Altogether, 6,511 telemedicine visits were completed via Health-e-Access by the end of the Primary Care Phase. Analysis assessing visit completion and continuity focused on the 2,554 visits of this phase, comprising 39.2% of all visits as of April 30, 2008.
Among Primary Care Phase visits, 82.0% were for children with a practice located in the city and 18.0% were for children with a practice located in the suburbs. Altogether, 61.1% of visits were for children whose practice was participating. Thus, 61.1% (1,560) was the proportion of visits with potential to be continuity visits. This proportion differed greatly by location of child's practice. For children with a city practice, 70.5% of telemedicine visits could have been continuity visits, whereas for children with a practice in the suburbs, this proportion was 19.1%. Insurance for the 2,554 Primary Care Phase visits included Medicaid Managed Care, 47.1%; fee-for-service Medicaid, 27.6%; commercial, 15.7; Child Health Plus, 4.2%; and uninsured or missing insurance information, 5.5%.
Among the 2,554 telemedicine visits attempted, 2,475 (96.9%) were completed by 47 providers from the 10 participating practices, leaving 79 (3.1% of attempted) not completed. Reasons for noncompletion might be useful information for quality improvement and replication initiatives. These reasons were categorized based on (1) an explicit response to a standard query in the Health-e-Access electronic medical record (EMR) or on (2) record review by provider-investigators experienced in telemedicine (K.M., C.t.H.). When a provider indicated in the telemedicine software that the visit was not completed (e.g., sent to ED, sent to office), a pop-up window presented several response options that might explain why. Most commonly (72.2%, ), providers attributed noncompletion to limitations of the Health-e-Access model, including a need for hands-on physical examination (29.1%), a need for treatment that could not be provided at a patient site (29.1%), and need for tests or imaging that were not included in the model (13.9%). Suboptimal performance of the Health-e-Access model (images not adequate, technical failure, stethoscope sounds inadequate, history inadequate) accounted for 17.7% of visits not completed. For the five noncompleted visits in which the provider failed to specify a reason, provider-investigators judged that they would have been confident in diagnosis and treatment decisions.
Reasons for Noncompletion of Visits
In addition to the 2,554 telemedicine visits attempted during the Primary Care Phase, 91 health problems came to the attention of the Health-e-Access Scheduler but were not attempted (i.e., were abandoned). Thus, among 2,645 potential visits (2,554 plus 91) during this phase, 3.4% were abandoned. Among abandoned visits, reasons included: parent picked up the child before telemedicine assistant completed information capture, 25.0%; telemedicine assistant unable to acquire some necessary clinical information (e.g., unable to remove cerumen, child uncooperative), 15%; administrative problem (e.g., unable to contact parent for consent), 13.3%; technical problem, 11.7%; Health-e-Access Scheduler determined that problem was beyond capacity of model, 10.0%; parent indicated problem already being treated, 6.6%; and five other categories, 18.3%.
For the 1,557 telemedicine visits by children with a participating provider, continuity averaged 83.2% among the 10 practices (range, 28.1–92.9%). Continuity for the five city practices averaged 85.2% (range, 41.2–92.9%), whereas that for the five suburban practices averaged only 49.4% (range, 28.1–92.3%). Continuity correlated strongly with the number of visits provided; city practices averaged 294 visits (range, 77–551), whereas suburban practices averaged 17 (range, 5–32).
For the 16.8% (n
261) of visits not seen by a continuity provider, the Scheduler documented reasons () why no provider from the child's own practice saw the child for 243. The most prevalent (96, 39.5%) reason was that a provider designated by the practice to provide telemedicine visits was not available. For 41 of these 96 noncontinuity visits, the Scheduler used unavailability (e.g., vacation) of the University of Rochester Medical Center nurse practitioner as an opportunity to involve other primary care practices in doing telemedicine visits. Other common reasons were as follows: practice indicated it was too busy (19.3%); practice refused because the child's insurance did not pay for telemedicine visits or the child had no insurance (17.7%); time of the visit request was beyond the end-of-day cutoff chosen by the practice (11.1%); and technical problems at the provider site (7.0%). All but one practice provided telemedicine visits regardless of insurance type.
Reasons for Noncontinuitya Visits
Survey of Provider Perceptions and Opinions
The mean (±standard deviation) number of visits managed per provider was 53.2 (±149.6), 24 providers managed 10 or more visits, and 12 managed 50 or more. Among the 47 providers in the 10 participating primary care practices, 40 responded to the provider survey. Most survey items applied only to the 30 (23 pediatricians, 6 pediatric nurse practitioners, and 1 physician assistant) that had completed at least one telemedicine visit at the time the survey was distributed (February 1, 2007).
As shown in , providers generally found the telemedicine software easy to learn (mean score was 3.8, with 5 indicating “very easy”). Technical problems interfered with completion of telemedicine visits less often than “sometimes” (mean, 2.4). Providers estimated the mean time required for decision making with telemedicine visits was 10.3
min, a period that they thought was slightly less (mean was 2.9, with a value of 3 indicating “about the same”) than for similar office visits. In contrast, they estimated a mean total time for completing the entire visit via telemedicine (including documentation and contacts with pharmacy, parents and telemedicine assistants) of 19.8
min. Providers thought that total time was longer (mean was 3.5, with 3 indicating “about the same”). Among the six providers who had completed 50 or more telemedicine visits, mean estimates for time involved in decision making and total time were 7.2 and 15
min, respectively. The mean score regarding ability of the practice to use telemedicine to reduce time to complete illness visits (2.7) indicated a consensus of no timesavings.
Although providers generally believed that they received information that was complete enough, and they generally felt comfortable collaborating with telehealth assistants, on average they did not feel as confident in diagnoses made via telemedicine as with usual care (mean, 2.4). Overall, however, 46.3% of providers were at least as confident of diagnoses made via telemedicine. And among the six providers who had completed 50 or more telemedicine visits, 83.3% were at least as confident of diagnoses made via telemedicine as in person.
Interestingly, although providers interacted directly with parents either via telemedicine or telephone for only 9.8% of the completed visits, confidence that provider communication met parent needs was relatively high (mean, 3.7). Providers had no strong opinions on their ability to use Health-e-Access to reduce their costs (mean, 2.8).
Likewise, providers had no strong opinions on the level of interest in telemedicine by their practice colleagues (mean, 3.0). Providers believed that fair reimbursement for telemedicine visits was the same as for usual visits (mean, 3.0), and that fair payment to the originating site for their part in completing a telemedicine visit was $11.50 (or 26% of an assumed total reimbursement of $45). Moreover, most (76.3%) believed that it would be fair if payment to the originating site reduced their own reimbursement commensurately.