Facilitators and Barriers to Adoption of a Successful Urban Telemedicine Model (New York)

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Summary:

Since its inception in 2001, the Health-e-Access (HeA) telemedicine network in Rochester, NY, has been used to manage acute childhood illness. HeA has developed three telemedicine service models focusing on care in schools, daycare facilities, and after-hours neighborhood settings, giving families in Rochester new options for care of children with acute illnesses. Each of the models is highly flexible in meeting patient needs, particularly given HeA’s use of Web-based and mobile patient access units.

This project deployed and solidified sustainable business models for each of the three telemedicine service models in the four inner-city zip code areas of Rochester. Additionally, the project identified facilitators of and barriers to implementation, monitored the impact on utilization patterns, and created and disseminated an implementation and sustainability toolkit.

The specific aims of this project were as follows:

  • Achieve substantial deployment and solidify sustainable business models for each of the three urban telemedicine service models. 
  • Identify facilitators and barriers to dissemination of the three telemedicine service models. 
  • Monitor impact of the HeA models on utilization patterns. 
  • Create and disseminate an implementation and sustainability toolkit. 

The HeA program completed 13,566 visits between May 2001 and June 2013, of which 4,985 visits occurred during the grant period. Fifty-five percent of visits were made by children dwelling in the inner-city target area. Primary parent concerns included 32 percent focused on the ear, 31 percent on the upper respiratory system, 20 percent on the skin, 11 percent on the eye, 2 percent on the lower respiratory system, and 4 percent on other miscellaneous causes. This breakdown informs the requirements for cameras and sound capture as well as clinical protocols that should be included in telemedicine initiatives, and were summarized in the developed implementation and sustainability toolkit.

Physicians identified convenience for parents; fast appointments; proximity to school, daycare, or home; and provider commitment to promotion as facilitators of adoption. Barriers were non-compatibility with the electronic medical record, limited provider time, lack of provider communication to patients about the availability of telemedicine, and discomfort with the unknown. Parents described telemedicine as a more convenient way to obtain medical care for children because it did not require waiting for an appointment or a visit to the doctor’s office. Ninety-eight percent of parents were satisfied or highly satisfied with telemedicine, and 95 percent agreed that it provides greater convenience than alternatives. The project showed that service provided by telemedicine holds potential to meet a large demand for care of acute childhood illness.

Facilitators and Barriers to Adoption of a Successful Urban Telemedicine Model - 2012

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS08-270: Utilizing Health Information Technology to Improve Health Care Quality (R18)
  • Grant Number: 
    R18 HS 018912
  • Project Period: 
    September 2010 – August 2013
  • AHRQ Funding Amount: 
    $418,029
  • PDF Version: 
    (PDF, 302.76 KB)

Summary: Since its inception in 2001, the Health-e-Access telemedicine network (HeA) in Rochester, NY, has been used to manage acute childhood illness. Three telemedicine service models have evolved from HeA’s ability to bring care directly to children, instead of children traveling to their care provider. The three models focus on care in school, daycare, and after-hours neighborhood settings. School settings include all Rochester city schools and a large center for children with severe developmental disabilities. These models give families in Rochester several new options for care of children with acute illnesses. Dr. McConnochie and his research team hypothesized that families will embrace the use of telemedicine via these new service models once they recognize their advantages over traditional care models, such as the use of emergency department care.

The goal of this project is for HeA to replace inefficient traditional models of care with more convenient, high-quality, lower-cost models. The project is deploying and solidifying sustainable business models for each of the three telemedicine service models in the four inner-city zip code areas of Rochester. Additionally, the project is identifying facilitators of and barriers to implementation, monitoring the impact on utilization patterns, and creating and disseminating an implementation and sustainability toolkit. The research team is using both qualitative and quantitative methods of research, including unstructured key informant interviews, semi-structured interviews, and statistical analysis of utilization patterns. The identification of facilitators and barriers to implementing a similar telemedicine model may promote widespread replication in other communities and for a broader range of patients.

