# Presentation: 809806

## Health-e-Access: Improving Care for Rochester’s Vulnerable Children

**Kenneth McConnochie, MD, MPH**
- ken_mcconnochie@urmc.rochester.edu

## Research and Program Funding

-  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 held equity positions in TeleAtrics, Inc., a vendor of telemedicine equipment, hosting and support services

**Notes:**
Several major funders have supported our efforts, listed here.

Key colleagues and I held equity positions in TeleAtrics, a vendor of telemedicine equipment a services.

## Health-e-Access

**  ****when and where you need it**
**  ****by people you know and trust**

**Providing Healthcare ...**

**Notes:**

Our efforts have been driven by values of effectiveness and efficiency.

Optimal access to health care has been defined as the right care in the right place at the right time.  
< NEXT> That’s essentially what we are talking about in our mission statement for Health-e-Access: 
Providing healthcare 
< NEXT> When and where you need it
< NEXT> By providers you know and trust

## Problem

**Large socioeconomic and city-suburban disparities in morbidity burden and in access to care.**

**Notes:**

Above all, our efforts are driven by the value of equity.

The very large socioeconomic and city-suburban disparities in morbidy burden, and in access to care for Rochester’s children, are painful to ponder

[... remain painful to ponder dispite robust efforts to address them for at least the past 40 years]

## Rochester’s Inner City Children:Sociodemographic Comparisons

**Notes:**
These disparities are also racial and ethnic, as shown here in the top two highlighted rows.

Almost half on Rochester’s children dwell the 4 zip code areas that comprise the inner city, which is conveniently divided into west and east segments by the Genesee River.  

These two areas are very similar, but are distinct from other parts of the city, and differences between the inner city and Monroe County’s most affluent suburb (at the far right), are absolutely stunning.
These differences range from about 50-fold -- for families with children < 5 below poverty level (0.9% for the suburban zip vs ~50% for the inner city) -- to 4-fold for median household income ($87,000 vs $20,000).
Note also the striking differences in educational attainment – high school graduation about 60% vs almost 100%, and bachelor’s degrees < 10% vs 63%.

## Hospitalization Among Rochester’s Children < 24 months old

-  **1990 – 1991**
** ****Areas defined by zip codes **
** ****Relative Risk: rates compared to **
**  ****baseline rate **
** ****Baseline (1.0) = Pittsford**
** ****Highest rates = 14605, 14621**
** ****Inner city relative risk > 5.0**

**Notes:**
A starting place for me, personally, was analysis we did some time ago on hospitalization rates in the first two years of life. This slide displays our findings.

We looked specifically at hospitalizations for a carefully selected group of problems, common problems for which early, effective treatment can prevent severity from reaching the point that hospitalization is required – problems such as asthma, skin/soft tissue infections, gastroenteritis-dehydration.

The numbers in the various zips on the map are values for relative risk of hospitalization. 
What we found was 5-fold differences.  Compared to the baseline rate (in the lower right-hand corner for Pittsford), inner city zips had over 5-fold greater hospitalization rates for conditions in which hospitalization is often avoidable through earlier treatment or better chronic disease management (the best pediatric example being asthma).

## Greater Morbidity Burden or Lower Utilization/Admission Threshold?

- 5-fold greater admission rate for asthma
- Asthma severity indicators demonstrate no city vs. suburban difference in:
- Severity at time of admission
- Severity during hospital stay
- Conclusion:  Much higher severity adjusted rates (much greater morbidity burden)

**Notes:**
In other hospitalization studies we focused especially on asthma.

Again, we found a 5-fold greater hospital admission rate.  

Then we asked the question, is this due to greater morbidity burden or to a lower severity threshold for admission.   

Children with less severe asthma might be admitted if the decision was made in the ED, or if the clinician was worried about parental judgment, ability to follow recommendations for care at home, or ability to get the child back to care if deterioration occurred at home.  All these conditions might be more likely for inner city children. At least the pediatric resident in the ED might think so.

What we found was there was no difference in severity threshold for admission.  Asthma severity was no different at time of admission or during admission based on physiologic measures, number and frequency of rescue med treatments, and hospital length of stay.

In other words, inner city kids simply had a much greater morbidity burden.

## Working Women’s Options

**Notes:**
I want to broaden the perspective on the implications of morbidity burden.  It’s not about hospitalization or ED visits and the 4 – 6 hours they each consume. 

