1. Health-e-Access: Improving Care for Rochester’s Vulnerable Children Kenneth McConnochie, MD, MPH ken_mcconnochie@urmc.rochester.edu

2. Research and Program Funding US Dept of Commerce Technology Opportunities Program Robert Wood Johnson Local Initiative Funding Partners Program Rochester Area Community Foundation Maternal and Child Health Bureau R40 MC03605 Agency for Healthcare Research and Quality R01 HS15165 Disclosure N. Herendeen, K. McConnochie and N. Wood held equity positions in TeleAtrics, Inc., a vendor of telemedicine equipment, hosting and support services

3. Health-e-Access when and where you need it by people you know and trust Providing Healthcare …

4. Problem Large socioeconomic and city- suburban disparities in morbidity burden and in access to care.

5. Rochester’s Inner City Children: Sociodemographic Comparisons

6. Hospitalization Among Rochester’s Children < 24 months old 1990 – 1991 Areas defined by zip codes Relative Risk: rates compared to baseline rate Baseline (1.0) = Pittsford Highest rates = 14605, 14621 Inner city relative risk > 5.0

7. Greater Morbidity Burden or Lower Utilization/Admission Threshold? 5-fold greater admission rate for asthma Asthma severity indicators demonstrate no city vs. suburban difference in: –Severity at time of admission –Severity during hospital stay Conclusion: Much higher severity adjusted rates (much greater morbidity burden)

8. Working Women’s Options

9. Health-e-Access as a Solution Overview - how it works Brief history Service provided and it impact

10. Childcare/School Clinician site secure web connection Video conference window - view at clinician site Video conference window - view at child site

11. Diagnostic Quality Observations

12. Service Provided First telemedicine visits May 2001 > 6500 visits since then 96% completion rate (Among visits initiated, 96% have diagnosis and management decisions and treatment based entirely on telemedicine visits.) 4701 children enrolled in Health-e-Access at any time Among children with a participating primary care practice, 83% continuity. (Visit completed by that practice.)

13. Child Care Absence Due to Illness Before and After Telemedicine Days Absent Due to Illness* * Absence from child care due to illness, in mean days absent per week per 100 registered child-days. Jan July Dec After Before Net impact of telemed: 63% reduction Pediatrics May 2005

14. 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 per telemed visit

15. Impact on Pattern of Care for Acute Illness 6 year cohort study Observations from May 2001 through October 2007

16. Children and Child-Months Studied

17. Comparability: Control vs. Intervention Groups Optimal match Intervention and Control child-months differ only on availability of telemedicine Actual match Perfect match on age, sex, month of year (illness season), zipcode of residence, socioeconomic area, insurance type School-age children – comparable exposure to peers Preschool children – 100% of intervention children in large childcare programs. Less so for control children. This introduces a conservative bias (against effect of telemed) when looking at overall utilization.

18. RESULTS: Attributes of Child-Months Studied

19. RESULTS: Telemed Impact on Utilization Patterns Annual visits per 100 children Telemed ED Office Illness 3.3% fewer office visits for illness 23.7% fewer ED visits 22.9% more illness visits overall

20. RESULTS: Fewer ED Visits Annual ED visits per 100 children 23.7% reduction

21. IMPLICATIONS FOR PAYERS: Break-Even Ratio Units of: Cost - overall illness visits increased Effectiveness - ED visits avoided Unit Values: Cost indicator - $51 (mean payment per telemed visit) Effectiveness indicator - $355 (mean payment per ED visit avoided) Break-Even Ratio: 355 ÷ 51 = 7:1 (visits increased to ED visits avoided) Observed Ratio: 5:1

22. Health-e-Access Summary: Impact of Health-e-Access Large reduction in absence due to child illness (63% for inner city child care) 96% of visits completed 87% continuity 23.7% drop in ED visits 22.9% increase in all visits for illness Net cost reduction by replacing expensive ED visits with low-cost primary care (via telemed)

23. Social and economic benefits accrue from extraordinary access Reduced economic burden of health services IMPLICATIONS

24. CONSERVATIVE BIAS Exclusion of short-term users from analysis Estimate for ED-related payment is low Telemedicine not available evenings, weekends, holidays, school vacations.

25. PATIENT-TO-PROVIDER TELEMDCINE: Next Steps - Organizational Expansion of insurance reimbursement beyond limits of the Demonstration Project Reimbursement for telemedicine “infrastructure fee” Mobile telemedicine units Telephone management as the gateway to telemedicine After-hours neighborhood access sites Health-e-Access lines of communication

26. PATIENT-TO-PROVIDER TELEMDCINE: Next Steps - Programmatic Telemedicine access for developmentally challenged children and adults Teledentistry Behavioral health Chronic illness prevention and management Primary care for deaf population Elder care ED diversion through EMS-based mobile telemed units

27. Thanks ! Kenneth McConnochie, MD, MPH ken_mcconnochie@urmc.rochester.edu

28. Under-Utilization by Inner City Children?

29. What does it take to keep Health-e-Access going? Components of the infrastructure Technical Personnel – triage role, trouble shooting, roaming telehealth assistants (roaming CTAs) Cost of the infrastructure