Telemedicine and the Patient-Centered Medical Home

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Telemedicine and the Patient-Centered Medical Home Neil Herendeen, MD, MMM; and Prashant Deshpande, MD, FAAP Abstract Neil Herendeen, MD, MMM, is Associate Professor of Pediatrics, Golisano Children’s Hospital, University of Rochester Medical Center. Prashant Deshpande, MD, FAAP, is Attending Pediatrician, Advocate Hope Children’s Hospital; Assistant Clinical Professor of Pediatrics, Midwestern University. Address correspondence to: Neil Herendeen, MD, MMM, Box 632, 601 Elmwood Avenue, Rochester, NY 14642; email: [email protected]. Disclosure: The authors have no relevant financial relationships to disclose. doi: 10.3928/00904481-20140127-07

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Imagine an environment where health care coordination is seamless; where the pediatricians and their care teams could significantly reduce the time it takes to communicate and transfer the information between physicians, patients, and their families. Imagine a situation where unnecessary referrals and investigations are avoided, saving costs and anxieties for the patients. Welcome to the world of telemedicine and a patient-centered medical home (PCMH). Comprehensive health care delivered in the most efficient manner with the least expense is the cornerstone of these concepts. The concept of PCMH was first introduced in 1967 by the American Academy of Pediatrics (AAP) Council on Pediatric Practice in the book , Standards of Child Health Care. The medical home concept originally referred to one central source of medical records for children with special health care needs. During the past 4 decades, this concept has transformed beyond data entry to methods of delivering the best quality of care for all children. In 2007, a joint statement by the AAP, the American Academy of Family Physicians, the American College of Physicians, and the American Osteopathic Association endorsed the PCMH concept.

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magine an environment where health care coordination is seamless; where the pediatricians and their care teams could significantly reduce the time it takes to communicate and transfer the information between physicians, patients, and their families. Imagine a situation where unnecessary referrals and investigations are avoided, saving costs and anxieties for the patients. Welcome to the world of telemedicine and a patient-centered medical home (PCMH). Comprehensive health care delivered in the most efficient manner with the least expense is the cornerstone of these concepts. The concept of PCMH was first introduced in 1967 by the American Academy of Pediatrics (AAP) Council on Pediatric Practice in the book , Standards of Child Health Care. The medical home concept originally referred to one central source of medical records for children with special health care needs.1 During the past 4 decades, this concept has transformed beyond data entry to methods of delivering the best quality of care for all children. In 2007, a joint statement by the AAP, the American Academy of Family Physicians, the American College of Physicians, and the American Osteopathic Association endorsed the PCMH concept.2 The model by the National Committee for Quality Assurance is the most widely accepted model in the country. It includes the following components: • Enhanced access to care through expanded hours and electronic communication. • Long-term partnerships between patients and clinicians, not a series of sporadic, hurried visits. • Clinician-led, teamcoordinated care, especially for prevention and chronic conditions. • Medical home-coordinated care from other clinicians

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and community resources, as needed. • Patient participation in decisions about their care to get better results. The concept of family-centered care is a crucial component of the medical home. In the 1800s, medical care was delivered by doctors making house calls, which may have been the ultimate in family centeredness but lacked in treatment options. In the 1900s, sophisticated medical treatments and diagnostic equipment moved the site of patient care to hospitals and doctor offices with a very “provider-centered” approach. With the latest advances in medical technology and broadband communication, telemedicine has allowed us to

Telemedicine offers new options for evaluating and treating children with both acute and chronic illnesses. come full circle with high-quality, patient-centered virtual house calls being provided in homes, schools, and workplaces. The Institute of Medicine defines patient-centered care as “providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.”3 It is hard to imagine a more respectful or responsive approach than having a technician bring a telemedicine unit directly to you to get the health care you need. Children younger than 15 years of age in the United States make an estimated 71 million office visits annually for acute problems. These visits account for 49% of all office visits for children and represent the leading cause of parents missing time from work.4 Fewer than 50% of working women in the United States believe they can avoid

conflict between family and work responsibilities the next time one of their children is sick.5 Clearly, the social and economic burden associated with caring for ill children is substantial, but there may be opportunities to rethink how and when children receive medical care. Telemedicine offers new options for evaluating and treating children with both acute and chronic illnesses with potential efficiencies for patients, parents, and providers. HOW TELEMEDICINE CAN ENHANCE THE PCMH Patients and physicians alike benefit when a relationship is established and continued over a prolonged time period. Traditionally, patient care has been rendered in physician offices, which will continue; however, telemedicine allows the physician to connect to the patient wherever he or she might be. Physicians use telemedicine to link with their patients in child care centers, preschools, schools, emergency departments (EDs), and juvenile detention facilities. Children need not leave day care for a minor illness. This will also save parents from taking time off of work and potentially losing wages. Hospital EDs are often inundated by patients whose minor illnesses, like eczema or pharyngitis, could have been cared for during the day so that a doctor’s return-to-school excuse can be obtained. No longer do children need to receive care in a busy ED, nor do they have to see a physician they may not be familiar with. It is estimated that every, year billions of dollars are wasted on unnecessary tests and imaging studies only because the patient’s medical history was unavailable to the health care provider.6 Telemedicine connectivity holds the promise to reduce these inefficiencies and allow patients to be cared for when and where they need it by providers they know and trust. Traditionally, patients who need subspecialty appointments have received Healio.com/Pediatrics | e29