Most childhood illness is not severe, of course.  In fact, most of it is self limited.  But even when childhood illness is mild, it accounts for substantial social and economic burden.

Here, for example, is an indication of what it means to working women.  This is based on a Kaiser foundation survey of a nationally representative sample – so we are talking about impact across the socioeconomic spectrum.  

When asked, “What will you do the next time a child is sick?”  here’s what women said.
 Over 50% are going to miss work. 

Childhood illness impacts not only the child but her parent, the parent’s employer, the child’s school, the primary care medical provider, the health insurance company and health policy makers trying to keep spiraling medical costs under control.   

## Health-e-Access as a Solution

**Overview - how it works**
**Brief history**
**Service provided and it impact**

**Notes:**
In talking about our telemedicine model as a solution, here’s what I plan to cover ...

## Childcare/School

**Childcare/School**

**Clinician site**

- secure web
- connection

**Video conference window -**
**view at child site**

**Notes:**
Overview: (CBS video clip substitutes for this slide!)
- Lets say that 3 y/o Sally wakes up from naptime holding her ear
- The telemed assistant (a child care staff person that we have trained to work with this system) contacts a parent to get further history about the illness and ask if the mom wants a telemed visit
After mom says yes, as they almost always do, the telemed assistant documents the history and captures images, video clips and audio clips, guided by protocols imbedded in the software.
A visit is then scheduled with the child’s own PCP through the telemed network coordinator (this person serves scheduling, triage, and trouble shooting functions).
Whether a real-time video conference is included in the visit is up to the clinician’s discretion.  Often, they are not necessary.
 Clinician reviews the text and media collected by the telemed assistant and makes diagnosis and management decisions.
 Then the clinician communicates with the parent, telemed assistant, and (perhaps) the pharmacy by phone, videoconference, computer-generated recommendations or fax.
 The pharmacy delivers the Amoxicillin to child care and the Sally gets her first dose right there.
 Often mom is able to stay at work and pick up the child at the end of the day, along with the rest of the Amoxicillin
 Even when the child needs to be picked up early because of illness, the doctor visit has already been done and the prescription is waiting at the pharmacy.  A 4-6 hr visit to the ED has been avoided.

## Diagnostic Quality Observations

**Diagnostic Quality Observations**

**Notes:**
Many people wonder about the quality of clinical observations that can be made via telemedicine.    It’s important, of course, for the clinician to think carefully about what information is necessary to the evaluation of each illness episode, and to recognize when they don’t have all the information they need.  But primary care clinicians caring for children make that type of decision all the time based on phone interactions.  

Telemedicine works this way too, only the telemed clinician gets a lot more information to work with. 

In the case of ear drum images, the information – based on images such as these -- is often better than obtained in the usual, in-person office setting.

--------------------------------------------------------------------------------
Normal ear drum in the upper left hand corner.

Near normal – except for ventilating tube – in the upper right-hand corner.

Every one of the other images show ear infections, and they all contain greater diagnostic detail than I have ever seen with a hand-held otoscope in over 3 decades of looking at ear drums with the typical hand-held otoscope. 

## Service Provided

- First telemedicine visits May 2001
- > 6500 visits since then
- 96% completion rate
-    (Among visits initiated, 96% have diagnosis and management decisions and treatment based entirely on telemedicine visits.)
- 4701 children enrolled in Health-e-Access at any time
- Among children with a participating primary care practice, 83% continuity. (Visit completed by that practice.)

**Notes:**
A word about the history of the program ...

Continuity of care – that’s the part about “people you know and trust” from the Health-e-Access mission statement.
 83% continuity overall, 87% by city practices

## Child Care Absence Due to Illness Before and After Telemedicine

**Child Care Absence Due to Illness ****Before and After Telemedicine**

**Days Absent Due to Illness***

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

- Jan

- July

- Dec

- After

- Before

- Net impact of telemed:
**63% reduction**** **
_*Pediatrics*_** **May 2005

**Notes:**
OK, what impact have we been able to measure?

On the Y axis, here, we have days absent from childcare due to illness, expressed and days absent per 100 enrolled child-days.  As you can see in this figure,  rates for absence due to illness were much less with telemedicine than before it.  Rates in winter months with telemed were down around the level they were in summer before telemed.  Also noteworthy is the fact that month-to-month variation with telemed is so much less.

