Problem Addressed

• High prevalence of acute childhood illness: Children under the age of 15 years with an acute condition account for 71 million physician office visits annually.¹
• No need for illness to cause absence from educational programs: The American Academy of Pediatrics' Health, Mental Health, and Safety Guidelines for Schools recommends that "students and staff who are well enough to carry on with school functions should not be sent home for colds, bronchitis, or the rash of Fifth Disease, because inclusion in these circumstances has not been found to increase the chances others will become ill . . . strep throat is infectious, but not after 24 hours of antibiotic treatment."² Symptoms concerning to educators may, in fact, be minor; one study found that a temperature of 99 to 99.9 degrees Fahrenheit was considered a fever by 35 percent of daycare staff.³
• High economic and social costs: The costs associated with childhood illness are high and include health care costs, a parent's time lost from work (which reduces productivity and can have a negative impact on a parent's income and/or employment status), children's time lost from educational programs,⁴ and transportation costs. For a child with severe disabilities, transportation might require a wheelchair van. One study reported that 40 percent of work missed by parents using childcare was due to a child's illness.⁵ Furthermore, lack of access to care prompts unnecessary use of the emergency department (ED); studies estimate that between 20 and 70 percent of pediatric visits to EDs are for nonurgent health problems.^2,3,4,5 Evidence from this group of investigators has shown that 85 percent of pediatric office visits for illness could be managed, instead, by telemedicine.⁶

Description of the Innovative Activity

• Determining the need for a remote visit: Telemedicine assistants can consider initiating a remote visit for any acute problem that might require exclusion from the school or childcare setting until a medical evaluation is obtained. Once a sick child is identified (e.g., a child who wakes up from a nap with a fever), the childcare center/school contacts the parent for approval to execute a remote consultation with the pediatrician. In 2009, the program expanded to include other neighborhood settings (e.g., family services center, church, settlement house). Four such after-hours sites now operate, covering five weekday evenings and Saturday morning.
• Calling triage staff: The telemedicine assistant calls a Health-e-Access triage staff member (scheduler/coordinator), who contacts the child's pediatrician and makes an appointment for the visit. If a child does not have a participating pediatrician, the scheduler/coordinator contacts a clinician within the University of Rochester Medical Center–based primary care pediatric practice who is "on call" for telemedicine visits.
• Gathering and sending patient data: Using telehealth units, the telemedicine assistant gathers patient data and saves it to a central server where it is available to the pediatrician via the Internet in advance of the visit. Telehealth units include a teleconferencing camera, an all-purpose digital camera with attachments to enhance imaging of ears, eyes, nose, throat, and skin; and an electronic stethoscope. Forwarded information includes text describing the child's medical history and may include images of ear drums, throat, and/or skin rash; lung sounds; results of a rapid strep test; and other assessments. Because key information that drives medical decisionmaking is generally available at the click of a mouse, a typical telemedicine visit takes the clinician just a minute or 2 for diagnosis and management decisions. Additional time is required for documentation and communication. The system allows prescriptions to be faxed directly to the family's pharmacy of choice.
• Real-time interaction as needed: When the physician requires additional information or observations that are best obtained through real-time interaction, a videoconference is initiated that enables the physician to view the patient and the patient to view the physician. When parents are present at a visit, videoconferencing is always used because this enhances communication and engagement.
• Discussion of findings and next steps: Once all information is gathered, the pediatrician has a videoconference or calls the onsite telemedicine assistant and/or the child's parent to discuss findings and next steps. As part of this conversation, the physician offers a diagnosis, guidance on treatment, and, if appropriate, faxes a prescription to a pharmacy. Many pharmacies will deliver to childcare sites, resulting in rapid initiation of treatment and even more time-saving for the family. Occasionally, the clinician recommends further assessment through a visit to the doctor's office, lab testing, or imaging studies (about 3 percent of telemedicine encounters). Diagnosis and treatment recommendations are confirmed and handouts about the child's condition that have been selected by the clinician are printed out on the child-site computer for the parent and child-site staff.
• Payment: Telemedicine services are reimbursed by local payers as a regular visit, with the exception of fee-for-service Medicaid, which is a statewide program that covers about 10 percent of program participants. Currently, providers absorb the costs of telemedicine visits for these patients. (See the Planning and Development Section for more information on how these payers were convinced to provide reimbursement.)

