Increasing Uptake of Lung Cancer Screening Among Emergency Department Patients: A Pilot Study.

BACKGROUND: Lung cancer is the leading cause of cancer death in the United States. Lung cancer screening (LCS) decreases lung cancer mortality. Emergency department (ED) patients are at disproportionately high risk for lung cancer. The ED, therefore, is an optimal environment for interventions to promote LCS. OBJECTIVES: Demonstrate the operational feasibility of identifying ED patients in need of LCS, referring them to LCS services, deploying a text message intervention to promote LCS, and conducting follow-up to determine LCS uptake. METHODS: We conducted a randomized clinical trial to determine the feasibility and provide estimates of the preliminary efficacies of 1) basic referral for LCS and 2) basic referral plus a text messaging intervention, grounded in behavioral change theory, to promote uptake of LCS among ED patients. Participants aged 50 to 80, identified as eligible for LCS, were randomized to study arms and followed up at 150 days to assess interval LCS uptake (primary outcome), barriers to screening, and perceptions of the study interventions. RESULTS: A total of 303 patients were surveyed, with 198 identified as eligible for LCS and subsequently randomized. Results indicated that 24% of participants with follow-up data received LCS (11% of the total randomized sample). Rates of screening at follow-up were similar across study arms. The intervention significantly improved normative perceptions of LCS (p = 0.015; Cohen's d = 0.45). CONCLUSION: This pilot study demonstrates the feasibility of ED-based interventions to increase uptake of LCS among ED patients. A scalable ED-based intervention that increases LCS uptake could reduce lung cancer mortality.

Intervention to increase colorectal cancer screening among emergency department patients: results from a randomised pilot study.

BACKGROUND: Colorectal cancer (CRC) is the second leading cause of cancer-related deaths worldwide. Emergency departments (ED) represent a promising setting to address preventive health measures like CRC screening. OBJECTIVES: The current study adapted an existing cervical cancer screening intervention for use in catalysing CRC screening. We evaluated feasibility of identification, provided preliminary effect size estimates and documented participant acceptability. METHODS: This study was funded by the University of Rochester (ClinicalTrials.gov # NCT05004376). We enrolled ED patients, 45-75 years old, in the Greater Rochester, NY region into a randomised controlled pilot from January to May 2022. Patients were excluded if non-English speaking, lacking a cell phone or had a history of CRC, colorectal resection, inflammatory bowel disease or abdominal radiation. Participants were surveyed to determine adherence with recommended CRC screening guidelines. Patients found non-adherent were randomised to receive (1) recommendation for CRC screening only or (2) recommendation and a text-based intervention aimed at generating intention and motivation to get screened. Patients were blind to allocation at enrolment. The primary outcome was patient CRC screening or scheduling. RESULTS: 1438 patients were approached, with 609 found ineligible, 576 declining participation and 253 enrolled. A randomised sample of 114 non-adherent patients were split evenly between the control and intervention arms. Among participants with follow-up data (n control=38, n intervention=36), intervention participants had a 2%-3% higher rate of scheduling or receiving screening (7%-27% relative improvement). When using the complete sample (n=114) and conservatively assuming no screening for those lost to follow-up, differences in screening across arms were mildly decreased (0%-2% absolute difference). Acceptability of CRC intervention was high, and participants offered formative feedback. CONCLUSION: The piloted text message intervention through the ED shows potential promise for catalysing CRC screening. Subsequent replication in a fully powered trial is needed.

Evaluating registry-based trial economics: Results from the STRESS clinical trial.

Background: Registry-based trials have the potential to reduce randomized clinical trial (RCT) costs. However, observed cost differences also may be achieved through pragmatic trial designs. A systematic comparison of trial costs across different designs has not been previously performed. Methods: We conducted a study to compare the current Steroids to Reduce Systemic inflammation after infant heart surgery (STRESS) registry-based RCT vs. two established designs: pragmatic RCT and explanatory RCT. The primary outcome was total RCT design costs. Secondary outcomes included: RCT duration and personnel hours. Costs were estimated using the Duke Clinical Research Institute's pricing model. Results: The Registry-Based RCT estimated duration was 31.9 weeks greater than the other designs (259.5 vs. 227.6 weeks). This delay was caused by the Registry-Based design's periodic data harvesting that delayed site closing and statistical reporting. Total personnel hours were greatest for the Explanatory design followed by the Pragmatic design and the Registry-Based design (52,488 vs 29,763 vs. 24,480 h, respectively). Total costs were greatest for the Explanatory design followed by the Pragmatic design and the Registry-Based design ($10,140,263 vs. $4,164,863 vs. $3,268,504, respectively). Thus, Registry-Based total costs were 32 % of the Explanatory and 78 % of the Pragmatic design. Conclusion: Total costs for the STRESS RCT with a registry-based design were less than those for a pragmatic design and much less than an explanatory design. Cost savings reflect design elements and leveraging of registry resources to improve cost efficiency, but delays to trial completion should be considered.