Specific Aims:

  • Achieve substantial deployment and solidify sustainable business models for each of the three urban telemedicine service models. (Ongoing)
  • Identify facilitators and barriers to dissemination of the three telemedicine service models. (Ongoing)
  • Monitor impact of the HeA models on utilization patterns (Ongoing)
  • Create and disseminate an implementation and sustainability toolkit. (Ongoing)

2012 Activities: A number of methods were used to identify and assess barriers and facilitators of telemedicine implementation. Key informant interviews were conducted with parents, nurses who manage parent phone calls, telemedicine assistants who enable visits, providers, site staff, and leadership from various collaborating organizations. Focus groups were conducted with parents of children who were eligible for these visits.

The research team developed and implemented a phone-based community illness survey to assess how families respond to the medical needs of a sick child. Survey recipients were obtained from a Rochester City School District list of randomly sampled children eligible for telemedicine visits. The survey has been completed and analysis is underway.

As last self-reported in the AHRQ Research Reporting System, project progress and activities are mostly on track and spending is on target.

Preliminary Impact and Findings: Information gathered from key informant interviews with office telephone triage nurses indicated that they believe telemedicine is valuable and would use it for their own children. These nurses speculate, however, whether the number of dropped calls (calls in which the parent hangs up while on hold) increases when nurse spend the time to offer the telemedicine option. Since most parents are unfamiliar with telemedicine, the process of explaining it requires significant time. This increases on-hold times and increases dropped calls. To address this, the team developed a script to help nurses explain telemedicine to parents more efficiently.

Focus groups have included urban mothers without telemedicine experience, the demographic target for the study. Telemedicine was described as a more convenient way to get medical care for children because it does not require going to the doctor’s office or waiting for an appointment. Among parents with telemedicine experience, satisfaction has been very high, and convenience has been a dominant theme among perceived benefits. Yet among mothers without telemedicine experience, most had a somewhat negative response to the “convenience” benefit. Participants perceived the convenience of telemedicine as “cutting corners,” and said that “good mothers” do not cut corners; rather, they bring their children to the doctor’s office. As a result, HeA now markets telemedicine as quality care that can reduce time spent in waiting rooms to allow more quality family time. The participants also expressed that a demonstration of telemedicine would greatly facilitate their understanding of the technology and that recommendations by their own providers would be a key determinant of their interest in using telemedicine for their children.

There were 1,946 telemedicine visits in 2011 and 1,578 in 2012. Among the 2011 visits, 55 percent resulted in a prescription. Because this value is similar to the proportion of in-person illness visits yielding a prescription, this observation supports findings of utilization studies (based on billing claims) that telemedicine visits replace traditional types of care rather than increasing utilization.

Target Population: InnerCity*, Pediatric*

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Implementation and Use

*This target population is one of AHRQ’s priority populations.

Facilitators and Barriers to Adoption of a Successful Urban Telemedicine Model - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS08-270: Utilizing Health Information Technology (IT) to Improve Health Care Quality (R18)
  • Grant Number: 
    R18 HS 018912
  • Project Period: 
    September 2010 - August 2013
  • AHRQ Funding Amount: 
    $418,029
  • PDF Version: 
    (PDF, 199.49 KB)

Summary: Since its inception in 2001, the Health-e-Access telemedicine network (HeA) in Rochester, NY, has been used to manage acute childhood illness. Three telemedicine service models have evolved from HeA's ability to bring care directly to children, instead of children traveling to their care provider. The three models focus on child, school, and after-hours neighborhood care. These models give families in Rochester several options for care of children with acute illnesses. Dr. McConnochie and his research team hypothesized that families will embrace the use of telemedicine via these new service models once they recognize their advantages over traditional care models, such as the use of emergency department care.

The goal of this project is for HeA to replace inconvenient, inefficient, and expensive traditional models of care with convenient, high-quality, and less-expensive models. The project is deploying and solidifying sustainable business models for each of the three telemedicine service models in four inner-city zip code areas in Rochester. Additionally, the project is identifying facilitators and barriers of implementation, monitoring the impact on utilization patterns, and creating and disseminating an implementation and sustainability toolkit. The research team is using both qualitative and quantitative methods of research, including unstructured key informant interviews, semi-structured interviews, and statistical analysis of utilization patterns. Identification of facilitators and barriers to replication of an existing telemedicine model may promote widespread replication in other communities and for a broader range of patients.

