Pediatric practices across the country are embracing digital technologies, from mobile apps to virtual care, to improve healthcare services provided to their pediatric patients, and their caregivers, and to bridge gaps in healthcare and access to care.
A leading private pediatric practice in Jacksonville, Florida is seeing success with the use of a telehealth platform targeting a particular population of pediatric patients, children diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD). In the U.S., the number of diagnoses of attention deficit disorder (ADHD or ADD) in the United States skyrocketed 43 percent between 2003 and 2011, bringing the total number of American children who had ever received an ADHD diagnosis to 6.1 million, or approximately 9.4 percent of U.S. children ages 2 to 17, according to 2015 statistics from the Center for Disease Control and Prevention (CDC). Of children with current ADHD, almost two thirds (62 percent) were taking medication and slightly less than half (46 percent) had received behavioral treatment for ADHD in the past year, according to the CDC data.
For pediatricians, it is important to schedule frequent medical visits and follow-up appointments with children diagnosed with ADHD to ensure their diagnosis remains accurate and that any related learning disabilities or mood problems are identified. “It’s a fluid diagnosis. It’s not just about starting medication, we need to see how that’s implemented, what kind of behavioral changes the child might be experiencing, if they are getting all the services that they need at school, any side effects of the medications and how compliant the kids are with their treatments, because they tend to be forgetful, and a lot of the times the parents tend to forget as well,” Prasanthi Reddy, M.D., founder and CEO of Rainbow Pediatric Center and the organization’s medical director, says. “By touching base more frequently, we’re able to reinforce the diagnosis and the prognosis as well as ongoing treatment changes that we need to implement.”
Established in 2004, Rainbow Pediatric Center has seven providers serving patients at two locations in Northeast Florida, a practice in Jacksonville and one in Ponte Vedra. Rainbow Pediatric has been designate a National Committee for Quality Assurance (NCQA) Level 3 Patient-Centered Medical Home (PCMH). “Our practice is known in the community for having a good reputation, and we’re recognized by payers and patients alike for providing quality healthcare. We’re known for having less ER rates, by keeping our doors open on holidays and weekends, so we work diligently at bridging the gaps in healthcare for our patients and being a true medical home,” Reddy says.
With regard to the practice’s ADHD patients, Reddy and her colleagues recognized that close follow-up with patients yielded better outcomes. However, the practice leaders also found that some parents were having difficulty getting children to regular appointments. Parents were unwilling to pull their children out of school for frequent check-ups and physicians were limited to the number of children they could see during after-school hours, Reddy notes.
“The challenge is that in order to do that close follow-up, we need to see these kids at least monthly or every other month. It’s difficult for families to pull kids out of school, especially ones who are already having difficulties and challenges in school due to their ADHD or other conditions. And we’re asking parents to take time out of work to bring the kids in during these visits. It was a big barrier to care,” Reddy says. “Parents were willing to bring kids in once every three months, but we felt that wasn’t enough of a follow-up to really make a dent as far as treatment.”
Prasanthi Reddy, M.D.
To address these gaps in care, Rainbow Pediatric Center last year worked with its electronic medical record (EMR) vendor, eClinicalWorks, to implement a telemedicine pilot program to offer tele-visits specifically for patients with ADHD and their caregivers. The goal, Reddy says, was to improve access to care while maintaining the practice’s high standards of care. Initially, 150 pediatric patients and their families participated in the telemedicine pilot program.
Prior to the telemedicine pilot, the compliance rate for ADHD patients showing up for their one-month follow-up appointment was about 40 percent. Since the implementation of the telemedicine platform, appointment compliance among ADHD patients is now 71 percent, according to Reddy, representing a 77 percent increase. Additionally, offering patients and their families tele-visits has helped to improve patient engagement, Reddy notes.
“When we did these tele-visits, the parents were excited about doing it this way because we were offering them after-hours, so their kids did not have to be pulled out of school and we were able to do the telehealth visit wherever the families were, so they would do tele-visits with their doctor from their car before the child went to the soccer game, or at the kitchen table. The parents and patients really enjoyed it,” Reddy says. “The parents were eager to make sure that we implemented that as a regular service as opposed to just a pilot program.”
