Valuation of Primary Care-Integrated Telehealth (New York)

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Valuation of Primary Care-Integrated Telehealth - 2008

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS04-012: Demonstrating the Value of Health Information Technology (THQIT)
  • Grant Number: 
    R01 HS 015165
  • Project Period: 
    09⁄04 – 09⁄08, Including No-Cost Extension
  • AHRQ Funding Amount: 
    $1,464,778
  • PDF Version: 
    (PDF, 74.52 KB)


Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Knowledge Creation

Summary: Childhood illness places parents in a difficult situation. One study found that a child’s illness accounted for 40 percent of missed work for parents of young children. Another study, based on a nationally representative sample of working women, found that only 39 percent had someone they could call on to help with childcare the next time their child is sick. Most women reported either that they would need to miss work (49 percent) or that they would not know what to do (7 percent) if this occurred. Work absence due to care for a sick child means loss of pay for most women of lower socioeconomic status. Inner city parents may jeopardize employment by leaving work as demanded. Other parents, anxious to keep jobs that they cannot afford to lose, try to avoid or delay picking up their child, or they hasten the return of ill children to childcare.

Childcare programs and elementary schools have the difficult responsibility of determining whether to exclude a child due to illness. Almost all childcare programs and schools in Rochester adhere to recommendations of the American Academy of Pediatrics (AAP) and the American Public Health Association (APHA). While the AAP/APHA recommendations have been systemically developed to reduce the spread of serious infectious disease and encourage treatable children to seek medical attention, exclusion policies are subject to judgment, and the decision to exclude a child because of illness is often a source of tension between childcare staff and parents. Prevailing policies often require an office visit for a physician to certify readiness for return to childcare.

The project’s telemedicine network is intended to address these problems. Health-e-Access (HeA) is a form of communications infrastructure to facilitate access to health services. The organizational and technical design of HeA focuses on: establishing and sustaining access sites in convenient community locations, using information technology to enhance communication with clinicians in a remote location, and enabling connection with clinicians from the patient’s own primary care medical home. In preliminary work, completed prior to the awarding of this grant, a study of five inner-city childcare programs demonstrated a large reduction in absence due to illness (63 percent) for children served by HeA. The HeA telemedicine model was designed to enable diagnosis and treatment decisions for acute problems that commonly arise in childcare and elementary school settings. Direct participants in telemedicine encounters include: a child with a health problem; a telemedicine assistant and sometimes a parent, all at the child site; plus a telemedicine clinician at a remote site. Visits are completed through real-time interactive (videoconference), store-and-forward, or both forms of telemedicine. The clinician site may be located anywhere with broadband Internet access and modest personal computer equipment.

Specific Aims

  • Expand Health-e-Access (HeA) as a telehealth model. (Achieved)
  • Assess the value of telehealth in child programs (childcare, schools) to the health care system. Achieved)
  • Describe the process of integrating telehealth in primary care, and assess the value of integrated telehealth to both families and clinicians. (Achieved)

2008 Activities: The observation period for Health-e-Access continued through April 30, 2008. Subsequently, analyses were conducted and findings prepared for publication.

Impact and Findings: The HeA Network expanded to include 22 child sites and 10 primary care practices serving the children at these sites. Child sites in the city included five childcare programs and seven elementary schools. Suburban child sites included five childcare programs and five elementary schools. The 10 medical practices were equally split between those located in city and suburban areas. Over the 7 years between May 1, 2001, when the first HeA visits were done, and April 30, 2008, the end of the study observation period, 6,511 telemedicine visits were attempted. Analysis demonstrated strong relationships (p<.001) between several potentially confounding variables and utilization. An exception was the relationship between socioeconomic area and overall utilization rate for acute illness, where there was no statistically significant difference. In stark contrast to use for illness, emergency department (ED) use rates were significantly greater for inner city (57.2 visits per 100 child-years) and rest-of-city children (51.2) than for suburban children (15.6). Overall illness use rates, including both visits to traditional sites (ambulatory and ED visits) and telemedicine visits were 22.9 percent greater for intervention than control children (336.4 vs. 273.7 visits per 100 child-years). The higher overall use for intervention children is attributable to telemedicine use, at a rate of 83.6 per 100 child-years. Rates among the intervention group for ED visits and illness office visits, however, were 23.7 percent less (44.1 vs. 57.7 per 100 child-years) and 3.3 percent less (208.8 vs. 216.0 per hundred child-years), respectively, than those for the control group.