CM E them by traveling to a distant tertiary care center. Such referrals will need to continue if subspecialty procedures are needed. It would be ideal, however, if a patient could receive some of his or her referrals and a part of their subspecialty care from the primary care doctor’s office. The primary care physician (PCP) or a nurse could establish a telemedical link to the subspecialist’s office; this is already being done in telepsychiatry, telecardiology, and teleradiology. The PCP or nurse is then able to step into his or her own office where the consult is being done and discuss the subspecialist’s findings with the subspecialist directly.7By connecting with the subspecialist, the PCP has the ability to prevent unnecessary referrals by the subspecialist who otherwise might not have realized that the PCP could manage a particular medical problem in-house. As a result, the PCP no longer has to wait for a referral letter from the subspecialist to effectively manage and coordinate the medical care. THREE CATEGORIES OF TELEMEDICINE 1. Electronic medical records and patient portals: Many of the current comprehensive electronic medical record (EMR) systems have a patient portal that allows patients to view portions of their medical records and test results, and to send secure messages directly to their medical home personnel. Establishing goals for optimal health and offering self-management tools are at the heart of the patient-centered medical home movement, and having access to one’s own medical information has been identified as a key component. 2. Conventional telemedicine: Episodic illness care has been shifting to urgent care centers and retail-based centers offering convenient access, but many pediatricians are concerned with the effect on quality and continuity. Telemedicine can recapture those lost visits e30 | Healio.com/Pediatrics

with the convenience of a virtual house call. Different programs have varying levels of diagnostic ability with their telemedicine connection, depending on the peripheral attachments used. At the most basic level, telephone triage can be enhanced with digital photographs or video conferencing to provide a picture

Common barriers to telemedical care include reimbursement issues and medico-legal ramifications. to go along with the history. Currently there is no reimbursement for this level of care, but some providers find the efficiency and time savings is worth the extra steps needed to establish a secure connection to communicate with their patients. Relatively simple direct-topatient telemedicine care has already been provided by physical therapists, speech therapists, nutritionists, behavior specialists, psychologists, and child psychiatrists using a variety of commercially available videoconferencing software platforms. 3. Technology-enhanced telemedicine: Use of enhanced medical online consults with video consulting and availability of medical gadgets at the point of care, such as day cares and schools, is becoming more widespread. A growing number of medical devices can now be connected to standard telemedicine equipment, including digital stethoscopes, otoscopes, ophthalmoscopes, radiograph readers, microscope attachments, or high-resolution examination cameras (for visualizing fine detail). Many of these attachments simply plug into the USB port of a standard computer. In one study, up to 85% of officebased pediatric illness visits could be replicated with a technology-enhanced telemedicine model that included a

high-resolution camera, electronic stethoscope, and digital otoscope.8 PCPs can also enhance their case management role by connecting patients in their office to pediatric subspecialists who may be otherwise inaccessible. Advanced care has been provided via telemedicine links to pediatric subspecialties for all types of routine and emergent situations. Advantages of teleconsultation include the PCP’s ability to ensure that all of the patient and referring provider’s questions are answered, that treatment plans are implemented immediately, and that ongoing follow-up can be provided by the most appropriate team member. For subspecialists in limited supply, such as those in the fields of genetics; child abuse; pediatric neurology; or endocrinology, telemedicine may allow them to cover an entire state or region without leaving their medical center, allowing patients to receive the best care without leaving their community. Case management of a child with special health care needs is often cited as a time-consuming service that is inadequately reimbursed. Quality standards recommend follow-up visits every 3 months for children with stable asthma, attention deficit disorder, or obesity, and even more frequent visits if medications are being changed. Working parents often find these visits difficult to attend, causing missed opportunities to fine-tune management or give preventive immunizations. Telemedicine can help providers meet pay-for-performance measures that are becoming more commonplace. Common barriers to telemedical care include reimbursement issues and possible medico-legal ramifications; however, payment represents the most important barrier for telemedical care in the PCMH. State-to-state variation in telemedicine reimbursement policies precludes an extensive discussion in this article, but progress continues to be made. Each year, more states are requiring tele-

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CM E medical reimbursement from insurance companies.9 Each state’s payment policy can be found on the Center for Telehealth and e-Health Law’s website: http://ctel. org/expertise/reimbursement. When providing online consults, practices need to ensure that patients are aware of the service and related fees. Practices should monitor which health plans cover and pay for online consults and notify patients so they are aware of any out-of-pocket expenses. Several insurance carriers, including Aetna, Cigna, WellPoint and Blue Shield of California, cover online consultations in select markets. These reimbursement services change on a frequent basis; therefore, providers are advised to check with insurance carriers for the most upto-date information.10 MEDICO-LEGAL AND HIPAA COMPLIANCE ISSUES With all new technologies and changes in health care delivery come legal and regulatory challenges. New definitions of what constitutes a “face-toface” encounter, who can be involved in a telemedicine visit on each end of the computer, which state has jurisdiction for delivery of patient-centered care, and what devices are approved to maintain confidentiality to meet HIPAA expectations are all factors being debated and addressed within the medical community and state legislatures. The diffusion of new innovations is a slower process in the medical field than it is in the technology world, adding to frustrations of providers, patients, and industry. New health care delivery models, such as accountable care organizations, add to the overall uncertainty, which further delays the acceptance of proven telemedicine applications. However, with guarded optimism and steady perseverance, these barriers to telemedicine implementation are being addressed, paving the way for technology-enhanced, patient-centered care.

