Rochester study shows telemedicine could reduce pediatric ED visits
Physicians remain skeptical, saying most visits are necessary
Telemedicine has long been recognized for improving access to care as well as access to specialist expertise, particularly in rural facilities. Now, in an unpublished study just completed in Rochester, NY, the lead author says it also can offer a possible solution to overcrowding when it comes to pediatric ED patients, many of whom, he asserts, easily could be treated by a primary care physician.
The report, which has not yet been published, analyzed data from 2006 and tracked all pediatric visits to the city's largest ED, at the University of Rochester Medical Center. The researchers then studied more than 6,000 telemedicine visits during the same period. The ED visits were categorized into ailments that always could be managed by telemedicine; those that were usually treated through telemedicine; and conditions that usually could not be treated with telemedicine. Results showed that nearly 30% of ED visits fell into the first category and could always be treated with telemedicine. If those problems had all been handled through telemedicine, the research concludes, Rochester would have had at least 12,000 fewer pediatric ED visits in 2006.
Many, if not most, pediatric-age ED visits are for nonemergency problems, says Kenneth McConnochie, MD, MPH, founder of Health-e-Access, the University of Rochester Medical Center telemedicine program that uses the Internet to connect pediatricians with sick children at inner city child care centers. "There are a number of studies showing that between 25% and 75% of ED visits for kids are nonemergency visits," he notes. "If you accept that as a bad thing, it's a crazy use of resources."
EDs have to be prepared to manage the most severe illness and injury episodes, McConnochie says. "They are set up to manage that, and they do it very well," he says.
Subacute visits, he adds, take precious time away from the ED staff, McConnochie says. "The average time to treat a sore throat, ear infection, or pink eye, is about 4.5 to six hours, according to what parents told us, and sometimes as long as 16 hours," he says. "We can do it in a telemedicine site in no time."
Drilling further down into his study's statistics, McConnochie says that for kids with telemedicine available in their day care center or elementary school, ED use dropped 22% based on a matched comparison of age, gender, socioeconomic status, and season of the year. "For every telemedicine child, they matched them month for month with children of the same age, gender, zip code, and so forth, who did not have access to telemedicine," he says. ED use was down 22%, McConnochie says. "That's good for payers, good for society, and ultimately good for the industry," he says.
But not everyone draws the same conclusions. "Telemedicine will do little to relieve pediatric ED overcrowding," claims Gregory P. Conners, MD, MPH, MBA, professor and interim chair, emergency medicine, University of Rochester Medical Center. "Telemedicine is most appropriate for minor visits, which we can usually manage in the ED fairly efficiently." Overcrowding comes from requiring EDs to manage inpatients or from receiving multiple simultaneously very sick patients, he says.
Ironically, Conners has collaborated with McConnochie on earlier studies and believes in the ability of telemedicine to deliver quality care. "We took kids who were sick and came for visits and examined them twice — once in person, and once by telemedicine," he recalls. "We found very good agreement between the in-person exam and the telemedicine; the care was just as good."1,2
But quality is not the issue in contention, Conners maintains. What he disputes is the fact that many pediatric ED visits are unnecessary "We in Rochester have great pediatric primary care, and yet we still get a certain number of children each day who come to the pediatric ED because of pinkeye or the equivalent, especially outside of the usual Monday-Friday daytime," he says. "As research in Rochester and other places has shown, if you ask parents why they brought the child to the ED, they often will tell you they were directed there, either by someone representing their primary care office — often a nurse or someone else in the office, sometimes following a written protocol — or a well-intentioned family member or neighbor."
Alternatively, he adds, parents often are unable to get to the doctor's office because there were no short-notice visits available, or they were at work or otherwise unable to get in during the limited hours offered by many primary care practices.
- McConnochie KM, Conners G, Brayer A, et al. Effective-ness of telemedicine in replacing in-person office visits for acute childhood illness. Telemed e-Health 2006; 12:308-316.