Parents were interviewed before and after experience with telemedicine to assess acceptance and satisfaction. The 896 completed surveys included 578 pre-telemedicine surveys and 318 surveys completed following at least one telemedicine encounter. Surveys were completed by 800 unique individuals. Both pre- and post-telemedicine surveys were completed by 96 respondents, allowing 96 pre versus post comparisons. Almost all (94.5 percent) of the 800 respondents identified a source of primary care for their children, and 57.4 percent of these primary caregivers were affiliated with HeA. Children with a primary care practice located in the city were much more likely (p<.001) to use a primary care practice that participated in HeA than children using a suburban practice. On average, parents estimated the total time for a doctor’s office visit, including transportation, was 2.44 hours. Among the 572 respondents working at the time of they were surveyed, 34.9 percent indicated they would lose pay when they missed work due to a child’s illness. Among all 800 respondents, 61.3 percent had, at some time, picked up a child due to illness and 72.5 percent had, at some time, kept a child home from school or childcare due to illness. For parents who had missed work or school to pick up a child within the past 3 months, the estimated number of times averaged 1.79 and the estimate hours lost averaged 7.72. For parents who had missed work or school to keep an ill child home within the past 3 months, the estimated number of times averaged 1.77, and the estimated hours lost averaged 11.94. Open-ended questions revealed strongly positive attitudes and perceptions among the 318 respondents who had experienced telemedicine.

The impact of Health-e-Access, especially the 63 percent reduction in absence from childcare due to illness, is partly attributable to protocols and procedures adopted in telemedicine implementation rather than the technology itself. For example, lines of communication and expectations established through HeA encouraged child site staff to engage clinicians and parents directly in useful communication, centered on management of the child’s health problem on-the-spot, rather than simply requiring parents to remove their child from school.

Overall, this study validates commitment to family convenience as an effective means to decrease costs while improving access.

Selected Outputs

McConnochie K, Wood N, Herendeen N, et al. Integrating telemedicine in urban pediatric primary care: provider perspectives and performance. Telemed J E Health 2010;16(3):280-8.

McConnochie KM, Wood NE, Herendeen NE, et al. Acute illness care patterns change with use of telemedicine. Pediatrics 2009;123(6):e989-95.

Kopycka-Kedzierawski D, Billings R, McConnochie KM. Dental screening of preschool children using teledentistry: a feasibility study. Pediatr Dent 2007 May-Jun;29(3):209-13.

McConnochie KM, Tan J, Wood NE, et al. Acute illness utilization patterns before and after telemedicine in childcare for inner-city children: a cohort study. Telemedicine J E Health 2007;13(4):381-90.

McConnochie KM. Potential of telemedicine in pediatric primary care. Pediatr Rev 2006 Sep;27(9):e58-65.

McConnochie KM, Conners GP, Brayer AF, et al. Differences in diagnosis and treatment using telemedicine versus in-person evaluation of acute illness. Ambul Pediatr 2006;6(4):187-95.

McConnochie KM, Conners GP, Brayer AF, et al. Effectiveness of telemedicine in replacing in-person evaluation for acute childhood illness in office settings. Telemedicine J E Health 2006;12(3):308-16.

McConnochie KM, Wood NE, Kitzman HJ, et al. Telemedicine reduces absence resulting from illness in urban child care: evaluation of an innovation. Pediatrics 2005;115(5):1273-82.

Grantee’s Most Recent Grantee Self-Reported Quarterly Status: This grant has been completed with all major aims achieved.

Milestones: Progress is completely on track.

Budget: On target.

Project Details - Ended

Project Categories

Summary:

Acute illness in pre-school and school-age children remains a major morbidity and economic burden across the socioeconomic spectrum. Using commercially-available technology that enables clinicians to evaluate and treat ill children at a distant childcare or school site, Health-e-Access (HeA) is a novel, yet logical and efficient, approach to this serious, nation-wide problem. HeA has operated in 8 inner-city childcare centers. Evidence supports high acceptance and satisfaction by parents and child programs. Reduction in child absence due to illness has been dramatic. Keys to optimization, sustainability and expansion of HeA are integration into primary care practice, physician acceptance, and insurance reimbursement. Physician acceptance and optimization can be anticipated if reimbursement is appropriate and telehealth can be integrated efficiently in the primary care medical home to maximize continuity of care. Insurance reimbursement can be anticipated if telehealth services can be shown to reduce healthcare costs. These key issues werel addressed in the (1) northeast Rochester, and (2) southeast suburbs telehealth demonstration projects. Using the HeA telehealth model, children in 9 schools and 13 childcare programs in designated geographic areas can be evaluated by their own primary care clinicians in 9 practices. Study A focused on impact of telehealth in child programs (childcare, schools) on utilization and cost at the level of child program (Study A1) and individual child (Study A2) utilizing a before-after design with historical and concurrent controls. Direct and indirect costs were assessed. Study B assessed integration in primary care, for example by measuring impact on continuity of care, adherence to well-child visit schedules and immunization rates.