Specific Aims:

  • Achieve substantial deployment and solidify sustainable business models for each of the three urban telemedicine service models. (Ongoing)
  • Identify facilitators and barriers to dissemination of the three telemedicine service models. (Ongoing)
  • Monitor impact of the HeA models on utilization patterns. (Ongoing)
  • Create and disseminate an implementation and sustainability toolkit. (Ongoing)

2011 Activities: A number of methods were used to identify and assess barriers and facilitators of telemedicine implementation. Key informant interviews were conducted with parents, nurses who manage parent phone calls, telemedicine assistants who enable visits, providers, site staff, and leadership from various collaborating organizations. Focus groups were conducted with the parents of children who were eligible for telemedicine visits.

The research team developed and implemented a phone-based community illness survey to assess how families respond to the medical needs of a sick child. The goal is to complete 300 surveys; 200 were completed by the end of 2011. Survey recipients were obtained from a Rochester City School District list of 1,800 randomly sampled children eligible for telemedicine visits. Nearly half of these were unable to be reached due to intermittent cellular phone access, use of prepaid phone cards, or change in phone numbers. A new list of eligible children was requested from the school district.

Another focus of 2011 was the engagement of stakeholders of telemedicine. Continuing from 2010, Dr. McConnochie met with parent groups, physician organizations, insurance companies, and policymakers to promote the benefits of telemedicine. He is also collaborating with the Finger Lakes Health Systems Agency (FLHSA) to promote reimbursement for telemedicine visits. FLHSA has identified telemedicine as a strategy to reduce non-emergency visits to the emergency department and has been instrumental in drawing local insurers into the discussion of broader reimbursement for telemedicine, especially telemedicine infrastructure.

As last self-reported in the AHRQ Research Reporting System, project progress and activities are mostly on track and project budget funds are somewhat underspent due to conserving funds for upcoming cost-intensive activities.

Preliminary Impact and Findings: The preliminary information gathered from key informant interviews with nurses indicated that they believe telemedicine is valuable and would use it for their own children. Additionally, the researchers found that the call center tracks the rate of dropped calls (the number of times a caller hangs up while on hold), and noted an increase in the number of dropped calls. The interviews revealed that the process of explaining telemedicine requires significant time because most parents are not familiar with the concept. This causes lengthy on-hold times and lead to the high dropped call rate. In response, the team developed a script to help nurses explain telemedicine to parents more efficiently.

The focus group participants were urban mothers without telemedicine experience, the main demographic targeted for the study. Telemedicine was described as a more convenient way to get medical care for children because it does not require going to the doctor's office or waiting for an appointment. Among parents with telemedicine experience, satisfaction has been very high, and convenience has been a dominant theme among perceived benefits. Yet among mothers without telemedicine experience, most had a somewhat negative response to the "convenience" benefit. Focus group participants perceived the convenience of telemedicine as "cutting corners," and explained that "good mothers" do not cut corners; rather, they bring their children to the doctor's office. As a result, HeA now markets telemedicine as quality care that can reduce time spent in waiting rooms to allow more quality family time. The participants also expressed that a demonstration of telemedicine would greatly facilitate their understanding of the technology and that recommendations by their own providers would be a key determinant of their interest in using telemedicine for their children.

For the grant efforts, there were approximately 2,000 telemedicine visits in 2011, of which 55 percent of visits resulted in a prescription. This may be an early indication that telemedicine visits are serving a need in the community.

Target Population: Inner City*, Pediatric*

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Implementation and Use

* This target population is one of AHRQ's priority populations.

Facilitators and Barriers to Adoption of a Successful Urban Telemedicine Model - 2010

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS08-270: Utilizing Health Information Technology (IT) to Improve Health Care Quality (R18)
  • Grant Number: 
    R18 HS 018912
  • Project Period: 
    September 2010 – August 2013
  • AHRQ Funding Amount: 
    $418,029
  • PDF Version: 
    (PDF, 331.76 KB)


Target Population: Inner City*, Pediatric*

Summary: Since its inception in 2001, the Health-e-Access telemedicine network (HeA) in urban Rochester, NY has been used to manage acute childhood illness efficiently. Three telemedicine service models have evolved from HeA’s ability to bring care directly to children, instead of children having to travel to see their care provider. The three models focus on child care, school care, and after-hours neighborhood care. These models give families in Rochester several options for care of children with acute illnesses. The researchers have hypothesized that families will embrace the use of telemedicine via these new service models once they recognize their clear advantages over traditional care models, such as the use of emergency department care.