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The elusive financial case for telemedicine is starting to be quantified. The Center for Information Technology Leadership put together a team of thought leaders to look at the costs and benefits of expanding telemedicine throughout the U.S. Potential savings were derived from ED avoidance, reduced admissions from the ED, reduction in referrals from ED, and reduction in unnecessary / duplicate tests. Other potential values include increased access to care, provider education, improved quality of care, reduced wait times for outpatient consultation, increased productivity, and reduction in patient travel expenses. In a head-to-head comparison of inperson and telemedicine evaluations of acute illness visits in a pediatric practice, telemedicine was shown to safely and accurately diagnose more than 92% of the conditions that children presented with on a daily basis.11 Satisfaction surveys of patients and providers ranked telemedicine high for convenience, quality of interaction, clarity of images, and confidentiality of information being discussed. After just one telemedicine encounter, 98% of parents of preschoolers said they would choose a child care center that offered telemedicine if given a choice over a similar center without telemedicine services.13 Absence due to illness from child care in Rochester, NY, was decreased by 63% after telemedicine was implemented in five inner-city child care centers.12 On average, parents reported a savings of 4.5 work hours that would have otherwise been lost if telemedicine had not been available to their child.11 Utilization studies have shown a slight increase in overall use of health services when telemedicine access was made available in elementary schools and child care centers during the day.8 This may represent an increase in nonessential convenience driven visits, or more likely, fulfillment of a previously

unmet need (ie, underutilization of health care in a vulnerable population). The cost associated with this slight increase in primary care visits was more than offset by a 22% reduction in costly emergency room visits for children.13 Telemedicine has been called the “Swiss Army knife” of medical care because its ability to enhance patient care is limited only by our imagination. PCMHs that utilize telemedicine can provide better care than PCMHs that have not yet taken advantage of the tools that telemedicine provides. Physicians and their patients will be well-served by adding telemedicine to their “toolbox.” REFERENCES 1. Council on Pediatric Practices, American Academy of Pediatrics. Pediatric records and a “medical home.” In: Standards of Child Health Care. Evanston, IL: American Academy of Pediatrics; 1967:77. 2. American Academy of Pediatrics Ad Hoc Task Force on Definition of the Medical Home: The Medical home. Pediatrics.1992;90(5):774. 3. Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Vol. 6. Washington, DC: National Academy Press; 2001.4. Herendeen NE, Schaefer GB. Practical applications of telemedicine for pediatricians. Pediatr Ann. 2009;38(10):567-569. 4. Salganicoff A, Ranji U. A Women’s Health Care Chart Book; Key Findings from the Kaiser Women’s Health Survey. The Henry J. Kaiser Family Foundation. Available at: kaiserfamilyfoundation.files.wordpress. com/2013/01/8164.pdf. Published May 2011. Accessed December 28, 2013; 37. 5. Smith M. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Institute of Medicine of the National Academies. Available at: http://www.iom. edu/Reports/2012/Best-Care-at-Lower-CostThe-Path-to-Continuously-Learning-HealthCare-in-America.aspx. Published September 6, 2012. 6. Deshpande PG, Burke BL Jr. Telemedicine a vital tool for patient centered medical home. AAP News. 2013;34(8):30. 7. McConnochie KM, Conners GP, Brayer AF, et al. Effectiveness of telemedicine in replacing in-person evaluation for acute childhood illness in office settings. Telemed J E Health. 2006;12(3):308-316. 8. Dehnel PJ, Rappo PD. Online consults can provide revenue, improve access to medical home. AAP News. 2013;34(8):28.

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CM E 9. McConnochie KM, Conners GP, Brayer AF, et al. Differences in diagnosis and treatment using telemedicine versus in-person evaluation of acute illness. Ambul Pediatr. 2006;6(4):187-195; discussion 196-197. 10. C herry DK, Burt CW, Woodwell DA. National Ambulatory Mecial Care Survey,

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2001 Summary. Available at: http:// www.cdc.gov/nchs/data/ad/ad337.pdf. Published August 11, 2003. Accessed December 28, 2013. 11. McConnochie KM, Wood NE, Kitzman HJ, et al. Telemedicine reduces absence resulting from illness in urban child care:

evaluation of an innovation. Pediatrics. 2005;115(5):1273-1282. 12. McConnochie KM, Tan J, Wood NE, et al. Acute illness utilization patterns before and after telemedicine in childcare for inner-city children: a cohort study. Telemed J E Health. 2007;13(4):381-390.

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