References/Related Articles

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Results

• Fewer absences due to illness: A study in five inner-city childcare centers found that absences due to illness declined from 8.78 to 4.07 per 100 child days after implementation of the program, a decline of 63 percent after adjustment for potential confounders in a multivariate analysis. Of the 940 telemedicine encounters conducted between January 1, 2001 and June 30, 2003, pediatricians recommended exclusion from childcare in only 7 percent of cases; in only 2.8 percent of cases was an in-person visit recommended.
• Fewer ED and physician visits: A community-based trial comparing health services utilization of children with telemedicine access with that of a closely matched control group without telemedicine access confirmed that over 6 years of participation (total of 39,304 child-months of observation), children served by the program had 22 percent fewer ED visits. Telemedicine and control children observations were matched on age, sex, month of the year, insurance type, and socioeconomic index. Also of note, a survey of parents following their child's first use of telemedicine found that in 93.8 percent of cases, the parent would have taken his or her child to a physician or an ED if the program had not been available. Finally, secondary analysis of an administrative data set, including ED visits at the University of Rochester Medical Center in 2006, estimated that the program had the potential to prevent 28 percent of ED visits.
• Less missed work for parents: The aforementioned survey also showed that 91.2 percent of parents said that a telemedicine visit had enabled them to remain at work.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Purchase and later development of technology: For the initial demonstration project, the pediatricians obtained commercially available computer equipment and telehealth units with peripheral devices. In initial studies of the program, the equipment was found to lack stability and did not fit workflow requirements of the program well (particularly workflow in a busy pediatric primary care office). Subsequently, Health-e-Access contracted with internet-based software developers and computer system integrators to create a customized telemedicine system with software and protocols tailored to the workflow and process requirements of the program. A commercial venture, TeleAtrics, arose from that endeavor.
• Initial demonstration project: An initial demonstration project was implemented in May 2001 with three inner-city childcare centers, with pediatric encounters handled by the two medical center pediatricians and one nurse practitioner. Health-e-Access staff trained on-site telemedicine assistants to perform their roles. As Health-e-Access clinicians gained experience in conducting telemedicine visits, they developed further understanding of the strengths and weaknesses of their telemedicine model and identified technical and organizational refinements that would promote effectiveness and efficiency and facilitate integration of the Health-e-Access system in busy primary care office settings.
• Ensuring payer reimbursement: Program developers contacted medical directors at local payers (commercial payers and payers offering Medicaid managed care products) to obtain agreement to reimburse primary care practices for providing telemedicine services for the duration of the demonstration project. After payers saw evidence of the program's potential to reduce ED visits based on the impact of the demonstration project, they agreed to continue reimbursing services on an ongoing basis.
• Program expansion: Based on the program's success, Health-e-Access expanded to several additional settings, including neighborhood centers in January 2009 (with evening and weekend hours), all Rochester City Schools in September 2010 (through mobile telemedicine units operated by roaming telemedicine assistants), and senior living communities in October 2010 (also through roaming telemedicine assistants). The Health-e-Access Geriatric Program is described more fully in a separate Innovations Profile.
  • Soliciting childcare center/elementary school participation: Program developers contacted childcare centers to solicit their participation. Developers provided site tours and demonstrations of the telemedicine technology to win their support.
  • Soliciting other facilities: In 2009, the program expanded to include to include other neighborhood settings (e.g., family services center, church, settlement house). Four such after-hours sites now operate, covering five weekday evenings and Saturday morning. In addition, the program serves a large, multisite facility, providing services for children with severe developmental disabilities, many of whom are also medically fragile.
  • Enlisting physician participation: Five practices serving roughly 80 percent of the children living in the primary target area (inner-city Rochester) are most heavily involved. Program developers contacted the physicians at these practices and highlighted the convenience of the program for families; most pediatricians were highly service-oriented and quickly understood the value of the program. Five additional practices that serve primarily suburban children have also participated.
  • Initial training and evaluation of technicians: The onsite telemedicine assistants must undergo a 12- to 16-hour, hands-on training program that focuses on symptom-driven protocols, electronic forms that guide the collection of medical history, and use of telemedicine peripheral devices. Additional skills addressed during training include obtaining vital signs, performing rapid streptococcal antigen testing, and administering nebulized medication. Once they complete training, telemedicine assistants are "on probation," and must demonstrate their competence during a 2-month internship in which they have to complete two (actual or simulated) telemedicine visits per week. This activity level criterion is important for sites that have their own telemedicine assistant. On completing the internship, the telemedicine assistants receive certification by Health-e-Access.
  • Ongoing performance evaluation: Once trained and certified, staff have to maintain their proficiency over time. The program's software includes performance evaluation tools—before the pediatrician closes out a visit, he/she must complete a brief rating of the telemedicine assistant's performance. The telemedicine assistant also has the opportunity to rate the clinician's performance during the developmental stage. To maintain their certification, telemedicine assistants must receive consistently good evaluations.
  • Piloting program to enhance management of other conditions: In 2011, local pilot funding was obtained to use this telemedicine network to enhance management of common chronic problems in childhood such as asthma and attention deficit hyperactivity disorder. Findings to date based on qualitative methods suggest that telemedicine enhanced, school-based chronic care management has tremendous potential.

