Taking Up the Challenge.

Proven capacity to enable both valid diagnostic decisions and effective management decisions should be required before health care innovations are adopted in routine practice. Various care models, although distinct in capacity for information acquisition and status of effectiveness and efficiency assessment, are marketed as telemedicine. Ability to meet criteria of effective and efficient decision making depends heavily on both the type of clinical problem at hand and the diagnostic and communication tools included in the telemedicine model. As an example of a problem-type-specific, connected care model supported by a well-developed evidence base, we review research findings that support widespread implementation of a model for primary care pediatrics. But, as an understanding of disruptive innovations would predict and as our experience has shown, such evidence is not sufficient by itself to ensure adoption and dissemination. Disruptive innovations are "cheaper, simpler, more convenient products and services that start by meeting the needs of less demanding customers." Such innovations threaten the value of existing services and organizations offering them. Consequently, dominant provider organizations positioned to develop telemedicine, but with important revenue streams threatened by telemedicine, anticipate negative financial impact. Accordingly, these organizations typically obstruct the adoption of disruptive innovations, or are at least slow to adopt them. Organizations funding health services research, investigators, provider organizations, individual providers, and payers, all share responsibility for developing the evidence base supporting connected care. For models supported by a solid evidence base, the challenge extends to ensuring widespread availability of this useful service.

High-Intensity Telemedicine Reduces Emergency Department Use by Older Adults With Dementia in Senior Living Communities.

OBJECTIVES: Individuals with dementia have high rates of emergency department (ED) use for acute illnesses. We evaluated the effect of a high-intensity telemedicine program that delivers care for acute illnesses on ED use rates for individuals with dementia who reside in senior living communities (SLCs; independent and assisted living). DESIGN: We performed a secondary analysis of data for patients with dementia from a prospective cohort study over 3.5 years that evaluated the effectiveness of high-intensity telemedicine for acute illnesses among SLC residents. SETTING AND PARTICIPANTS: We studied patients cared for by a primary care geriatrics practice at 22 SLCs in a northeastern city. Six SLCs were selected as intervention facilities and had access to patient-to-provider high-intensity telemedicine services to diagnose and treat illnesses. Patients at the remaining 15 SLCs served as controls. Participants were considered to have dementia if they had a diagnosis of dementia on their medical record problem list, were receiving medications for the indication of dementia, or had cognitive testing consistent with dementia. MEASURES: We compared the rate of ED use among participants with dementia and access to high-intensity telemedicine services to control participants with dementia but without access to services. RESULTS: Intervention group participants had 201 telemedicine visits. In participants with dementia, it is estimated that 1 year of access to telemedicine services is associated with a 24% decrease in ED visits (rate ratio 0.76, 95% confidence interval 0.61, 0.96). CONCLUSIONS/IMPLICATIONS: Telemedicine in SLCs can effectively decrease ED use by individuals with dementia, but further research is needed to confirm this secondary analysis and to understand how to best implement and optimize telemedicine for patients with dementia suffering from acute illnesses.

Webside Manner: A Key to High-Quality Primary Care Telemedicine for All.

Evaluation of telemedicine, including videoconferencing, specifically focused on primary care, has demonstrated quality as good as in-person care, reduced cost, elimination of socioeconomic disparities in access, and high levels of patient satisfaction. Distinctly different care models are currently marketed by provider organizations as telemedicine. Inclusion (or not) of videoconferencing capacity constitutes a distinguishing feature that is likely to impact effectiveness, but provider organizations, regulatory agencies, and payers have largely overlooked this distinction. Reassurance reducing patient and family anxiety has long been recognized as essential to both patient satisfaction and value of the medical profession. Interaction that reduces anxiety requires empathic communication. Interpersonal communication involves more than words; also key are intonation of voice, facial expression, body language, and capacity to accurately "read" emotions in others and to respond effectively. Telemedicine with videoconferencing has been shown to redress disparities in access while providing high-quality care that is well accepted by both patients and providers. Technical and practical barriers to inclusion of videoconferencing in telemedicine are minimal. Real-time video interaction, enabling "webside manner," should be the default communication mode as telemedicine is increasingly accepted by patients, clinicians, and provider organizations as a tool to ensure high-quality primary care for all.

Effect of the School-Based Telemedicine Enhanced Asthma Management (SB-TEAM) Program on Asthma Morbidity: A Randomized Clinical Trial.

