Telemedicine Integrated in the Primary Care Medical Home: When Virtual is Better than Reality

1. Telemedicine Integrated in the Primary Care Medical Home:When Virtual is Better than Reality Kenneth McConnochie Neil Herendeen Nancy Wood Division of General Pediatrics

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

3. 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

4. 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

7. 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

10. 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 interaction • and store and forward • Prescription called to pharmacy when appropriate • Usually OK to remain in child care

11. Impact on ADI

12. Parent Satisfaction Based on interviews with parent after first use of telemedicine. N = 229. ED After hours % of families Primary Care Physician Yes Yes Allowed to stay at work* Saved parent trip to: Would choose child care with telemed over one without * Estimated time saved = 4.5 hours (SD 2.2) per telemed visit

13. 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%

14. 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

15. 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

16. Visits by StageMay 2001 - October 2006

17. 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.

18. 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.

19. 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

20. 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)

21. 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

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

23. Thanks!

24. Parachute use to prevent death and major trauma related to gravitational challenge: systematic review* Parachutes and Gravitational challenge Conclusion: Parachutes appear to reduce the risk of injury after gravitational challenge, but their effectiveness has not been proven with randomized controlled trials. * Smith GCS, Pell JP. British Medical Journal 2003:327:1459-61

25. Diagnosis Distribution