## Parent Satisfaction

**% of families**

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

**ED**

**Allowed to **
**stay at work***

**Would choose child care**
**with telemed over one without**

**Saved parent **
**trip to:**

**Primary**
**Care**
**Physician**

**After **
**hours**

**Yes**

**Yes**

*** Estimated time saved = 4.5 hours per telemed visit**

**Notes:**

Not surprisingly, parents are delighted with this service.  Parent survey responses here were obtained from 229 parents, representing 76.1% of the families who had a child evaluated through telemedicine.  Parents were contacted after their first use of telemedicine.  
Moving from left to right, among these respondents, 93.8% of parents indicated that the problem managed by telemedicine would otherwise have led to an office or emergency department visit.  
As in the 2nd bar, 91.2% indicated that the telemed visit allowed them to stay at work, with the amount of time saved estimated on average at 4.5 hr per telemedicine visit.
Finally, 93.8% indicated that they would choose a child care center with telemedicine over one without this service.  

## Impact on Pattern of Care for Acute Illness

**6 year cohort study **
**Observations from May 2001 through October 2007**

**Notes:**
While the findings I just reviewed speak to the value to our program to families and the community, the most important study for the sake of promoting the long-term sustainability of HeA is the one we finished just this spring.  
That study focused on the impact on utilization patterns, especially ED utilization, and impact on healthcare costs. What I mean, in the title here, by impact on pattern of care for acute illness is what is the shift in utilization, of all sources of care for acute illness (office, ED and Urgent Care Centers, and telemedicine), after telemedicine is introduced in the system.  

This study was based on our experience from May 2001 through October 2007.

## Children and Child-Months Studied

**Notes:**
Key inclusion criteria for the analysis were: 
 At least 6 consecutive months of enrollment in Health-e-Access, at a time when covered by an insurance organization that provided claims data
 Only considered months before 13th birthday
  We also required that a perfect match (to be defined) for each child-month with a control child to be available.

Each child among the 1,216 contributed, on average, about 16 months of observation.

## Comparability:Control vs. Intervention Groups

***Optimal match***** **
**Intervention and Control child-months differ only on  availability of telemedicine **
** **
***Actual match***** **
**Perfect match on age, sex, month of year (illness season), zipcode of residence, socioeconomic area, insurance type**
**School-age children – comparable exposure to peers**
**Preschool children – 100% of intervention children in large childcare programs.  Less so for control children.  This introduces a conservative bias (against effect of telemed) when looking at overall utilization.**

**Notes:**
With optimal matching, of course ...

Actual match ...
-
-

Preschool children – 100% of intervention children were in large childcare programs.  This is less so for control children, perhaps as low as 50%.  This introduces a conservative bias (against effect of telemed) when looking at overall utilization because childcare attendance – especially center-based childcare -- is an important risk factor for common infectious diseases.

## RESULTS:Attributes of Child-Months Studied

**Notes:**
Moving on to RESULTS, total observations included 39,304 child-months, or the equivalent 3023 child-years, half each from Intervention and Control groups. This table displays the relationships of key potential confounding variables with key outcome variables, rates for ED visits and overall illness visits in the total study population.  

These rates for the entire population, expressed as visits per 100 child-years were 50.9 and 305.1, respectively. In other words, study children averaged about 3 illness visits per year, overall, and an ED visit about every other year.  POINT

We have enough observations here that our estimates are very precise. The probability that differences indicated here occurred by chance, alone, is < 1 in 1,000 in most cases.

The only difference that is not statistically significant is in the lower right-hand corner.  Based on what we know about the morbidity burden for inner city children, it is surprising that that overall utilization for illness did not vary among inner city, rest of city, and suburban children.   As expected, ED utilization is strikingly different, almost 4-fold greater for inner city children than suburban children.  

Other findings here were also pretty much as expected, for example, children with Medicaid Managed Care had almost 3-fold greater ED use than those with commercial insurance or Child Health Plus. 

## RESULTS:Telemed Impact on Utilization Patterns

**Annual visits **
**per 100 children**

**Telemed**

**   ****3.3% fewer office visits for illness**
** ****23.7% fewer ED visits**
** ****22.9% more illness visits overall**

**Notes:**
Here are the most important findings.
Moving from bottom to top on these stacked bars, key findings include:

<NEXT> A modest 3.3% fewer office visits for illness for intervention children
<NEXT> A substantial 23.7% fewer ED visits for intervention children
<NEXT> Then, after you add on the telemed visits there was an overall increase in illness visits of 22.9%.  In essence, these telemed visits represent the cost of reducing traditional visits to the office and the ED.