Importance: Poor adherence to recommended preventive asthma medications is common, leading to preventable morbidity. We developed the School-Based Telemedicine Enhanced Asthma Management (SB-TEAM) program to build on school-based supervised therapy programs by incorporating telemedicine at school to overcome barriers to preventive asthma care. Objective: To evaluate the effect of the SB-TEAM program on asthma morbidity among urban children with persistent asthma. Design, Setting, and Participants: In this randomized clinical trial, children with persistent asthma aged 3 to 10 years in the Rochester City School District in Rochester, New York, were stratified by preventive medication use at baseline and randomly assigned to the SB-TEAM program or enhanced usual care for 1 school year. Participants were enrolled at the beginning of the school year (2012-2016), and outcomes were assessed through the end of the school year. Data were analyzed between May 2017 and November 2017 using multivariable modified intention-to-treat analyses. Interventions: Supervised administration of preventive asthma medication at school as well as 3 school-based telemedicine visits to ensure appropriate assessment, preventive medication prescription, and follow-up care. The school site component of the telemedicine visit was completed by telemedicine assistants, who obtained history and examination data. These data were stored in a secure virtual waiting room and then viewed by the primary care clinician, who completed the assessment and communicated with caregivers via videoconference or telephone. Preventive medication prescriptions were sent to pharmacies that deliver to schools for supervised daily administration. Main Outcomes and Measures: The primary outcome was the mean number of symptom-free days per 2 weeks, assessed by bimonthly blinded interviews. Results: Of the 400 enrolled children, 247 (61.8%) were male and 230 (57.5%) were African American, and the mean (SD) age was 7.8 (1.7) years. Demographic characteristics and asthma severity in the 2 groups were similar at baseline. Among children in the SB-TEAM group, 196 (98.0%) had 1 or more telemedicine visits, and 165 (82.5%) received supervised therapy through school. We found that children in the SB-TEAM group had more symptom-free days per 2 weeks postintervention compared with children in the enhanced usual care group (11.6 vs 10.97; difference, 0.69; 95% CI, 0.15-1.22; P = .01), with the largest difference observed at the final follow-up (difference, 0.85; 95% CI, 0.10-1.59). In addition, children in the SB-TEAM group were less likely to have an emergency department visit or hospitalization for asthma (7% vs 15%; odds ratio, 0.52; 95% CI, 0.32-0.84). Conclusions and Relevance: The SB-TEAM intervention significantly improved symptoms and reduced health care utilization among urban children with persistent asthma. This program could serve as a model for sustainable asthma care among school-aged children. Trial Registration: clinicaltrials.gov Identifier: NCT01650844.

Development of School-Based Asthma Management Programs in Rochester, New York: Presented in Honor of Dr Robert Haggerty.

In the spirit of Dr. Haggerty's teachings, we present an overview of our work to improve care for children with asthma in the context of 3 lessons learned: 1) the importance of providing integrated services across disciplinary boundaries for children with chronic illness, 2) the need to move from a care model focused only on the individual child to a model focused on the child, family, and community, and 3) the need to expand beyond the local community and take a broad perspective on improving health on a national level. The goal of our program is to develop sustainable models to overcome the multiple obstacles to effective preventive care for urban children with asthma. The primary intervention for our original School-Based Asthma Therapy program was directly observed administration of preventive asthma medications in school (with dose adjustments on the basis of National Heart, Lung, and Blood Institute guidelines). We found that children who received preventive medications in school through directly observed therapy had improved outcomes across multiple outcome measures. Our subsequent asthma programs have focused on dissemination and sustainability, with the incorporation of communication technology to enhance the system of care. We are currently testing the 'School-Based Telemedicine Enhanced Asthma Management' program, including 400 children with persistent asthma from the Rochester City School District. This program includes directly observed administration of preventive asthma medication at school, and school-based telemedicine to assure appropriate evaluation, preventive medication prescription, and follow-up care. It is designed to implement and sustain guideline-based asthma care through existing community infrastructure, and could serve as a model for the integration of services in rural as well as urban communities.

Urban Telemedicine Enables Equity in Access to Acute Illness Care.

