OBJECTIVE: The goal was to evaluate the feasibility and acceptance of a new model for well-child care (WCC) in a large health maintenance organization.
METHODS: We designed a new model of WCC that engages families in Internet-based developmental and behavioral screening, allows for review of the results before the visit, and allows for selection of the appropriate visit type (e-visit, e-visit with brief provider visit, or extended encounter). The new model was pilot-tested in 2 practices within a large health maintenance organization. Seven providers and 70 parents participated in the study. Parents and providers were surveyed regarding their experience and satisfaction with the encounter.
RESULTS: Seventy-five percent of parents thought that the online previsit assessment improved or very much improved the WCC visit. However, 12% of parents found the online assessment somewhat or very difficult to use. All of the parents found the e-visit or the e-visit with brief provider visit acceptable or very acceptable, compared with a standard WCC visit. All 7 providers thought that use of the new model helped focus the visit and that they would continue or definitely continue to use the model.
CONCLUSIONS: We demonstrated the feasibility of a new model of WCC that engaged parents in previsit assessment and used alternative visit types to tailor care to the needs of the family. Future research will be needed to examine the impact of this model on important WCC outcomes.
Well-child care (WCC) visits represent the primary way in which children in the health care system receive developmental and preventive care services. WCC constitutes almost 25% of pediatric visits and >50% of all visits in the first year of life. Despite this considerable allocation of time and resources; many children do not receive the care they need.1 Research has shown that ∼50% of parents think that their child's developmental and behavioral issues are not addressed adequately by health care professionals.2,3 Currently, only 20% of children receive structured, validated, developmental assessments in the physician's office, with 1 of 3 developmental problems going unrecognized by pediatricians.4,5 Surveys of children entering school showed that 20% of children had a cognitive problem and >25% had a behavioral or developmental problem that would have benefited from early identification and treatment.6 Such gaps in care persist in the presence of evidence-based practices that have been documented to improve the identification and treatment of children at risk.7,8 Pediatricians want to do a better job but think they do not have enough time, resources, or training to deliver the prescribed services.9–13
Fortunately, it is an opportune time for change.3,14 Research has shown that interventions in the primary care office can affect significantly the effectiveness, patient-centeredness, timeliness, and efficiency of child development and health promotion practices.15,16 Moreover, pediatricians are cognizant of the need for changes in both the way in which WCC is delivered and who delivers it.17 Innovative technologies offer promising new approaches for health promotion and education and can facilitate caring encounters that do not require a face-to-face visit with a doctor or nurse.18,19 The widespread use of home computers makes e-mail communication between families and providers possible, and Internet-based interactive programs can provide parents with needed information 24 hours/day.20 Advances in practice design have improved access to care markedly,21 have changed the nature of visits to allow for shared group experiences,16 and have remodeled the primary care office into a medical home for children. Finally, collaboration with new health professionals in the areas of child development and health promotion has increased parent knowledge and satisfaction with care markedly and has improved some of the key outcomes of WCC.22
In an effort to improve the effectiveness and efficiency of delivery of developmental and preventives services in WCC, we evaluated the feasibility and acceptance of an innovative model for WCC. This system incorporates 3 improvements to the WCC visit, that is, (1) use of an Internet-based previsit assessment completed by the family before the visit, so that the practitioner can tailor the visit to the family needs; (2) use of different visit types (eg, e-visit alone or e-visit with brief provider visit) that allow the practitioner to tailor the visit further to the needs of the child; and (3) use of extended visits for children with special health care needs (CSHCN).
The site for our project was Kaiser-Permanente Colorado, a group model health maintenance organization (HMO) serving 100000 children in the Denver, Colorado, metropolitan area. Kaiser-Permanente Colorado has a long track record in practice redesign and has implemented an electronic health record and e-mail communication between providers and families.
Oversight of the design and implementation of our new model was provided by a steering committee composed of providers, project staff members, and parents. Each of the 3 areas of improvement had an associated work group, again composed of providers, project staff members, and parents. An advisory group composed of nationally recognized experts in developmental and preventive services for children assisted in the planning and implementation of the new model.
Design and Implementation Process
In a previous project,14 we developed a set of change ideas that were used to build a series of scenarios for best practices in WCC. The project steering committee reviewed these change ideas and selected 3 areas for possible improvement, that is, (1) use of an Internet-based, previsit assessment completed by the parent, (2) use of different visit types that involve Internet-based technologies, and (3) design of a specific WCC visit for CSHCN. We divided the implementation process into 3 parts, corresponding to the 3 areas of improvement. We used the improvement model developed by Langley et al23 to develop specific aims and outcome measures for each of the improvements. Each work group also developed process flows, which were reviewed by providers and site staff members. We then used plan-do-study-act improvement cycles to test and to improve the care process iteratively.
