1. Economic Model of Organizational Architecture* to Guide Design and Performance Evaluation in an Urban, Primary Care Telemedicine Network Kenneth M. McConnochie, MD, MPH * Brickley J, Smith C, Zimmerman J. The economics of organizational architecture. J Applied Corp Finance 1995;20:19-31

2. What makes this an economic model? Essence of economics – theory of values how individuals make choices

3. What’s this got to do with HIT? Primary challenge = organizational innovation Adopting and integrating new technology requires change in individual and organizational roles and responsibilities

4. What’s this got to do with evaluation? Evaluation - an essential component of innovation strategy Primary objective - to demonstrate use of model to guide evaluation strategy

5. Health-e-Access: Health, Healthcare and Social Problems Addressed Marked socioeconomic disparities in childhood morbidity burden. More than half of US pre-school children spend time in child care. Rates of common acute illness are increased in child care. Illness in childcare accounts for 40% of work absence for parents using child care. 20% - 70% of pediatric visits to the emergency department are for non-urgent problems.

6. Short Story … about a long-running nose 1 week later

7. Organizational Problem Usual Healthcare Every child has a primary care “medical home” Physician(s) controls the organization directly versus Health-e-Access Many childcare sites Many different primary care offices No telemedicine utility service (yet)

8. Conceptual framework – the 3-legged stool (1) Incentives (2) Decision rights (3) Performance evaluation

9. Health-e-Access Stakeholders Parent and Child Private Insurance Organizations State and County Government, Medicaid Industry Primary Care Physicians Childcare Programs

10. Stakeholders and their Decision Rights Parent Use of telemedicine services vs. traditional alternatives Choice of insurance company and plan Industry Payment for telehealth services, if self-insured Qualify/cover telehealth services in dependent care or healthcare components of Flexible Spending Accounts Negotiate health insurance premiums, covered services Change health insurance company

11. Decision Rights - continued Health Insurance organizations - Private Coverage of telemed services (yes/no) Type of coverage (e.g., fee-for-service, capitated) Reimbursement rates for telemed services Sponsorship of telemed Health Insurance organizations, Public; County & State Government Licensing new types of healthcare workers Administrative approval of reimbursement for new services (i.e., Medicaid Managed Care) Support adoption of telehealth services (vs. ignore potential) Legislation that requires insurance reimbursement for telehealth Primary Care Physician Provide/refuse telehealth services Promote/obstruct adoption of telehealth services, e.g., through participation on insurance organization committees that recommend coverage of new services

12. Dominant Stakeholders Health Insurance Organizations Physicians

13. Stakeholders and their Incentives Parent and child Improve child health and development Increase sense of security Increase access to healthcare Minimize symptom severity and duration in child Minimize disruption to usual activities/responsibilities family from child illness Minimize out-of-pocket costs to family Improve financial status through steady employment and advancement Maintain a “medical home”

14. Incentives - continued Industry Minimize work absence Maximize employee productivity - “presenteeism” Reduce healthcare costs

15. Stakeholders and Performance Evaluation Absence due to illness Perceived benefits Parent satisfaction Childcare program support Parents, Childcare Programs, Industry

16. Absence Due to Illness Before and After Health-e-Access Days Absent Due to Illness* * Mean days absent per week per 100 registered child-days. Jan July Dec After Before Net impact : 63% reduction (Pediatrics May 2005)

17. Parent Satisfaction % of families Based on interviews with parent after first use of telemedicine. N = 229. ED Allowed to stay at work* Would choose child care with telemed over one without Saved parent trip to: Primary Care Physician After hours Yes * Estimated time saved = 4.5 hours (SD 2.2) per telemed visit

18. Utilization – Preliminary Data

19. Utilization Predicted by Telemed: Bivariate Analysis

20. Utilization of Any Site for Illness: Other Determinants Sex Insurance type Child care site Primary care practice Child’s age

21. Logistic Regression: Telemed Effects on Utilization

22. Expanded Program 22 child sites, 8500 total children eligible –7 current city child care programs –5 city elementary schools –5 suburban elementary schools –5 suburban child care programs (SE suburbs) 5 urban practices 6 suburban practices (SE suburbs) Insurance reimbursement for demonstration project telehealth visits