These results for office, ED, telemed and all visits were replicated in multivariate analysis using Generalized Estimating Equations fitting Poisson regression models. That analysis adjusted for potential confounders and for within-child clustering of child-months.

## RESULTS:Fewer ED Visits

**Notes:**
The most relevant finding to healthcare costs was, of course, the 23.7% less ED visits for Intervention children.

## IMPLICATIONS FOR PAYERS:Break-Even Ratio

- Units of:
-   *Cost* - overall illness visits increased
-   *Effectiveness* - ED visits avoided
- Unit Values:
-   Cost indicator - $51
- 	(mean payment per telemed visit)
-   Effectiveness indicator - $355
- 	(mean payment per ED visit avoided)
- Break-Even Ratio:  355 ÷ 51 = 7:1
- 	(visits increased to ED visits avoided)
- Observed Ratio:  5:1

**Notes:**
Here’s one way to think about these findings, from the perspective on insurance organizations. 

This program has a cost, to them, in terms of increased illness visits overall.  At the same time, it is effective in terms of reducing ED visits, that are much more costly to the payers.

Based on another recent study, unit values average $51 for the increased illness visits (the payment for telemed visits) and $355 each for the ED visits avoided.  

That means that insurers are going to break even on adopting this telemed model if the ratio of increased visits to ED visits avoided is < 7:1.

What we observed, in fact, in the numbers I just presented, is that this ratio was 5:1.  

So payers are going to do better than break even on adopting this telemedicine model, given the current reimbursement rates

## Summary: Impact of Health-e-Access 

**Large reduction in absence due to child illness (63% for inner city child care)**
**96% of visits completed**
**87% continuity**
**23.7% drop in ED visits**
**22.9% increase in all visits for illness**
**Net cost reduction by replacing expensive ED visits with low-cost primary care (via telemed)**

**Notes:**

<NEXT> - Large reduction in absence due to child illness (63% for inner city child care)
<NEXT> - 96% of visits completed
<NEXT> - 87% continuity
<NEXT> - 23.7% drop in ED visits – the most important finding
<NEXT> - 22.9% increase in all visits for illness.  It’s no surprise that dramatically increased access is associated with an overall increase in illness visits.
<NEXT> -  A net cost reduction results -- from replacing expensive ED visits with low-cost primary care (via telemed)

## Social and economic benefits accrue from extraordinary access

Reduced economic burden of health services

**Reduced economic burden of health services**

** ****IMPLICATIONS**

**Notes:**
Implications of these findings, coupled with findings of other published research, are that 
<NEXT>  the Health-e-Access telemed model enables large social and economic benefits by providing extraordinary access and, at the same time,
<NEXT> reduces the economic burden of health services.

Not many innovations come along with potential to reduce costs at the same time that they deliver extraordinary benefits.

## CONSERVATIVE BIAS

**Exclusion of short-term users from analysis**
**Estimate for ED-related payment is low**
**Telemedicine not available evenings, weekends, holidays, school vacations. **

**Notes:**
There are several reasons why we believe that this 5:1 ratio is conservative – but I’m going to skip over most of these for now.

I do want to mention one that is not listed here ---  that many of the telemed visits – which account for the increase in overall utilization --  probably could have been handled by phone.  These probably were for illness episodes that suburban parents bring to their pediatrician and get handled by phone.  We made no attempt to introduce telephone triage into our telephone model, because we did not want to do anything to discourage the use of this new approach, but that is an obvious next step. 

