# Presentation: 659567

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

- Kenneth McConnochie
- Neil Herendeen
- Nancy Wood

- Division of General Pediatrics

**Notes:**
Most people think of telemedicine as second-best, something you might resort to when great distance makes for  difficult access to usual care.  We want you to consider whether telemedicine might offer better care, even for common problems in urban settings ...  whether, in a sense, virtual is better than reality

Given your expertise, the National Resource Center for HIT is inviting you to speak during the session, “Improving Quality Care for Children through HIT.” The focus of this session will include a discussion around the implementation of HIT developed to improve the safety and quality of health care for children.  The following three people have also been invited to participate in this session: Carmen Lozzio, MD, FACMG; Paula Edwards, MD; and Richard Shiffman. Each speaker will have 15 minutes to present, followed by questions from the audience. The session, “Improving Quality Care for Children through HIT” is scheduled for Wednesday, September 26, 2007 from 8:00 am – 9:30 am.

NEED TO ADD:
Characteristics of TeA model that enable integration.  
Text that links access and care delivered by PC practice to quality.

## 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

**Notes:**
We call our program Health-e-Access.

I want to acknowledge several sources of funding and also disclose a potential conflict of interest.

## 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

**Notes:**
Because many have no direct experience with telemedicine, a substantial part of this presentation addresses background as well as characteristics of our telemed model.

Health-e-Access was designed to address a problem of national significance.

<NEXT> In the US, the majority of preschool children are in child care

<NEXT>  Acute illness is more common among these children

<NEXT> For parents using child care, a child’s illness accounts for 40% of work absence

<NEXT>  From a nationally representative sample in the 2001, over 50% of working mothers say they will miss work the next time one of their children is ill.

Although most of these illness episodes are minor, they impose a tremendous social and economic burden.

[Resources for dealing with this challenge are not readily available to many inner city families. Thus, the children and families most burdened by illness, whose reliance on child care is most important to their ability to improve economic circumstances, are those least equipped to deal with the challenge ]

## 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

**Notes:**
Here’s another issue ... a rapidly developing problem for the primary care pediatrician.

<NEXT>   Retail-based clinics (RBCs) appeal to families ... and understandably so.  What working parent of a preschooler doesn’t have too many demands on their time?  In light of their rapid growth, it’s obvious that  RBCs are filling an important need ... parents can address healthcare needs of their children, and themselves, in the same trips they make to feed and clothe their families.  

<NEXT>   Marketed under such names as Minute Clinic, Quick Clinic and
And catchy slogans such as “you’re sick, we’re quick”, RBCs are being developed rapidly by such dominant firms as Wal-Mart, Targets, CVS, Walgreen. 

<NEXT>   They have the capacity to address the minor acute illness episodes that generate 52% of primary care pediatric visits and also about half the revenue for pediatric practices.
Hing E, Cherry DK, Woodwell DA. National Ambulatory Medical Care Survey: 2004 summary. Advance data from vital and health statistics; no 374. Hyattsville, MD: National Center for Health Statistics. 2006. Table 10, p19

<NEXT>   To make things worse, RBCs appeal to 3rd party payers because they offer an equally convenient, but much less costly, alternative to the emergency department. 

In addition to their economic threat, RBCs threaten continuity of care with the medical home. Confronted by a choice between convenience and continuity for a minor problem, parents understandably will choose convenience almost every time.   

## Slide 5

**Notes:**
Here’s what people are seeing in many Wal-Mart, Target and similar stores around the country.

Note the tag line, “You’re sick, we’re quick” – I love that. 

If development continues at the current pace, the total number of retail clinics is likely to reach 700 by the end of 2007.  By early August this year, there were over 500.

Projected earlier this year 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). 

## Slide 6

**Notes:**
The thing is, in today’s world you just never know when or why you might have an immediate need for health care !  

Credit for the notion of the Healthy Lover special – a $240 value for less than $200 – goes to a piece that appeared in the NY Times Sunday Magazine that named Retail Based Clinics as one of the best new ideas to emerge in 2006.  

Time will tell whether that was serious or just a tongue in cheek proposal. 

## 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

**Notes:**
Moving on to Health-e-Access -- our solution to the problem that no one has time to be sick ...

<NEXT>
At child care site, there’s a child with health problem and a telehealth assistant. The telehealth assistant is childcare staff, who may - or may not - have any prior healthcare experience.  We train these folks in about 16 hours to collaborate with telemed clinicians.

<NEXT>
At the remote clinician site is a physician or nurse practitioner.  Most clinicians don’t seem to want more than 30 min of training (if that).  

