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

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Telemedicine Integrated in the Primary Care
Medical HomeWhen Virtual is Better than
Reality
Kenneth McConnochie Neil Herendeen Nancy Wood
Division of General Pediatrics
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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
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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 childs illness
  accounts for 40 of work absence
• Over 50 of working mothers will miss work the
  next time one of their children is ill

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Related Problem Pediatricians 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 lt 15 years
• RBCs appeal to public and private payers
• RBCs threaten continuity of care

2004 National Ambulatory Medical Care Survey
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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

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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

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Impact on ADI
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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
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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

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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

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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

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Visits by StageMay 2001 - October 2006
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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.
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Measures of Successful Integration

• Continuity of care the proportion of
  telemedicine visits seen by the childs 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.

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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

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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)
  

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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
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Implications
Healthcare - when and where you need it, - by
people you know and trust.
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Thanks!
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Parachutes and Gravitational challenge
Parachute use to prevent death and major trauma
related to gravitational challenge systematic
review
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
20033271459-61
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Diagnosis Distribution
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