EXPERT ANALYSIS FROM AAP 16
SAN FRANCISCO (FRONTLINE MEDICAL NEWS) – Telementoring empowers primary care pediatric providers (PCPs) to take on a greater role in managing their patients’ chronic diseases, new data suggest. Leaders in this emerging field gave a snapshot of early experience with the model at the annual meeting of the American Academy of Pediatrics.
“About a quarter of children live with chronic health conditions, and there is an increasing need for specialty care. But many children don’t have access to the quality specialty care that they really need, particularly in rural and medically underserved areas,” explained Dr. Sucheta M. Joshi , a pediatric neurologist and epileptologist at the University of Michigan, Ann Arbor. “The goal of telementoring is to build the capacity of primary care doctors.”
Pioneers in the field recognized that a sizable share of the population referred to specialists are lower-complexity, lower-acuity patients who could be managed in the primary care setting with adequate guidance.
“We need to empower primary care providers to work ‘at the top of their license’ because we don’t have enough specialists,” agreed Dr. David L. Wood , a general pediatrician and chair of the department of pediatrics at East Tennessee State University in Johnson City. “We as primary care [physicians] have to shoulder more of the care of kids with chronic disease. But we need backup, we need support to do that because the science is growing rapidly, we can’t keep up.”
Telementoring first gained recognition through the University of New Mexico’s Project Extension for Community Healthcare Outcomes ( ECHO ), which links specialists at an academic “hub” with PCPs in local communities, or “spokes,” in a learning network.
Through regular, interactive, multisite telementoring sessions, ECHO provides training to increase PCPs’ knowledge, self-efficacy, and comfort in managing chronic diseases not typically considered within their scope of practice. Sessions combine short didactic presentations and case-based learning.
The model was initially tested in pediatrics as ECHO for Epilepsy , a partnership of the AAP and the University of New Mexico, Albuquerque. Topics covered ranged from first seizures to work-up to treatment, including when to refer to a neurologist, according to Dr. Joshi, who helped develop the curriculum. Encouraging findings among the 49 clinics participating in the first year led to expansion of the program to five more states.
Preliminary data from the full cohort show reductions from baseline to end of the program in the proportions of participants who felt not at all or not very knowledgeable about pharmacologic management of pediatric epilepsy (from 69% to 45%), related school and education issues (from 51% to 18%), pertinent state driving laws (from 69% to 45%), and when to refer to a specialist (from 34% to 0%), Dr. Joshi reported.
There were also reductions in the proportions of participants who felt not at all or not very confident about aspects of care such as medical testing in this population (from 52% to 45%), communicating with patients about the transition to adult care (from 52% to 27%), and communicating with families and caregivers about the impact of epilepsy on everyday life (from 59% to 36%).
“This has been a good demonstration to say that telementoring does improve provider knowledge and confidence,” Dr. Joshi maintained. “Everybody felt quite uniformly that the case discussions were useful, and it really fostered a sense of a community of learners and was very much an iterative process.”
The AAP has since been designated as a “ superhub ” for Project ECHO that can train others to start programs in specialty areas. Additional programs have been developed in pediatric endocrinology, sickle cell disease, and surgery.
Dr. Wood’s institution is located in a rural area where diverse providers care for the pediatric population, he explained. His department has trained as an ECHO hub to offer telementoring, attracting not only pediatricians but also family physicians, nurse practitioners, and nurses.
The main costs of ECHO are the personnel and physician time, and financing has yet to be worked out. “Unlike traditional telemedicine, where it’s one patient and one physician, and you can actually bill for it, this is not a billable service,” Dr. Joshi noted. “What you can get is more of a downstream effect, which can take some time to become obvious.”
The key attraction for providers is obtaining CME credits, where offered. And a draw for institutions is the potential impact of ECHO in reducing provider turnover and improving value-based reimbursement.
“This is really an innovative program that can help us achieve the triple aim” of improving the patient’s experience, reducing costs, and achieving better health outcomes, Dr. Wood said. “I think this is a great enhancement to the medical home.”
Both Dr. Joshi and Dr. Wood disclosed that she had no relevant conflicts of interest.