## PATIENT-TO-PROVIDER TELEMDCINE: Next Steps - Organizational

- Expansion of insurance reimbursement beyond limits of the Demonstration Project
- Reimbursement for telemedicine “infrastructure fee”
- Mobile telemedicine units
- Telephone management as the gateway to telemedicine
- After-hours neighborhood access sites
- Health-e-Access lines of communication

**Notes:**
Well, where do we go from here? 	
CHECK MARKS INDICATE PROGRAMS THAT HAVE BEEN, AT LEAST, INITIATED

## PATIENT-TO-PROVIDER TELEMDCINE: Next Steps - Programmatic

- Telemedicine access for developmentally challenged children and adults
- Teledentistry
- Behavioral health
- Chronic illness prevention and management
- Primary care for deaf population
- Elder care
- ED diversion through EMS-based mobile telemed units

**Notes:**
Well, where do we go from here? 	

## Thanks !

**Thanks !**

**Kenneth McConnochie, MD, MPH**
**ken_mcconnochie@urmc.rochester.edu**

**Notes:**
My grandson and I say thanks! ... and I look forward to your comments and questions.

## Under-Utilization by Inner City Children?

## What does it take to keep Health-e-Access going?

**Components of the infrastructure**
**Technical**
**Personnel – triage role, trouble shooting, roaming telehealth assistants (roaming CTAs)**
**Cost of the infrastructure**

**Notes:**
Total Technology, staffing, support =       290,597 

   Type of site 		Site 	ED visits that
   (sites of this type)		Enrollment	need replacement to 
			cover costs*
Urban childcare centers (6)	809	
Urban elementary schools (6)	2946	
	Total	3755	2.11
Annual Cost per Enrolled Child	77.39 	0.25
Monthly Cost/ Child Enrolled 	6.45 	
Annual Cost/ 100 Child Enrolled	7,739 	24.96

Assumes $310 savings for every ED visit replaced by a telemed visit

	The Health-e-Access infrastructure involves both technical and staffing components. The system involves desktop or laptop PCs at both the sending (child-site) end and provider end, and a central server that manages all of the data and manages the videoconferencing. We pay for the on-site equipment which includes the PCs and also some clinical attachments at the sending end, server maintenance (space, back-ups, security measures), annual software licensing, software support, HELPDESK support, on-site proactive support, and on-site reactive support when technical problems develop. Sites are expected to have broadband internet access already so that isn’t a component of our network costs.
	Staffing to maintain the program is very dependant on the model used, but to manage the 12 urban sites that we currently have requires some administrative staffing, a triage person, and several roaming telehealth assistants. Child care centers typically have their own staff person who handles health issues.  Child care sites only require the assistance of a roamer when one of their staff members is unavailable. 
	School health staff has not been able to absorb the role of telehealth assistant as readily.  Urban schools require 1 roaming telehealth assistant per 3 schools to conduct the visits.  The roamer conduct almost all the school visits. 
	The triage role is critical, particularly for the primary care practices. It would not work for these practices to have multiple staff members from various child sites calling the doctors' offices directly.  Consequently, Health-e-Access handles the triage centrally.  What we call triage is actually much broader than the way the word is typically used.  Our triage function includes: (1) brokering the scheduling and flow of visits (sometimes the child’s regular practice feels too busy to do the visit, different practices have different rules about when they can accommodate telemed visits); (2) screening for appropriate use (is this a problem that could be handled just as well with a phone call?); (3) screening to be sure that quality of images and other information gathered by the telehealth assistant is adequate; (4) serving as the first-line trouble shooter (sorting out user errors and technical problems).  
	It’s hard to provide a single value for the unit cost of the program (e.g., cost per school site) because there are many possible ways to structure the model. We can tell you that the current 12 urban sites cost about $290,000/year to maintain.  This number includes all of the technical and staffing costs (as above), as well as planned replacement for hardware as it needs to be replaced over time. This number does not include payments to the providers because they currently bill insurance for their visits. 

## Slide 30

**Notes:**
	Here is another reason why primary care practices around the country will be using telemedicine for primary care – competition in providing ready access for minor problems.
	Retail-based clinics (RBCs) are springing up in many Wal-Mart, Target, CVS and similar stores around the country. Note the tag line for Minute Clinic, “You’re sick, we’re quick”.  I applaud the convenient access of RBCs, but I see telemedicine access in these same sites as a better alternative.  Continuity of care at RBCs is, of course, 0% (compared to the 87% average continuity rate that we have achieved with telemedicine). 
	If development continued at the pace documented in August 2007, the total number of retail based clinics across the US was 700 by the end of 2007.  By early August 2007, there were over 500.

------------------------------------------
Projected by the Convenient Care Association (CCA; Philadelphia PA). In April 2007, Feed-back.com's research indicated there were 408 facilities in operation. By early August, the number exceeded 500 (September 2007 update to Feed-back.com's "Retail Clinic Markets” report).