BACKGROUND: Children with care for acute illness available through the Health-e-Access telemedicine model at childcare and schools were previously found to have 22% less emergency department (ED) use than counterparts without this service, but they also had 24% greater acute care use overall. INTRODUCTION: We assessed the hypothesis that increased utilization reflected improved access among impoverished inner-city children to a level experienced by more affluent suburban children. This observational study compared utilization among children without and with telemedicine access, beginning in 1993, ending in 2007, and based on 84,287 child-months of billing claims-based observation. MATERIALS AND METHODS: Health-e-Access Telemedicine was initiated in stepwise manner over 187 study-months among 74 access sites (childcare, schools, community centers), beginning in month 105. Children dwelled in inner city, rest-of-city Rochester, NY, or in surrounding suburbs. Rate of total acute care visits (office, ED, telemedicine) was measured as visits per 100 child-years. Observed utilization rates were adjusted in multivariate analysis for age, sex, insurance type, and season of year. RESULTS: When both suburban and inner-city children lacked telemedicine access, overall acute illness visits were 75% greater among suburban than inner-city children (suburban:inner-city rate ratio 1.75, p < 0.0001). After telemedicine became available to inner-city children, their overall acute visits approximated those of suburban children (suburban:inner-city rate ratio 0.80, p = 0.07), whereas acute visits among suburban children remained at least (worst-case comparison) 56% greater than inner-city children without telemedicine (rate ratio 1.56, p < 0.0001). DISCUSSION: At baseline, overall acute illness utilization of suburban children exceeded that of inner-city children. Overall utilization for inner-city children increased with telemedicine to that of suburban children at baseline. Without telemedicine, however, inner-city use remained substantially less than for suburban counterparts. CONCLUSIONS: Health-e-Access Telemedicine redressed socioeconomic disparities in acute care access in the Rochester area, thus contributing to a more equitable community.

Reducing Emergency Department Utilization Through Engagement in Telemedicine by Senior Living Communities.

BACKGROUND: High-intensity telemedicine has been shown to reduce the need for emergency department (ED) care for older adult senior living community (SLC) residents with acute illnesses. We evaluated the effect of SLC engagement in the telemedicine program on ED use rates. MATERIALS AND METHODS: We performed a secondary analysis of data from a prospective cohort study evaluating the effectiveness of high-intensity telemedicine for SLC residents. We compared the annual rate of change in ED use among subjects who resided in SLC units that were more engaged in telemedicine services with that among subjects who resided in SLC units that were less engaged in telemedicine and control subjects who lived at facilities without access to telemedicine services. RESULTS: During the study, subjects had 503 telemedicine visits, with 362 (72.0%) in the more engaged SLCs and 141 (28.0%) in the less engaged SLCs. For subjects residing in more engaged SLCs, ED use decreased at an annualized rate of 28% (rate ratio [RR] = 0.72; 95% confidence interval [CI], 0.58-0.89), whereas in the less engaged (RR = 0.962; 95% CI, 0.776-1.19) and control (RR = 0.909, 95% CI, 0.822-1.07) groups there was no significant change in ED use (p = 0.036 for group × time interaction). CONCLUSIONS: Individuals residing in more engaged SLCs experienced a greater decrease in ED use compared with subjects residing in less engaged SLCs or those without access to high-intensity telemedicine for acute illnesses. We identified potential factors associated with more engaged SLCs, but further research is needed to understand resident and staff engagement and how to increase it.

High-Intensity Telemedicine Decreases Emergency Department Use by Senior Living Community Residents.

BACKGROUND: The failure to provide timely acute illness care can lead to adverse consequences or emergency department (ED) use. We evaluated the effect on ED use of a high-intensity telemedicine program that provides acute illness care for senior living community (SLC) residents. MATERIALS AND METHODS: We performed a prospective cohort study over 3.5 years. Six SLCs cared for by a primary care geriatrics practice were intervention facilities, with the remaining 16 being controls. Consenting patients at intervention facilities could access telemedicine for acute illness care. Patients were provided patient-to-provider, real-time, or store-and-forward high-intensity telemedicine (i.e., technician-assisted with resources beyond simple videoconferencing) to diagnose and treat acute illnesses. The primary outcome was the rate of ED use. RESULTS: We enrolled 494 of 705 (70.1%) subjects/proxies in the intervention group; 1,058 subjects served as controls. Control and intervention subjects visited the ED 2,238 and 725 times, respectively, with 47.3% of control and 43.4% of intervention group visits resulting in discharge home. Among intervention subjects, ED use decreased at an annualized rate of 18% (rate ratio [RR]=0.82; 95% confidence interval [CI], 0.70-0.95), whereas in the control group there was no statistically significant change in ED use (RR=1.01; 95% CI, 0.95-1.07; p=0.009 for group-by-time interaction). Primary care use and mortality were not significantly different. CONCLUSIONS: High-intensity telemedicine significantly reduced ED use among SLC residents without increasing other utilization or mortality. This alternative to traditional acute illness care can enhance access to acute illness care and should be integrated into population health programs.