Concordance between 8-1-1 HealthLink BC Emergency iDoctor-in-assistance (HEiDi) virtual physician advice and subsequent health service utilization for callers to a nurse-managed provincial health information telephone service.

BACKGROUND: British Columbia 8-1-1 callers who are advised by a nurse to seek urgent medical care can be referred to virtual physicians (VPs) for supplemental assessment and advice. Prior research indicates callers' subsequent health service use may diverge from VP advice. We sought to 1) estimate concordance between VP advice and subsequent health service use, and 2) identify factors associated with concordance to understand potential drivers of discordant cases. METHODS: We linked relevant provincial administrative databases to obtain inpatient, outpatient, and emergency service use by callers. We developed operational definitions of concordance collaboratively with researcher, patient, VP, and management perspectives. We used Kaplan-Meier curves to describe health service use post-VP consultation and Cox regression to estimate the association of caller factors (rurality, demography, attachment to primary care) and call factors (reason, triage level, time of day) with concordance as hazard ratios. RESULTS: We analyzed 17,188 calls from November 16, 2020 to April 30, 2021. Callers advised to attend an emergency department (ED) immediately were the most concordant (73%) while concordance was lowest for those advised to seek Family Physician (FP) care either immediately (41%) or within 7 days (47%). Callers unattached to FPs were less likely to schedule an FP visit (hazard ratio = 0.76 [95%CI: 0.68-0.85]). Rural callers were less likely to attend an ED within 48 h when advised to go immediately (0.53 [95%CI:0.46-0.61]) compared to urban callers. Rural callers advised to see an FP, either immediately (1.28 [95%CI:1.01-1.62]) or within 7 days (1.23 [95%CI: 1.11-1.37]), were more likely to do so than urban callers. INTERPRETATION: Concordance between VP advice and subsequent caller health service use varies substantially by category of advice and caller rurality. Concordance with advice to "Go to ED" is high overall but to access primary care is below 50%, suggesting potential issues with timely access to FP care. Future research from a patient/caller centered perspective may reveal additional barriers and facilitators to concordance.

Use of Routine Emergency Department Care Practices with Deaf American Sign Language Users.

BACKGROUND: Deaf individuals who communicate using American Sign Language (ASL) seem to experience a range of disparities in health care, but there are few empirical data. OBJECTIVE: To examine the provision of common care practices in the emergency department (ED) to this population. METHODS: ED visits in 2018 at a U.S. academic medical center were assessed retrospectively in Deaf adults who primarily use ASL (n = 257) and hearing individuals who primarily use English, selected at random (n = 429). Logistic regression analyses adjusted for confounders compared the groups on the provision or nonprovision of four routine ED care practices (i.e., laboratories ordered, medications ordered, images ordered, placement of peripheral intravenous line [PIV]) and on ED disposition (admitted to hospital or not admitted). RESULTS: The ED encounters with Deaf ASL users were less likely to include laboratory tests being ordered: adjusted odds ratio 0.68 and 95% confidence interval 0.47-0.97. ED encounters with Deaf individuals were also less likely to include PIV placement, less likely to result in images being ordered in the ED care of ASL users of high acuity compared with English users of high acuity (but not low acuity), and less likely to result in hospital admission. CONCLUSION: Results suggest disparate provision of several types of routine ED care for adult Deaf ASL users. Limitations include the observational study design at a single site and reliance on the medical record, underscoring the need for further research and potential reasons for disparate ED care with Deaf individuals.

Health system use and outcomes of urgently triaged callers to a nurse-managed telephone service for provincial health information after initiation of supplemental virtual physician assessment: a descriptive study.