<NEXT>
The telemed technology includes a broadband communications link, computer-driven digital sensors, and a software package that integrates all the components. 

The HeA model uses both real-time videoconference and store-and-forward information exchange. Telehealth assistants capture ear, eye, mouth, throat and skin images with an all-purpose camera.  Lung sounds are captured with an electronic stethoscope. 

## Slide 8

**Notes:**
Here’s a child with a telehealth assistant, capturing lung sounds in this case.

## Slide 9

**Notes:**
And, at the other end, a couple of my clinician colleagues

## 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

**Notes:**
<NEXT>
We’ll skip most of these operational details.  
The most important is the outcome, that problems are diagnosed and treated very quickly and most children are judged to be OK to remain in childcare.  

## Impact on ADI

**Notes:**
And this leads to a tremendous reduction in absence from childcare due to illness.

As we have published, in multivariate analysis adjusting for potential confounders such as child age and season of the year, we found a 63% reduction in absence due to illness
 – that was attributable to telemedicine.  

## 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 (SD 2.2) per telemed visit

**Notes:**
No surprise -- parents love this. 

Following their child’s first telemed visit, 94% reported telemed had allowed them to avoid an office, after hours clinic, or ED visit.  

94% also reported the telemed visit allowed them to stay at work, and the average time saved was 4.5 hr per visit.

Finally, 92% said they would choose a childcare program with telemed over one without.  

## 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%

**Notes:**
Today, I’m reporting on our experience with 
<NEXT> the first 6 inner-city child care centers.
<NEXT> Telemed was initiated in stepwise fashion starting with first center in May 2001
<NEXT> Observations on utilization that I’m presentint run thru October 2006  
<NEXT> Centers averaged 138 children 
<NEXT> And Medicaid covered 66%

## 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

**Notes:**
<NEXT> The network also included 5 urban primary care practices 

<NEXT> These participating practices provide primary care to 71% of children in the 6 participating child care programs

<NEXT> Integration into these primary care practices began in May 2005, four years after our first childcare telemed visit.  Prior to that time, telemed visits had been done only by investigators based at our Medical Center

## 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

**Notes:**
Our program has developed in multiple stages,
<NEXT> <NEXT> The first 7 months after expansion funding was received in October 2004, nothing changed in network operations while we awaited development of a new telemed system that would fit the work flow of busy primary care practices. This technology development phase was completed May 2005, allowing efforts at integration to begin in earnest. 

<NEXT> Integration began with installation of technology and training in PCP offices.  This took 11 months to complete, mostly because information technology staff at some collaborating institutions were not very collaborative.  Several practices were actively doing visits during these 11 months.  PCP ramp-up was defined by the date that all PCPs were both technically and clinically functional, indicated by completion of at least one telemed visit.

The Integration phase, a total of 17 months, is what we are reporting on today.

## Visits by StageMay 2001 - October 2006

**Notes:**
Here’s the breakdown of all visits done through last October. 
We are looking now at the 1,530 that occurred during the Integration Stage <POINT> 

[ ... in essence, when funding and maturation of the technology gave us the opportunity to address the challenge of integration in primary care office settings.]

## 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.

**Notes:**
The hypothesis that focused our descriptive analysis was that the Health-e-Access model can be integrated successfully in the primary care medical home to provide care for acute illness episodes identified in inner-city child care. 

## 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.

**Notes:**
Primary measures of success were continuity of care and telemed visit completion.
<NEXT>  Continuity of care was measured as the proportion of telemed visits seen by the primary care practice (PCP).  This measure was applied only for children with a participating PCP.  Note that we measured continuity with the practice, not with the child’s designated continuity provider.  
Our view on continuity is that if telemed can be used to enable a connection with the primary care practice, it could also be used to connect with the designated primary care provider.  The next step, connection with the primary care provider, has little to do with telemed – telemed is just a communication technology.  Instead, it has everything to do with how clinicians decide to organize their practices. 

<NEXT> Telemed visit completion was measured as the proportion of telemed visits attempted that are completed, with completion defined as diagnosis decisions and treatment without subsequent, in-person physical exam, lab tests or treatment.

## 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

**Notes:**
<NEXT> <NEXT> Among 1530 telemed visits attempted, 96%) were completed by 43 different clinicians.  So telemed was effective in almost always giving clinicians everything they needed to know for clinical decision making. 