Care Offered by an Information-Rich Pediatric Acute Illness Connected Care Model.

BACKGROUND AND OBJECTIVES: Prevailing regulatory and financing issues constrain dissemination of connected care despite evidence supporting acceptability, effectiveness, and efficiency. In this analysis we describe care provided over a 12-year period by Health-e-Access, an evidence-based, information-rich, connected care model designed to serve children with acute illness. We demonstrate the broad clinical capacity of this care model and key components imparting this capacity. MATERIALS AND METHODS: Since 2001, Health-e-Access has been used in childcare, elementary schools, neighborhood after-hours sites, and a school for children with severe disabilities in Rochester, NY. With Health-e-Access, videoconference (preferably) or telephone enables parent, patient, and provider engagement. Technology includes the capacity for acquisition and exchange of a broad range of clinical observations, qualifying Health-e-Access as an information-rich model and differentiating it from multiple other connected care models commonly labeled telemedicine. Primary diagnoses recorded for completed visits were classified according to resources (technology, personnel, examination type) required to complete encounters appropriately. RESULTS: Among 13,812 Health-e-Access visits initiated through June 2013, 98.2% were completed. Capacity for ear-nose-throat examination and close inspection of eye and skin were sufficient to identify positive findings supporting 95.2% of primary diagnoses. Videoconference and stethoscope were considered essential for observations required to rule out serious conditions often presenting in similar fashion to these 95%. CONCLUSIONS: Health-e-Access included technology essential for establishing diagnoses, ruling out more serious conditions, and identifying problems beyond its scope. Regulations enabling and financing incentivizing replication of similar connected care models would benefit families and communities substantially. Observations challenge regulatory bodies and payers to support connected health services of comparable value.

Pursuit of Value in Connected Healthcare.

INTRODUCTION: Potential for direct patient care through remote exchange of health-related information has expanded enormously with the proliferation of technologies leveraging ubiquitous connectivity, but implementation of connected care has been slow and controversial. MATERIALS AND METHODS: This review demonstrates that controversy regarding connected care arises largely from the fact that proponents and critics are generally considering distinctly different care models. Differences are highlighted to mitigate controversy and to distinguish capacities of these different models. RESULTS: Distinguishing capacities is essential for establishing the evidence base supporting safety, effectiveness, and efficiency. In care of a particular patient's problem, value is achieved when resources allocated meet requirements for diagnosis and intervention but do not exceed them. Robust evidence supports the value of some well-defined connected care models, exemplified by the Health-e-Access Telemedicine Model. CONCLUSIONS: The pursuit of value in connected care is fundamentally the same as with in-person care. Provider organizations, legislators, regulators, and payers face not only a complex task in defining standards and enabling appropriate use, but also a heavy burden of responsibility for unleashing connected care that will benefit the entire community.

High-Intensity Telemedicine Decreases Emergency Department Use for Ambulatory Care Sensitive Conditions by Older Adult Senior Living Community Residents.

BACKGROUND: Emergency department (ED) visits for ambulatory care sensitive conditions (ACSCs) are common among older adults. The high-intensity telemedicine model of care has been proposed as an innovative approach to expand access to acute illness care, thereby preventing ED visits. The aim of this study was to assess the effect of a high-intensity telemedicine program for senior living community (SLC) residents on the rate of ED use for ACSCs. METHODS: We performed a prospective cohort study at a primary care geriatrics practice that provides care to 22 SLCs. Six SLCs selected as intervention facilities, with the remaining SLCs serving as controls. Consenting practice patients at intervention facilities could have patient-to-provider, real-time, or store-and-forward high-intensity telemedicine services to diagnose and treat illnesses. The primary outcome was the rate of ED visits for which the primary diagnosis was an "ambulatory-care-sensitive" condition by the Institute of Medicine, which we compared between control and intervention participants. RESULTS: During the study period, control participants had 310 ED visits for ACSCs, for a rate of 0.195 visits/person-year. Intervention participants visited the ED for ACSCs 85 times, for a rate of 0.138 visits/person-year [unadjusted rate ratio (RR): 0.71, 95% confidence interval (CI): 0.53-0.94]. Among intervention participants, ED use for ACSCs decreased at an annual rate of 34% (RR: 0.661, 95% CI: 0.444-0.982), whereas, in the control group there was no statistically significant change in ED use over time (RR: 1.01, 95% CI: 0.90-1.14). CONCLUSIONS: Providing acute illness care by high-intensity telemedicine to older adults residing in SLCs significantly decreases the rate of ED use for ACSCs over 1 year, compared with no change in the rate of ED use for ACSCs among the control group.