- McConnochie KM, Conners G, Brayer A, et al. Differences in diagnosis and treatment using telemedicine versus in-person evaluation of acute illness. Ambul Ped 2006; 6:187-195.
For more information on telemedicine and pediatric emergency care, contact:
- Gregory P. Conners, MD, MPH, MBA, Professor and Interim Chair, Emergency Medicine, University of Rochester (NY) Medical Center. Phone: (585) 463-2939.
- Kenneth McConnochie, MD, MPH, Founder, Health-e-Access, University of Rochester Medical Center. Phone: (585) 273-4119.
Is telemedicine too limited for ED use?
Although a recent study at the University of Rochester (NY) seems to indicate that telemedicine could eliminate many pediatric ED visits, a pediatric ED physician with extensive experience with telemedicine believes that its applications are not broad enough to have a significant impact on ED overcrowding.
"Our group actually worked with telemedicine as far back as 10 years ago," says Michael Gerardi, MD, FAAP, FACEP, director of pediatric emergency medicine and an emergency physician at Morristown (NJ) Memorial Hospital. "I think we are looking for a solution [to overcrowding], but this is not it."
While calling the Rochester research "a good, novel study," Gerardi adds that it paints a picture of parents of telemedicine patients as people who tend to use doctors more — a bunch of 'nervous Nellies' who were coming to a doctor for nonemergency cases."
But many parents don't do that, he says. "They may think the patient really does have meningitis, or maybe they have abdominal pain, and you can't asses that with telemedicine," he notes.
Gerardi says he is doing more than just offering an opinion. "I worked telemedicine, and you certainly cannot diagnose otitis media unless the kid is really cooperative, and the only way to diagnose UTI [urinary tract infection] is to have a urine sample," he notes. Those diagnoses don't take a great deal of provider time, he adds, "but the kids need to be checked in person."
However, Gerardi says, he is not totally dismissing the potential use of telemedicine in regard to pediatric emergency medicine. "In the right hands of a big clinic like Kaiser [Permanente], which has lots of resources, you could pull some utility out of it," he notes.
For more information on the limits of telemedicine, contact:
- Michael Gerardi, MD, FAAP, FACEP, Director of Pediatric Emergency Medicine, Morristown (NJ) Memorial Hospital. Phone: (973) 464-3351.
Are 'televisits' a threat to EDs?
A recent study by the University of Rochester (NY) indicates that not only would the use of telemedicine reduce "unnecessary" pediatric ED visits, but it also would save parents and insurance payers a significant amount of money. The reason? The reimbursement rate for telemedicine visits is about one-seventh that for a similar ED visit.
At the University of Rochester Medical Center, Health-e-Access, a telemedicine program, uses the Internet to connect pediatricians with sick children at inner-city child care centers. Kenneth McConnochie, MD, MPH, founder of Health-e-Access and lead author of the recent study, wonders whether as Health-e-Access expands from day care centers and elementary schools into retail clinics that could that represent a financial threat to EDs in the area.
Gregory P. Conners, MD, MPH, MBA, professor and interim chair, emergency medicine, University of Rochester Medical Center, concedes, "We might lose some revenue, and we might not be able to fund as many programs as we now have available for sick kids or have the infrastructure ready when the really sick kids come in, but the most important thing is to do what's right for kids and help the community, and I sincerely believe that."
Michael Gerardi, MD, FAAP, FACEP, director of pediatric emergency medicine and an emergency physician at Morristown (NJ) Memorial Hospital, agrees. "Emergency medicine should not worry as much about revenue and competition, but quality of care," he says. "Our volumes are going up, although from a competitive standpoint I am naturally worried."
Besides, adds Conners, ED managers are not the ones who should have the greatest concern. Retail clinics threaten the pediatric-primary care relationship, he says. "Telemedicine will do the same thing if it is not linked in with primary care — otherwise, it is just another kind of retail clinic," he says. "Sure, siphoning off some patients from the ED could reduce ED revenues, but I doubt after-hours telemedicine by primary care physicians will ever be a big endeavor, since it still requires the primary care physician to be awake and seeing patients."