<NEXT> Continuity averaged 87% among the 5 PC Practices. 87% continuity sounds pretty good, especially in light of survey results with parents of study children indicating that if they call their doctor in the afternoon about an illness, 75% are referred to an emergency department or after-hours clinic.  

<NEXT> Continuity with practice at 87%, of course, is a lot better than the 0% continuity that is  inherent with retail based clinics.

<NEXT> We’re going to skip practice to practice variation in continuity for now.

<NEXT> The 587 participating children averaged 182 TM visits/100 children/yr.  Based on national illness visit rates, this value of 182 is about half the expected annual illness visit rate for pre-school children.  So it seems that this service is playing a major role in the healthcare of participating children.  

[For the 13% of visits not seen by a continuity PC practice, the reason was because (1) the PC practice was unwilling to see the patient because the patient was covered by fee-for-service Medicaid (which would not reimburse), (2) the practice’s telemed champion was not in the office when the telemed visit was requested and no other clinician in the office was able/willing to do the visit, or (3) the PC practice clinician felt he/she was too busy to accommodate the telemed visit within the available time frame (e.g., school was closing in 45 minutes).  ]

## 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)

**Notes:**
Our conclusions are that –
Health-e-Access can be integrated in busy primary care practices serving urban children, enabling...
<NEXT>  exceptional access
<NEXT>  completion of almost all illness visits
<NEXT>  continuity of care (unlike RBCs)    

This is a simple message based on very simple methodology ...

But the process to achieve these outcomes might well be described as complex and demanding.  
Widely accepted wisdom among telemed advocates is that implementation is at most 10% about the technology and 90% or more about “politics”. 

## 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**

**Notes:**
But I think it’s worth it, partly because of threats to the medical home concept and threats to primary care pediatric practice posed, among other forces, by retail based clinics.   As summed up by the current US Secretary of DHHS, organizations have 3 options when confronted by new technology,

<NEXT> ignore it and die,
<NEXT> adapt and survive, 
<NEXT> lead and prosper

## Implications

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

**Notes:**
But I mostly think its worth it because of what telemed has to offer.  Telemed has potential to enable healthcare when and where you need it, by people you know and trust. The patient site for telemed could just as easily be a retail setting as a child care center.  

The trusted primary care clinician providing the telemed visit could be anywhere with internet access.   Thus, it’s clearly up to clinicians ... and health policy decision makers ... to determine whether telemed will be used to enhance continuity of care as well as provide ready access.    

## Thanks!

## Parachutes and Gravitational challenge

**Parachute use to prevent death and major trauma related to gravitational challenge: systematic review***

- * Smith GCS, Pell JP. British Medical Journal 2003:327:1459-61

- _Conclusion_:
- Parachutes appear to reduce the risk of injury after gravitational challenge, but their effectiveness has not been proven with randomized controlled trials.

**Notes:**
RESPONSE TO ANY QUESTION ABOUT DIAGNOSTIC ACCURACY OR RELIABILITY –

I was hoping someone would ask that.  I don’t mean to make light of that important question, although this slide might make you wonder.  The slide makes the point, very well, that not every question needs to be answered through rigorous study.   FACE VALIDITY IS NOT A TRIVIAL CONCEPT.  We’ve taken a rigorous look at reproducibility of primary diagnosis, but I think the most important thing to say is:  SEE FOR YOURSELF. The telemed technology we use has the capacity of obtain superb images.  When I review sets of tympanic membrane and other images with residents and students, they usually ask me why we don’t use this technology for usual in-person care – to them, the images are obviously much superior for providing diagnostic information than the hand-held otoscope they typically use. 

## Diagnosis Distribution

**Notes:**
FOR QUESTION ABOUT PROBLEMS ADDRESSED

16 diagnoses or diagnosis groups accounted for 91% of the completed visits.  The diagnoses on this list are certainly comparable to illness seen in office practice, although the proportion diagnosed with acute otitis media seems high at almost 29%.  You can’t make much out of illness distributions or utilization patterns without a matched control group of inner city children using childcare without telemed.  That analysis is under way (come back next year). 

## Slide 26

**Notes:**

According to this NY Times article from last month (August 2007) ...
As an example of how these work, Duane Reade, a pharmacy chain with stores on just about every corner in Manhattan, plans to open as many as 60 stores over the next 14 to 18 months.  Unlike most RBCs, which use NPs or PAs as clinicians, will use physicians.  Also of great interest, the Duane Reade RBCs linked with the parent company of St.Lukes-Roosevel and Beth Israel Medical Centers.  This gives the Duane Reade patients and doctors streamlined access to subspecialists and the emergency departments of these medical meccas.