Effectiveness and Safety of Acute Care Telemedicine for Children with Regular and Special Healthcare Needs.

OBJECTIVE: To assess the hypothesis that effectiveness and safety of the Health-e-Access telemedicine model for care of children with special healthcare needs (CSHCN) with acute illness equaled those for care of children in regular childcare and schools (CRS). MATERIALS AND METHODS: We examined healthcare use through insurance claims and telemedicine records spanning 5.7 and 7.3 years for CSHCN and CRS, respectively. Effectiveness was measured as telemedicine visit completion, duplication, and adverse events. Completed visits had diagnosis and management decisions made, and treatment implemented, based solely on telemedicine. Duplicating visits addressed related problems in-person following telemedicine visits within 1 or 3 days. An adverse event was defined as an emergency department visit following a telemedicine visit within 3 days for a problem probably related. RESULTS: Comparisons addressing these measures included 483 and 10,008 telemedicine visits by CSHCN and CRS, respectively. Claims files captured health services use for varying periods of time among 300 different CSHCN and among 1,950 different CRS. Among the 483 telemedicine visits initiated for CSHCN over their telemedicine observation period, 9 were not completed. The CSHCN completion rate of 98.1% equaled the 97.6% completion observed among CRS. Within 3 days, in-person visits duplicated 16.1% of telemedicine visits for both CSHCN and CRS. Within 1 day, in-person visits duplicated 5.3% and 8.9% of telemedicine visits for CSHCN and CRS, respectively. Adverse events following telemedicine visits included 0.3% of telemedicine visits for CSHCN and 0.5% for CRS. CONCLUSIONS: Observations support safety and effectiveness of Health-e-Access telemedicine for both CSHCN and CRS.

Patient evaluation of an acute care pediatric telemedicine service in urban neighborhoods.

BACKGROUND: Telemedicine has enhanced care for children with illness in Rochester, NY, since May 2001, enabling 13,568 acute illness visits through December 2013. Prior findings included high parent satisfaction with childcare- and school-based telemedicine ("school telemedicine") and potential to replace 85% of office visits for illness. Urban neighborhood telemedicine ("neighborhood telemedicine") was designed to offer convenient care for illness episodes that school telemedicine often cannot serve because illness arises when children are at home or symptoms preclude attendance. This study was designed to characterize health problems prompting neighborhood telemedicine use and to assess parent perceptions of its value. MATERIALS AND METHODS: A parent satisfaction instrument was developed with input from parents and providers. Neighborhood telemedicine was initiated in January 2009 and totaled 1,362 visits through November 2013. During a 29-month survey period through January 2012, 3,871 acute illness telemedicine visits were completed, 908 (23.5%) of them via neighborhood telemedicine. Instruments were completed for 392 (43.2%) of the 908 visits. RESULTS: Neighborhood telemedicine comprised 27% of all telemedicine visits during the year of peak neighborhood activity. Almost all survey respondents were satisfied or highly satisfied with neighborhood visits (97.6%) and endorsed greater convenience than alternatives (94.5%). CONCLUSIONS: Family preferences and the high value placed on neighborhood telemedicine suggest such service is important, especially in health systems driven by patient values. Service provided by neighborhood telemedicine holds potential to meet a large demand for care of acute childhood illness. Financing reform to support patient-centered care (e.g., bundled payments) should encompass sustainable business models for this service.

High-intensity telemedicine-enhanced acute care for older adults: an innovative healthcare delivery model.