Resources Used and Skills Needed

• Staffing: The program employs a coordinator and a nurse manager. Some telemedicine assistants are existing schools/childcare staff members. Telemedicine assistants may or may not have had prior health care training or experience. In schools, school nurses may serve as telemedicine assistants, but in situations where they are too busy with other mandated responsibilities, telemedicine visits are handled by health aides. Large child sites (e.g., a childcare center with 150 preschool children) can be served efficiently with an onsite, dedicated telemedicine assistant. Multiple small sites (e.g., childcare for 5 to 10 children based in a family home) can be served much more efficiently with a roaming telemedicine assistant using a mobile telemedicine unit with wireless connectivity. Most participating elementary schools are now served by roaming telemedicine assistants as well.
• Costs: Health-e-Access costs $115,000 annually to cover the salary and benefits for the coordinator and nurse manager. In addition, the telemedicine equipment costs roughly $15,000 for hardware, software, setup, and training. TeleAtrics charges schools and childcare centers a $4,000 annual fee after the first year for software licensing, connectivity, and support. Physician practices pay a small setup fee but no annual fee for participation, thus allowing them to view images, participate in videoconferences (see below), and share other information and services enabled through Health-e-Access.

Funding Sources

Tools and Other Resources

Getting Started with This Innovation

• Solicit payer agreement to reimburse telemedicine visits by emphasizing the cost savings potential due to fewer ED visits. Insurers should reimburse at greater than the rate of the usual office visit for illness, as they generally do for visits to urgent care centers. As with urgent care center visits, telemedicine visits visits often allow ED visits to be avoided. Moreover, with the Health-e-Access telemedicine model, most telemedicine visits are conducted within the primary care medical home. Such continuity of care not only avoids large payments for an ED visit; continuity is also associated with less "defensive medicine" (e.g., fewer laboratory and imaging studies).
• Engage payers and provider organizations on the issue of telemedicine infrastructure costs. Infrastructure components include the following: telehealth assistants; training of clinicians and telemedicine assistants for use of the technology and for collaboration; management of telephone calls about illness, including triage to telemedicine or inperson care; technical and clinical troubleshooting and quality control; and telemedicine hardware, software, and connectivity. Infrastructure might logically be financed from a "facility fee" carve-out from usual office visit reimbursement, from supplemental financing from insurance organizations or industry, from subscription fees paid by parents, or from a combination of the above.
• Approach childcare centers, schools, or other sites that are especially oriented towards serving family needs and elicit their commitment to the program. Although the program can work anywhere, childcare centers with an altruistic mission tend to be more effective partners.
• Identify and accommodate site-specific needs when possible, as failing to address these needs could have a negative impact on the success of the program. Some medical practices, for example, would rather "squeeze in" telemedicine visits between regularly scheduled patients, whereas others prefer to allocate specific appointment slots for telemedicine visits.
• Consider sharing telemedicine assistants, especially among smaller childcare centers and schools. A telemedicine assistant with portable telemedicine equipment and wireless broadband technology can serve several sites, leading to enhanced cost-effectiveness (because childcare centers can share the salary and equipment cost).

Sustaining This Innovation

• Pursue ongoing grant funding to cover the costs of telemedicine infrastructure until agreements about covering infrastructure costs are negotiated successfully.
• Continually track and share data on the impact of the program; payers will be particularly interested in data showing reduced health care utilization and costs, which will likely encourage them to continue providing reimbursement for program services.

Additional Considerations and Lessons

• Children who are more than mildly ill do not go to childcare or school. Thus, to extend the convenience of neighborhood telemedicine access to more families, other neighborhood access sites are important, especially early in the evening (after usual medical office hours) when pediatric emergency departments are busiest.
• To optimize efficiency and effectiveness of care for acute childhood illness, full integration of telemedicine and telephone management in primary care is critical.
• Telemedicine enables a high level of elasticity of capacity in health services, allowing providers almost anywhere (including their own homes) to bring their professional expertise to wherever surges in demand for care might occur. This consideration is especially relevant in light of anticipated epidemics (e.g., swine flu).

Use By Other Organizations

• Akron Children's Hospital, Akron, OH
• My Health-e-Schools, Mitchell and Yancy Counties, North Carolina