Valuation of Primary Care-Integrated Telehealth - Final Report

Citation:
McConnochie K. Valuation of Primary Care-Integrated Telehealth - Final Report. (Prepared by University of Rochester under Grant No. R01 HS015165). Rockville, MD: Agency for Healthcare Research and Quality, 2009. (PDF, 211.47 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.
Principal Investigator: 
Document Type: 
Technology: 
This project does not have any related resource.
This project does not have any related survey.

Telemedicine Project Connects, Kids, Doctors for Better Care

Kenneth McConnochie, M.D.For many parents, it's an all-too-common scenario: A call from the school nurse in the middle of the day. Their child is complaining of an earache and needs to be picked up from school. The parents scramble to leave work, pick up their child and bring him or her into the doctor's office. In some cases, parents end up taking their children to the emergency department if they cannot get an appointment with a doctor that day.

But it doesn't have to play out this way. A project in Rochester, N.Y., is using telemedicine to connect child care centers and elementary schools to physician offices, allowing a child to be diagnosed remotely by his or her primary care physician. Using telemedicine, the doctor can diagnose the patient on the spot and, if needed, call in a prescription to a pharmacy.

With the help of a grant from the Agency for Healthcare Research and Quality (AHRQ), Kenneth McConnochie, M.D., and colleagues at the University of Rochester Medical Center have established the first telemedicine network that's integrated into daily primary care medical practice. Health-e-Access, as the network is called, connects children in 23 schools and child care programs to 10 primary care practices. The program, which began in May 2001 in five inner-city Rochester child care programs, has shown a 63 percent reduction in absences from child care due to illness.

"This is about access to your primary care physician," McConnochie says. "It's both convenience -- health care when and where you need it -- and continuity -- by people you trust. Who couldn't use more of that from health care?"

The Health-e-Access project uses store-and-forward as well as real-time, interactive technology to connect child care centers to pediatric practices. At the child care center, a trained telehealth assistant collects information, including video images and audio files, about the child's condition and medical history. A digital camera with special attachments allows the telehealth assistant to take detailed eye, mouth, ear drum, and skin images or collect information from an electronic stethoscope.

The information is then sent to the child's primary care practice, where a clinician can use the information to diagnose or treat thepatient. If necessary, the clinician can conduct a live video conference with the patient, staff, and parents to better determine the child's condition. Parents initially participated via videoconference in the visits about 20 percent of the time, but this has fallen to less than 10 percent as parents have gained confidence in telemedicine care.

If a prescription is appropriate, the physician can instantly fax it in to the pharmacy for delivery to the child care center or school. Once the telehealth visit is complete, an assistant at the child's site prints for the parents a personalized letter about the visit, which is generated from the clinician's documentation in the Health-e-Access record, and any diagnosis-specific handouts chosen by the clinician.

Reaction to the technology has been positive, says McConnochie. Initially, some parents were skeptical of using telehealth to treat their children remotely. But surveys of parents have shown that the project has allayed their concerns and that they are very happy with the results, he says. Parents indicate that almost all illness episodes evaluated by telemedicine would have resulted in time lost from work and a doctor's appointment or emergency department visit. Yet for more than 96 percent of these visits, the clinician is confident completing the visit without supplementary laboratory evaluation or an in-person examination, McConnochie says. To date, more than 5,000 visits between the child sites and physician offices have been conducted using telemedicine.

In the future, McConnochie believes the technology could be used in many additional settings, such as group homes, assisted living facilities and summer camps to enhance patient access to care. For now, researchers are evaluating the technology's impact on health care quality, utilization and cost.

Insurer reimbursement is a major issue for the project, as it commonly is for telemedicine initiatives. But McConnochie says heis optimistic that an analysis of the impact on utilization and cost in the project's final year will show that the telemedicine model is cost-effective and that local insurance organizations will continue reimbursement after the AHRQ funding ends.

"With the support of AHRQ, this project has demonstrated the potenial for telemedicine to enable high-quality health care that is readily available," McConnochie says. "The biggest lesson learned is that this really works." 

This project does not have any related emerging lesson.