Accessing timely acute medical care is a challenge for older adults. This article describes an innovative healthcare model that uses high-intensity telemedicine services to provide rapid acute care for older adults without requiring them to leave their senior living community (SLC) residences. This program, based in a primary care geriatrics practice that cares for SLC residents, is designed to offer acute care through telemedicine for complaints that are felt to need attention before the next available outpatient visit but not to require emergency department (ED) resources. This option gives residents access to care in their residence. Measures used to evaluate the program include successful completion of telemedicine visits, satisfaction of residents and caregivers with telemedicine care, and site of care that would have been recommended had telemedicine been unavailable. During the first 2 years of the program's operation, 281 of 301 requested telemedicine visits were completed successfully. Twelve residents were sent to an ED for care after the telemedicine visit. Ninety-four percent of residents reported being satisfied or very satisfied with telemedicine care. Had telemedicine not been available, residents would have been sent to an ED (48.1%) or urgent care center (27.0%) or been scheduled for an outpatient visit (24.4%). The project demonstrated that high-intensity telemedicine services for acute illnesses are feasible and acceptable and can provide definitive care without requiring ED or urgent care use. Continuation of the program will require evaluation demonstrating equal or better resident-level outcomes and the development of sustainable business models.

A qualitative evaluation of a telemedicine-enhanced emergency care program for older adults.

OBJECTIVES: To document the experiences of patients, their caregivers, healthcare personnel, and staff members with a program that provides telemedicine-enhanced emergency care to older adults residing in senior living communities (SLCs) and to delineate perceived barriers and facilitators. DESIGN: Qualitative study. SETTING: A primary care geriatric medicine practice. PARTICIPANTS: Stakeholders associated with telemedicine visits: patients, family caregivers, telemedicine dispatcher, certified telemedicine assistants, telemedicine providers, and SLC staff. MEASUREMENTS: Between June and August 2011, telemedicine encounters were observed, and field notes were recorded. After each telemedicine visit, all participants were interviewed using a semistructured guide. Discrete statements from interviews and field notes were coded and arranged into themes. Concordance or discordance in field notes and stakeholder responses were grouped for analysis. RESULTS: After 10 telemedicine visits and 34 interviews from 21 unique participants, redundancy was achieved. Participants and their families overwhelmingly reported satisfaction with their care, remarking particularly on the convenience, speed, and completeness of the evaluation. Participants reported some unmet expectations regarding provider presence at home and visit length. Providers thought telemedicine made them more efficient overall and improved diagnostic certainty but considered in-person visits to be superior. All stakeholders, including patients, noted inadequate telemedicine technician training, leading to low confidence levels and performance difficulties. Participants, providers, and telemedicine technicians cited problems with the reliability, weight, and size of the equipment as serious challenges, decreasing their satisfaction and increasing their frustration. CONCLUSION: Telemedicine-enhanced emergency care is an acceptable method of providing emergency care to older adults in SLCs. Stakeholders report a number of advantages. Training and technology barriers require particular attention.

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 Rochester's 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 child's 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.

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 > or =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.

Acute illness utilization patterns before and after telemedicine in childcare for inner-city children: a cohort study.

The ready access provided by telemedicine benefits families and society but might increase total healthcare utilization with uncertain implications for costs. The objective of this study was to assess the net impact on healthcare utilization of introducing into inner-city childcare a telemedicine model designed to manage acute illness. A cohort study was done using comparable periods before and after introduction of telemedicine for all qualifying children (n = 112) using three innercity childcare centers. Because the utilization histories of these children differed in length, we chose child-months as the unit of analysis. Acute illness visits were ascertained for 1806 child-months among the 112 qualifying children. Following telemedicine startup, children's office and emergency department (ED) visits for illness fell by 1.73 and 0.20/child/year, respectively, replaced by telemedicine visits at 1.07/year. These observations could be misleading, however, because of the possibility of confounding factors. For example, the cohort aged during observation, and illness visits fall with age. Accordingly, in multivariate analysis we adjusted for season of the year, age, and within-child correlation. In this analysis, reduction in illness utilization overall tended toward an increase (rate ratio = 1.26, p = 0.13). The worst-case estimate (based on upper 95% confidence interval for rate ratio) for increase in illness utilization was 3.38 visits/child/year, and the most likely case was an increase of 1.26. Assuming (1) the worst-case effect (largest increase) on overall utilization and (2) reimbursement for ED, office, and telemedicine visits of 350 dollars, 45 dollars, and 45 dollars, respectively, the healthcare system would break even on telemedicine if it replaced 0.50 ED visits per child annually.