We conducted provider and parent telephone surveys to assess the feasibility and acceptance of the improvement. We also collected data on visit times for each visit type, provider time for review of the previsit assessment, and preparation for the visit. Finally, we collected data on how the high-performing system of WCC compared with usual WCC.
Use of Previsit Assessment
The Committee on Practice and Ambulatory Medicine and the Bright Futures Steering Committee of the American Academy of Pediatrics recommend >200 practices for WCC visits in the first 3 years of life.24 However, the average pediatrician has only 234 minutes (18 minutes per visit) for WCC encounters during this time period. For many pediatricians, it is difficult to complete even the basic recommendations for preventive and developmental care.9,25 Even if sufficient time were available, research has shown that the provision of more information may lead to decreased recall of the information provided.26 In our new model of WCC, we used a Internet-based tool, the Child Health and Development Interactive System (CHADIS),27 to engage parents in the developmental and behavioral assessment and screening for autism, maternal depression, and domestic violence and to articulate their child's challenges and strengths, as well as their agenda for the upcoming visit. Table 1 lists the selected CHADIS questionnaires. Parents completed the CHADIS assessment up to 2 weeks before the visit, and the results were communicated to the practitioner, who then tailored the content and length of the visit and the involvement of other health care professionals to meet the identified needs of the family.
Use of Different Visit Types Tailored to Biopsychosocial Risk
The American Academy of Pediatrics guidelines specify that ≥10 visits occur during the first 3 years of life. Many experts have questioned the need for all of these visits, as well as components of the visits such as a physical examination.28,29 Some have advocated for a tiered schedule for WCC adapted to the risk of the child.3,30 Initially, we considered 3 tiers of WCC, geared to the biopsychosocial risk of the child. However, the lack of clear-cut predictors for increased utilization of health care services31 and valid biopsychosocial risk factors other than poverty (C. Forrest, MD, PhD, oral communication, 2008), as well as the fact that families move into and out of high-risk status frequently, made it difficult to define the different groups clearly. In place of a tiered system of WCC, we devised a model that allows the provider to choose from different visit types to match the experience and needs of the family with the frequency and mode of delivering WCC. In this pilot study, we tested each of the visit types separately, so that we could evaluate the feasibility and acceptance of each type. The 3 visit types were as follows.
The first type is an e-visit. This is a fully electronic visit for use in place of a traditional visit, in which developmental and behavioral screening documents normal development and parental concerns can be addressed via e-mail exchange; the parent and provider agree on this visit format.
The second type is an e-visit with a brief provider visit. This visit is for the family that demonstrates normal results for all of the developmental and behavioral tests but needs to come to the office for immunizations, measurement of growth parameters, or other issues. The brief visit differs from a traditional WCC visit in that it assumes that much of the information-gathering and interaction with the family has been accomplished before the visit, through CHADIS and e-mail. The face-to-face part of the encounter is intended to provide a brief physical examination and to validate and to support the findings from the previsit assessment.
The third type is an extended visit for CSHCN. This visit is for the child who has chronic or extenuating problems that require more attention and who may need the involvement of other health care professionals, such as a developmental specialist or chronic care coordinator.
Use of Extended Visits for CSHCN
On average, CSHCN have more visits with their physicians, compared with other children,32 and are more likely to receive preventive care.33 Of interest is research that shows that parents of CSHCN prefer to combine preventive care and illness care and to discuss the “whole child.”34 In designing a WCC encounter for CHSCN, we thought that having an elective visit free from the urgency of exacerbation of a chronic illness would allow for greater focus on the whole child. We also elected to lengthen the visit and incorporated a chronic care coordinator, developmental specialist, or mental health professional as needed. As part of the visit, we had the appropriate health care professionals call the family ≥2 weeks before the visit, to assess current concerns, to review preventive care needs, and to create or to update a care plan. CHADIS could be used when there was a need for standardized screening. Information from this previsit assessment was forwarded to the provider through the electronic health record. At the end of the office visit with the provider, the collaborating health professional joined the visit in person or through a conference call.