The goal of this project is to use HeA to replace inconvenient, inefficient, and expensive traditional models of care with convenient, high-quality, and less-expensive models. It aims to deploy and solidify sustainable business models for each of the three telemedicine service models in four inner-city zipcode areas. Additionally, it will identify facilitators and barriers of implementation, monitor the impact on utilization patterns, and create and disseminate an implementation and sustainability toolkit. The research team will use both qualitative and quantitative methods of research, including key informant unstructured interviews, semi-structured interviews, and statistical analysis of utilization patterns. Identification of facilitators and barriers to replication of an existing telemedicine model may promote widespread replication in other communities and for a broader range of patients.

Specific Aims:
  • Achieve substantial deployment and solidify sustainable business models for of each of the three urban telemedicine service models. (Ongoing)
  • Identify facilitators and barriers to dissemination of the three telemedicine service models. (Ongoing)
  • Monitor impact of the HeA models on utilization patterns. (Upcoming)
  • Create and disseminate an implementation and sustainability toolkit. (Upcoming)

2010 Activities: This first quarter focused on key informant interviews to assess barriers to and facilitators of telemedicine implementation. Key informants include parents, nurses who manage calls, telemedicine assistants who enable visits, providers, site staff, and leadership from various collaborating organizations.

Grantee's Most Recent Self-Reported Quarterly Status (as of December 2010): The project is meeting most milestones on time. The budget is somewhat under spent due to major upcoming milestones.

Preliminary Impact and Findings: The preliminary information gathered from key informant interviews with nurses indicated that the nurses believe that telemedicine is valuable and would use it for their own children. Additionally, the researchers found that the call center records the rate of dropped calls, the number of times a caller hangs up while on hold, and noted that they had increased. The interviews revealed that the process of explaining telemedicine requires significant time because most parents are not familiar with the concept. This causes lengthy on-hold times leading to the high dropped call rate. The team therefore developed a script to help nurses explain telemedicine to parents more efficiently.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Implementation and Use

*AHRQ Priority Population.

Facilitators and Barriers to Adoption of a Successful Urban Telemedicine Model - Final Report

Citation:
McConnochie K. Facilitators and Barriers to Adoption of a Successful Urban Telemedicine Model - Final Report. (Prepared by the University of Rochester under Grant No. R18 HS018912). Rockville, MD: Agency for Healthcare Research and Quality, 2014. (PDF, 704.69 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services. (Persons using assistive technology may not be able to fully access information in this report. For assistance, please contact Corey Mackison)
Principal Investigator: 
Document Type: 
Technology: 

Phone Triage Protocols for Telemedicine, Use of Telephone Management Algorithms in Guiding Families on Use of Telemedicine

PDF: Phone Triage Protocols for Telemedicine, Use of Telephone Management Algorithms in Guiding Families on Use of Telemedicine (PDF, 381.74 KB)

Telemedicine and Non-Telemedicine Visit Experience Interview Guides

This is an interview guide designed to be conducted with patients, physicians, nurses, and office Staff in an ambulatory setting. The tool includes questions to assess user's satisfaction and perceptions of telehealth.

Year of Survey: 
2011
Survey Link: 
Telemedicine and Non-Telemedicine Visit Experience Interview Guides (PDF, 95.96 KB) (Persons using assistive technology may not be able to fully access information in this report. For assistance, please contact Corey Mackison)
Document Type: 
Research Method: 
Care Setting: 
Technology: 
Copyright Status: 
Permission has been obtained from the survey developers for unrestricted use of this survey; it may be modified or used as is without additional permission from the authors.

Health-E-Access Telemedicine Interview Guide

This is an interview guide designed to be conducted with physicians in an ambulatory setting. The tool includes questions to assess user's perceptions of telehealth.

Year of Survey: 
2011
Survey Link: 
Health-E-Access Telemedicine Interview Guide (PDF, 199.28 KB) (Persons using assistive technology may not be able to fully access information in this report. For assistance, please contact Corey Mackison)
Document Type: 
Research Method: 
Population: 
Care Setting: 
Technology: 
Copyright Status: 
Permission has been obtained from the survey developers for unrestricted use of this survey; it may be modified or used as is without additional permission from the authors.
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