Neil E. Herendeen

Telemedicine Reduces Absence Resulting From Illness in Urban Child Care: Evaluation of an Innovation

Background. Common acute illness challenges everyone involved in child care. Impoverished inner-city families, whose children are most burdened by morbidity and whose reliance on child care is most important, are those least equipped to deal with this challenge. Objective. To assess the impact of telemedicine on absence from child care due to illness (ADI). Design/Methods. A before-and-after design with historical and concurrent controls was used to study ADI in 5 inner-city child care centers in Rochester, New York, between January 1, 2001, and June 30, 2003. Enrollment averaged 138 children per center, of whom Medicaid covered 66%. Center 5 provided only concurrent controls. Telemedicine service began in the first 4 centers in a staggered fashion starting in May 2001. Baseline data on ADI before availability of telemedicine were collected in each center for a minimum of 18 weeks. The telemedicine model for diagnosis and treatment of common acute problems involved both real-time and store-and-forward information exchange between a child and telemedicine assistant in child care and an office-based telemedicine clinician. Devices used were an all-purpose digital camera (with attachments designed to facilitate capture of ear, nose, throat, skin, and eye images) and an electronic stethoscope. ADI indexed illness that had interrupted care and education for children and burdened both parents and the community with work loss and health care-related costs. Detailed attendance records and staff and parent interviews provided data. The total number of days of attendance expected from all registered children over the course of a week (total child-days) served as the denominator in calculating rates for ADI. The center-week served as the primary unit of analysis. This study is descriptive in character; statistics are not inferential but instead serve to summarize observations. Results. For the 400 weeks of valid observations contributed by the 5 centers, the mean ADI was 6.41 absences per 100 child-days per week. In bivariate analysis, predictors of ADI were childrens mean age, child care center, proportion of children covered by Medicaid, season of the year, and availability of telemedicine. ADI during weeks with telemedicine (4.07 absences per 100 child-days) was less than half that during weeks without telemedicine (8.78 absences per 100 child-days). After adjusting for potentially confounding variables using the generalized estimating equations method, telemedicine remained the strongest predictor of ADI. A 63% reduction in ADI was attributable to telemedicine, an effect similar to the 59% variation in ADI with season of the year. During the 201 total weeks that telemedicine services were available, 940 telemedicine encounters occurred. Telemedicine clinicians for these 940 encounters recommended exclusion from child care for 7.0% and in-person visits for 2.8% of the children. In surveys, parents indicated that 91.2% of telemedicine contacts allowed them to stay at work and that 93.8% of problems managed by telemedicine would otherwise have led to an office or emergency department visit. Conclusions. Telemedicine holds substantial potential to reduce the impact of illness on health and education of children, on time lost from work in parents, and on absenteeism in the economy.

Acute Illness Care Patterns Change With Use of Telemedicine

OBJECTIVE. Health-e-Access, a telemedicine service providing care for acute illnesses in children, has delivered >6500 telemedicine visits from 10 primary care practices in Rochester, New York, by using telemedicine access at 22 child care and school sites. The goal was to assess the hypotheses that children served by Health-e-Access received health care more often for acute illnesses but had fewer emergency department (ED) visits and lower health care expenditures than did children without access through this service. METHODS. By using insurance claims, this case study compared utilization (starting in May 2001) of telemedicine, office, or ED care for children with versus without telemedicine access. Children included in analyses had ≥6 consecutive insurance-covered months through July 2007. Claims data captured all utilization. A total of 19 652 child-months from 1216 children with telemedicine access were matched with respect to age, gender, socioeconomic status, and season with child-months for children without telemedicine availability. RESULTS. The mean age at utilization was 6.71 years, with 79% of all child-months being covered by Medicaid managed care. The overall utilization rate was 305.1 visits per 100 child-years. In multivariate analyses with adjustment for potential confounders, overall illness-related utilization rates (in-person or telemedicine visits per 100 child-years) for all sites were 23.5% greater for children with telemedicine access than for control children, but ED utilization was 22.2% less. CONCLUSION. The Health-e-Access telemedicine model holds potential to reduce health care costs, mostly through replacement of ED visits for nonemergency problems.

An Asthma Management Program for Urban Minority Children

Morbidity and mortality continue to increase for children with asthma. Minority children have disproportionately higher rates of adverse outcomes on almost all disease measures. An asthma management program for urban minority children was developed with research-based intervention strategies and insights gained from the child and family perspectives on illness and health care delivery. The goal of the intervention program was to deliver care that was culturally sensitive, focused on decreasing barriers to appropriate self-management, and committed to promoting partnerships among children, families, the health care system, and the broader community.