On the operational side, Reddy says the eClinicalWorks telemedicine solution seamlessly integrates with providers’ workflow. “We use eClinicalWorks as our EMR, so it was a natural extension of that. We do the tele-visits right through our EMR, and it’s basically like any other office visit, we’re able to type up the note as we’re talking to the patient with a little window to the side where we can see the patient,” she says, adding, “The parents already are familiar with the patient portal and the Healow app, so it was just a matter of allowing them to do the tele-visits.” (eClinicalWorks developed the Healow app, a tool that enables patients to integrate data from all their healthcare providers.)
Overall, parents and patients are comfortable conducting the medical visits through a virtual platform, Reddy says. “As long as the system is secure, I think the families felt very secure because they would see us face-to-face, and so it’s not any different from being in the office.”
Consumers are increasingly demanding the same convenience and mobility they experience in other aspects of their lives, such as retail and transportation, in their healthcare experiences. And, as Millennial parents come onto the scene, the demand for digital services will only grow. “I see [telehealth] playing a huge rule in pediatrics, so any sort of behavioral concerns, parenting concerns, or mental health and behavioral health issues can easily be dealt with via tele-visit. In fact, most of the time, in pediatrics, the parents’ questions are not medical, it’s more parenting and behavioral questions, and those can be easily tackled by tele-visit,” she says, adding, “It’s something that is in high demand by parents. Everybody is looking for convenient services and what’s better than this, where they don’t have to take time off work or leave their home even.”
Tackling Reimbursement Issues
Rainbow Pediatric Center has plans to roll out telehealth visits as a service to all of its patients and families, but Reddy acknowledges that reimbursement from insurance providers continues to be a thorny issue and an ongoing challenge. “We were running into some problems with payers recognizing it as a needed service, and we’re making some gains on that. It’s still an evolving discussion we’re having with them,” she says, and then elaborates, “It’s an up-and-coming field, as far as insurance and payers are concerned. I think patients and parents are already savvy to it and already use it, but some payers are behind the times with regard to telehealth because it’s hard to delineate which type of services they would allow via tele-visits versus having the patient come into the office.”
Reddy continues, “When we specifically approach [insurance companies] with ADHD patients, they were excited about it because they could see it would be a useful service for their patients with ADHD. Just with this diagnosis alone, when we approached them, they were much more receptive to at least consider adding that addendum to our contracts.”
According to the Center of Connected Health Policy, a national telehealth resource center, in a fact sheet about telehealth reimbursement published in February, while telehealth continues to grow, reimbursement gaps remain. “These gaps impede expansion of telehealth services within the healthcare field. Medicare, Medicaid, and private payers offer varying degrees of telehealth reimbursement, with their reimbursement policies differing greatly in terms of services covered, and other requirements and restrictions,” the CCHP report states.
As of October 2017, 36 jurisdictions (including DC) have enacted (or will enact at a later date) laws that govern private payer telehealth reimbursement. In most cases, these laws offer coverage parity, requiring insurers to cover the same services delivered through telehealth, as are covered in-person, as long as it meets the same standard of care. And, a few states (including New York) have begun to introduce payment parity legislation that requires private payers to cover telehealth services “at the same rate” as when the service is provided in-person.
In addition to her medical practice, Reddy is a medical advisor at EpicMD, a Miami-based provider of a telehealth technology platform and service solutions. Speaking to the broader issues of the growth of telemedicine and the reimbursement landscape, Reddy says, “I think, honestly, it’s just a matter of time until all payers embrace it. It’s a question of quality medical care. There’s a limit to how much you can do through tele-visit, as most of the time you need to do a thorough exam in order to come to a diagnosis. As long as we’re careful about which type of diagnosis and conditions that we’re using tele-health with and not abusing it and not replacing a formal exam, then I think we’re taking the right approach. There’s a fine balance that you have to have. I don’t think it’s the answer for everything, but I think it’s going to have a place in the future of medicine.”