BACKGROUND: British Columbia's 8-1-1 telephone service connects callers with nurses for health care advice. As of Nov. 16, 2020, callers advised by a registered nurse to obtain in-person medical care can be subsequently referred to virtual physicians. We sought to determine health system use and outcomes of 8-1-1 callers urgently triaged by a nurse and subsequently assessed by a virtual physician. METHODS: We identified callers referred to a virtual physician between Nov. 16, 2020, and Apr. 30, 2021. After assessment, virtual physicians assigned callers to 1 of 5 triage dispositions (i.e., go to emergency department [ED] now, see primary care provider within 24 hours, schedule an appointment with a health care provider, try home treatment, other). We linked relevant administrative databases to ascertain subsequent health care use and outcomes. RESULTS: We identified 5937 encounters with virtual physicians involving 5886 8-1-1 callers. Virtual physicians advised 1546 callers (26.0%) to go to the ED immediately, of whom 971 (62.8%) had 1 or more ED visits within 24 hours. Virtual physicians advised 556 (9.4%) callers to seek primary care within 24 hours, of whom 132 (23.7%) had primary care billings within 24 hours. Virtual physicians advised 1773 (29.9%) callers to schedule an appointment with a health care provider, of whom 812 (45.8%) had primary care billings within 7 days. Virtual physicians advised 1834 (30.9%) callers to try a home treatment, of whom 892 (48.6%) had no health system encounters over the next 7 days. Eight (0.1%) callers died within 7 days of assessment with a virtual physician, 5 of whom were advised to go to the ED immediately. Fifty-four (2.9%) callers with a "try home treatment" disposition were admitted to hospital within 7 days of a virtual physician assessment, and no callers who were advised home treatment died. INTERPRETATION: This Canadian study evaluated health service use and outcomes arising from the addition of virtual physicians to a provincial health information telephone service. Our findings suggest that supplementation of this service with an assessment from a virtual physician safely reduces the overall proportion of callers advised to seek urgent in-person visits.

A scalable approach to determine cervical cancer screening needs among emergency department patients in the United States.

The emergency department patient population is disproportionately under-screened for cancer, making it an optimal environment to promote cancer screening among hard-to-reach populations and those without routine access to primary care. The first step in a cancer screening process is identifying screening eligibility (e.g. age, sex) and need (i.e. due or past due). In an effort to support the scalability of an emergency department (ED)-based cervical cancer screening intervention, we examined the performance of a low-resource approach of determining cervical cancer screening needs among ED patients. A convenience sample of ED patients (N = 2807) was randomized to (a) an in-person interview with human subjects research staff or, (b) a self-administered, tablet computer-based survey for determining cervical cancer eligibility and need. Patients were recruited from a high-volume urban ED in Rochester, NY and a low-volume rural ED in Dansville, NY between December 2020 and December 2022. Results of these approaches were compared for equivalence of method for determining adherence status with screening guidelines and under/over-reporting of screening activity. Nearly identical reported rates of non-adherence with screening were identified across conditions (1.7% absolute difference; Χ21 = 0.96, p = 0.33). Our results demonstrate that a low-resource approach of using a tablet-based self-administered survey to determine cervical cancer screening needs is equivalent to a labor intensive in-person interview approach conducted by trained research staff among ED patients.

Academic and Professional Outcomes of Participants in an Emergency Department Research Associate Program.

OBJECTIVES: Studies have found that participation in emergency department research associate (EDRA) programs is associated with medical school acceptance. However, little is known about the association between EDRA program participation and other academic and professional outcomes. We sought to characterize the academic and professional outcomes of EDRA program participants and their perception of program influence on academic and professional outcomes. METHODS: We conducted a cross-sectional study of University of Rochester EDRA program participants who graduated from the program May 2010 to May 2017. EDRAs were sent a secure, deidentified, survey. Standard descriptive statistics were used to characterize participant demographics and outcomes. National acceptance rates were referenced from sources. RESULTS: A total of 56 graduates completed the survey (64% response rate). Forty (71%) identified as female, 12 (21%) identified as Asian, one (2%) identified as Black or African American, and three (5%) identified as Hispanic or Latino. Acceptance rates to MD programs, DO programs, PhD programs, and master's programs were 88% (22/25), 92% (12/13), 100% (2/2), and 100% (9/9), respectively. Rates were significantly higher compared to national rates (all p < 0.001). Eighty-three percent (30/36 responses) and 74% (37/50) spoke about the EDRA program during postgraduate program and job interviews, respectively, and 78% (35/45 responses) included the EDRA program in their personal statements. Twenty-five percent (14/55) changed their career goals after participating in the EDRA program, of which 36% (5/14) left medicine and 21% (3/14) were undecided and chose to become a physician. CONCLUSIONS: An EDRA program can help develop and support a career in medicine and science. EDRA graduates used their experiences directly in their postgraduate program applications and job interviews. Acceptance rates of EDRA program graduates to postgraduate programs were higher than national averages. An EDRA program can help clarify career goals after program participation.

An Intervention to Increase Uptake of Cervical Cancer Screening Among Emergency Department Patients: Results of a Randomized Pilot Study.