Telemedicine in urban and suburban childcare and elementary schools lightens family burdens.

BACKGROUND Acute illness challenges all families with young children. The Health-e-Access Telemedicine Network in Rochester, NY, has enabled >7,000 telemedicine visits since 2001 among children in childcare or elementary schools, predominantly from Rochesters inner city. Large reductions in illness-related absence and emergency department use among Health-e-Access participants have occurred. OBJECTIVE The study was aimed to assess parent perception of telemedicine as a means to reduce burdens associated with childhood illness. DESIGN/METHODS A total of 800 parents were surveyed before (578) or after (318) a child had at least one Health-e-Access visit. Queries addressed access to healthcare, conflicts between work/school and childs care during illness, and concerns and likes about telemedicine. Perceptions were elicited through open-ended and direct queries. RESULTS Among all respondents, 16% had high-school education and 25% had a college education. Race/ethnicity of the respondents included black (43.6%), Hispanic (22.9%), white (30.0%), and other (3.5%). All identified a primary care practice as a source for well childcare. Most (58%) had given antipyretics to their child to avoid being called by childcare or elementary school staff about illness. Likert scale interview items addressing quality of care elicited low levels of worry or concern. Worry scores trended lower after experience. Among 532 comments about Health-e-Access elicited through open-ended probes, positive ones (likes) predominated (84.6%). Likes most commonly included convenience/time saved (33.6% of all comments), parent stayed at work (13.5%), drug delivered to child site (7.1%) or called ahead to pharmacy (4.9%), and confidence in care (2.3%). Negative responses (concerns) totaled 15.4% of comments and most commonly included reliability of diagnosis (2.6%), technical problems (1.3%), and preference for in-person care (0.8%). CONCLUSIONS Health-e-Access was well accepted by a substantial, diverse group of parents despite unfamiliarity with this approach to care. Convenience and convenience-related experience dominated perceptions. This model enables service beyond that mandated by payers and beyond that generally provided by medical practices.

Integrating Telemedicine in Urban Pediatric Primary Care: Provider Perspectives and Performance

BACKGROUND Health-e-Access, an urban telemedicine service, enabled 6,511 acute-illness telemedicine visits over a 7-year period for children at 22 childcare and school sites in Rochester, NY. OBJECTIVES The aims of this article were to (1) describe provider attitudes and perceptions about efficiency and effectiveness of Health-e-Access and (2) assess hypotheses that (a) providers will complete a large proportion of the telemedicine visits attempted and (b) high levels of continuity with the primary care practice will be achieved. DESIGN/METHODS This descriptive study focused on the 24-month Primary Care Phase in the development of Health-e-Access, initiated by the participation of 10 primary care practices. Provider surveys addressed efficiency, effectiveness, and overall acceptability. Performance measures included completion of telemedicine visits and continuity of care with the medical home. RESULTS Among survey respondents, the 30 providers who had completed telemedicine visits perceived that decision-making required slightly less time and total time required was slightly greater than for in-person visits. Confidence in diagnosis was somewhat less for telemedicine visits. Providers were comfortable collaborating with telemedicine assistants and confident that communications met parent needs. Among the 2,554 consecutive telemedicine visits attempted during the Primary Care Phase, 2,475 (96.9%) were completed by 47 providers. For visits by children with a participating primary care practice, continuity averaged 83.2% among practices (range, 28.1-92.9%). CONCLUSIONS Providers perceived little or no advantage in efficiency or effectiveness to their practice in using telemedicine to deliver care; yet they used it effectively in serving families, completing almost all telemedicine visits requested, providing high levels of continuity with the medical home, and believing they communicated adequately with parents.

Telemedicine and the Patient-Centered Medical Home

Imagine an environment where health care coordination is seamless; where the pediatricians and their care teams could significantly reduce the time it takes to communicate and transfer the information between physicians, patients, and their families. Imagine a situation where unnecessary referrals and investigations are avoided, saving costs and anxieties for the patients. Welcome to the world of telemedicine and a patient-centered medical home (PCMH). Comprehensive health care delivered in the most efficient manner with the least expense is the cornerstone of these concepts. The concept of PCMH was first introduced in 1967 by the American Academy of Pediatrics (AAP) Council on Pediatric Practice in the book, Standards of Child Health Care. The medical home concept originally referred to one central source of medical records for children with special health care needs. During the past 4 decades, this concept has transformed beyond data entry to methods of delivering the best quality of care for all children. In 2007, a joint statement by the AAP, the American Academy of Family Physicians, the American College of Physicians, and the American Osteopathic Association endorsed the PCMH concept.