealth assistant prepares for visit

• Connect at the scheduled time

• Information exchange - both real-time interactionand store and forward

• Prescription called to pharmacy when appropriate

• Usually OK to remain in child care

Absence Due to Illness Before and After Telehealth

JanJuly

Dec

* Absence from child care due to illness, in mean daysabsent per week per 100 registered child-days.

0

5

10

15

20

Before

Da

ys A

bse

nt

Du

e to

Illn

ess*

After

Net impact of telehealth:63% reduction

Pediatrics May 2005

Jan

July

Dec

Impact on ADI

Parent Satisfaction%

of

fam

ilie

sBased on interviews with parent after first use of telemedicine. N = 229.

0

10

20

30

40

50

60

70

80

90

100

ED

Allowed to stay at work*

Would choose child carewith telemed over one without

Saved parent trip to:

Pri

mar

yC

are

Ph

ysic

ian

After hours

YesYes

* Estimated time saved = 4.5 hours (SD 2.2) per telemed visit

Population and Setting

• 6 inner-city child care centers, Rochester, NY

• Telemedicine initiated in stepwise fashion starting with first child care center in May 2001

• Observations on utilization among pre-school children May 2001 thru October 2006

• 138 children per center

• Medicaid covers 66%

Population and Setting - continued

• 5 participating urban primary care practices

• Participating practices provide primary care for 71% of children in the 6 participating child care programs

• Integration of telemedicine in these practices began May 2005

Stages of Program Development

Pre-expansion: 5/8/01 - 9/30/04 begins with first childcare telemed visit Expansion: 10/1/04 -• Technology development - 7 months, begins with receipt of expansion funding• Integration – begins May 2005 - PC Practice installation/training: 11 months - PC Practice ramp-up: 6 months, begins when all PC Practice telemed systems functional and training completed

Visits by StageMay 2001 - October 2006

Pre-integration 2709

IntegrationPCP installation, training 1053PCP ramp-up 477

1530

Total through 10/06 4239

Hypothesis

The Health-e-Access telemedicine model can be integrated successfully in the primary care medical home to provide care for acute illness episodes identified in inner-city child care.

Measures of Successful Integration

• Continuity of care – the proportion of telemedicine visits seen by the child’s regular primary care practice (PC Practice).

• Telemed visit completion – the proportion of telemed visits attempted that are completed, defined as diagnosis decisions and treatment without subsequent, in-person physical exam, lab tests or treatment.

Results

• Visit completed = 96%. Among the 1530 visits integration stage visits, 1474 (96%) had diagnosis and management decisions based entirely on telemed model

• Continuity of care with PC Practice = 87% - vs. continuity of care for RBCs = 0%

- practice to practice variation 50% - 93%

• 182 telemed visits/100 children/yr

Conclusions

Health-e-Access can be integrated in busy primary care practices serving urban children, enabling…• exceptional access• completion of almost all illness visits• continuity of care (unlike retail based clinics)

Confronted with new technology, organizations have 3 options …

- ignore it and die,

- adapt and survive,

- lead and prosper

Michael Leavitt, Secretary

US Department of Health and Human Services

Implications

Healthcare- when and where you need it, - by people you know and trust.

Thanks!

Parachutes and Gravitational challenge

Parachute use to prevent death and major trauma related to gravitational challenge:

systematic review*

* Smith GCS, Pell JP. British Medical Journal 2003:327:1459-61

Conclusion:Parachutes appear to reduce the risk of injury after gravitational challenge, but their effectiveness has not been proven with randomized controlled trials.

Diagnosis DistributionDiagnoses for All Completed Telemedicine Visits

%1 acute otitis media 28.72 upper respiratory illness 17.53 conjunctivitis 7.94 viral illness 7.65 tinea corporis 4.16 diaper dermatitis 3.87 otitis media with effusion 3.48 dermatitis, other 2.89 pharyngitis, other 2.8

10 skin infection 2.211 atopic dermatitis 2.112 minor trauma 2.013 pharyngitis, strep 1.714 insect bites 1.715 lower respiratory illness 1.416 skin, other 1.417 all other 8.9

100.0