BACKGROUND: Emergency departments (EDs) have the potential to promote critical public and preventive health interventions. Cervical cancer (CC) screening has been a cornerstone of preventive health efforts for decades. Approximately 20% of U.S. women are not adherent with CC screening guidelines-considerably below the U.S. Federal Government's target. ED patients are disproportionately nonadherent with CC screening guidelines. The ED, therefore, is an optimal setting to target women with an intervention that promotes CC screening. OBJECTIVES: To assess the feasibility and potential efficacy of an intervention, grounded in behavioral change theory, to promote uptake of CC screening among ED patients. METHODS: Design: Randomized clinical trial pilot study; Patients: Women aged 21-65 years that were identified in the ED to be nonadherent with CC screening recommendations; Setting: Single center urban academic ED. RESULTS: Among enrolled participants, 355 (79%) were determined to be adherent with screening recommendations and 95 (21%) were determined to be either nonadherent or have uncertain adherence. Among the nonadherent/uncertain group, 47 were randomized to the control condition (referral only) and 48 were randomized to the intervention condition. Thirty-six percent of participants in the control condition received or scheduled screening during the follow-up period. In the intervention condition, 43% received or scheduled screening during the follow-up period-a 19% relative improvement over the control condition. CONCLUSION: This pilot study demonstrates feasibility and preliminary efficacy of a behavioral intervention to increase uptake of CC screening among ED patients.

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.

Aminopyrazole Carboxamide Bruton's Tyrosine Kinase Inhibitors. Irreversible to Reversible Covalent Reactive Group Tuning.

Potent covalent inhibitors of Bruton's tyrosine kinase (BTK) based on an aminopyrazole carboxamide scaffold have been identified. Compared to acrylamide-based covalent reactive groups leading to irreversible protein adducts, cyanamide-based reversible-covalent inhibitors provided the highest combined BTK potency and EGFR selectivity. The cyanamide covalent mechanism with BTK was confirmed through enzyme kinetic, NMR, MS, and X-ray crystallographic studies. The lead cyanamide-based inhibitors demonstrated excellent kinome selectivity and rat pharmacokinetic properties.

Implementation of an Emergency Medicine Research Associates Program: Sharing 20 Years of Experience.

INTRODUCTION: The use of research associates (RA) programs to facilitate study enrollment in the emergency department was initiated during the mid-1990s. The University of Rochester Medical Center (URMC) was an early adopting site for this model, which has experienced considerable growth and development over the past 20 years. METHODS: Our goal was to detail the Emergency Department Research Associates (EDRA) program processes developed at the URMC that has led to our program's sustainability and productivity. These processes, and the lessons learned during their development, can assist institutions seeking to establish an RA program or refine an existing program. RESULTS: Defined procedures for selecting, training, and monitoring EDRAs have been created and refined with the goal of maximizing study enrollment and minimizing protocol deviations. Our EDRA program functions as a paid service center for investigators, and our EDRAs engage in a variety of study-related activities including screening and enrolling patients, administering surveys, collecting bio-specimens, and making follow-up calls. Over the past two years, our program has averaged 222 enrollments/month (standard deviation = 79.93), gathering roughly 25 participants per study per month. CONCLUSION: Our EDRA model has consistently resulted in some of the highest number of enrollments across a variety of recently funded, multi-center studies. Maintaining a high-quality EDRA program requires continual investment on the part of the leadership team, though the benefits to investigators within and outside the department outweigh these costs.

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.

Passive Smoke Exposure and Its Effects on Cognition, Sleep, and Health Outcomes in Overweight and Obese Children.

BACKGROUND: Passive smoke exposure (PSE) may be a risk factor for childhood overweight and obesity and is associated with worse neurocognitive development, cognition, and sleep in children. The purpose of the study is to examine the effects of PSE on adiposity, cognition, and sleep in overweight and obese children using an objective measure of PSE. METHODS: Overweight or obese children (n = 222) aged 7-11 (9.4 ± 1.1 years; 58% black; 58% female; 85% obese) were recruited from schools near Augusta, Georgia, over the course of the school year from 2003-2006 for a clinical trial, with data analyzed in 2009-2010. Passive smoke exposure was measured with plasma cotinine. Health, cognitive, and sleep measures and parent report of smoke exposure were obtained. RESULTS: Overweight and obese children with PSE had greater overall and central adiposity than nonexposed overweight and obese children (p < 0.03). However, PSE was unrelated to prediabetes, insulin resistance, or visceral fat. PSE was linked to poorer cognitive scores (p < 0.04) independent of adiposity, but was not related to sleep-disordered breathing. CONCLUSIONS: PSE is associated with fatness and poorer cognition in children. Tailored interventions that target multiple health risk factors including nutrition, physical activity, and tobacco use in children and families are needed to prevent adverse health outcomes related to tobacco use and obesity.

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.

Expanding Telemedicine to Include Primary Care for the Urban Adult.

This article describes the effective use of telemedicine for the urban adult patient. A successful pediatric telemedicine program was expanded to include care for adults. The pilot program resulted in high levels of patient satisfaction, decreased loss of work time, and decrease in inappropriate use of the emergency department.