1. Telemedicine Integrated in the Primary Care Medical Home: When Virtual is Better than Reality Kenneth McConnochie Neil Herendeen Nancy Wood Division of General Pediatrics

2. 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

3. 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

4. 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

7. 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

10. 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

11. Impact on ADI

12. 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 * Estimated time saved = 4.5 hours (SD 2.2) per telemed visit

13. 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%

14. 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

15. 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

16. Visits by Stage May 2001 - October 2006

17. 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.

18. 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.

19. 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

20. 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)

21. 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

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

23. Thanks!

24. 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.

25. Diagnosis Distribution