Seventy-eight families participated in the pilot study. The data presented represent the average response over the 2 or 3 plan-do-study-act cycles that were conducted for the 3 components of the model. Twenty-eight families participated in the tailored WCC visit with the previsit assessment. Ten families participated in the e-visit with use of the CHADIS tool before the visit, 25 families participated in the e-visit with a brief provider visit with use of the CHADIS tool before the visit, and 15 families participated in the extended visit for CSHCN. The results of the parent experiences with the previsit assessment, the brief provider visit, and the e-visit are presented in Table 2. On average, the online CHADIS tool required ∼20 minutes for parents to complete. Overall, most parents were satisfied with their encounter types, thought that the components of the new model enabled them to be better prepared for the visit and helped them to identify issues for discussion, and thought that the visit was more efficient than their usual WCC visits. Comments from the parent telephone survey showed that the families thought that the previsit assessment helped them to identify problems and to confirm that their child was on track developmentally. Parents in general felt satisfied with the e-visit but would not like to see it replace a regular visit. Of note, 12% of families had difficulty navigating CHADIS and were not able complete the previsit assessment. The results from the parent and provider experiences with the extended visit for CHSCN are presented in Table 3. Again, most families were satisfied with the visit and thought that the encounter enabled them to identify problems more effectively, enhanced the efficiency of the visit, and increased care coordination. Comments from parents showed that they thought that this visit type afforded them more opportunity to communicate with their pediatrician and helped them to “bring together” the various aspects of their child's care.
Seventeen providers participated in the plan-do-study-act cycles. Although the number of participating providers was small, all participating providers thought that the use of previsit assessments was more or much more efficient than usual WCC and was helpful or very helpful to parents for identification of WCC issues. For the brief provider visit, 5 of 7 providers thought that the encounter was more efficient than usual WCC but 2 of 7 thought that there was no time savings. The time range for the previsit review of all CHADIS data was 2 to 7 minutes. Review of the CHADIS summary page ranged from 20 seconds to 2 minutes, The e-visit was viewed as satisfactory by all participating providers. All participating providers thought that the extended WCC visit for CHSCN enhanced the efficiency of the visit, aided parents in identifying health issues, and increased the amount of care coordination.
In this pilot project, we were able to articulate a redesigned model for WCC and to demonstrate its feasibility and acceptance in pediatric practices in a large HMO. Our results showed a high degree of satisfaction with the use of a computer-assisted previsit assessment (CHADIS). These results are consistent with previous research on patient portals, which also demonstrated a high degree of satisfaction with computer-assisted engagement in the care process.35 We also demonstrated a high degree of provider satisfaction with use of the preassessment tool, different visit types, and a special visit for CSHCN. Previous research assessing physician attitudes toward Internet-based communication with patients showed mixed results. In some studies, providers showed resistance to the use of Internet-based communication with patients.36 In other studies, providers had a positive attitude toward this mode of communication with patients.37 Our high level of satisfaction among providers may be attributable to the early extensive engagement of providers in the planning and implementation process.
Although many of the individual design principles, such as the use of a previsit assessment,38,39 the use of an Internet-based e-visit, and the use of an e-visit combined with a brief provider visit,40 have been tested, to our knowledge this is the first time these 3 specific changes have been combined in a single model for developmental and preventive services. The results of this study, however, need to be interpreted with care. Because our effort involved iterative improvement cycles to improve the design of the WCC encounter and to examine feasibility and satisfaction with a new model of WCC, we did not use a control group. Ultimately, our results need to be verified in a controlled trial to ensure the validity of our findings.
It may be possible to use components of our WCC model in the context of a more-traditional WCC visit in a private practice setting. For example, the CHADIS tool has been used with success as a complement to more-traditional WCC.27 In this setting, CHADIS allows the practitioner to conduct a previsit assessment and to tailor the visit appropriately without using different visit types. Furthermore, our use of a different visit type for CSHCN, with previsit evaluation by an allied health professional, is intended to support the attributes of a medical home in pediatric practice, and this visit type can be used in traditional WCC without the need to incorporate the complete model.
Caution must be used in generalizing our results to other settings and populations. First, it is likely that, when our design principles are translated to different settings, changes in the model to meet site-specific needs will be necessary. In fact, some authors have argued that large-scale innovation and change require continuous improvement to foster continuous adoption of innovation.41 Second, our work was performed in a group model HMO, where we did not need to contend with fee-for-service reimbursement of services. In fee-for-service settings, some of our proposed activities might not be reimbursed. This lack of reimbursement undoubtedly would decrease the likelihood of adoption of our model in such settings. However, we completed an economic analysis using Current Procedural Terminology codes and showed that the proposed change in our model would be cost-neutral, compared with a traditional fee-for-service pediatric practice (D.A.B., unpublished data, 2009). Third, this work was performed in a population with a high degree of health and computer literacy. Even in this population, however, 12% of users had difficulty navigating the CHADIS program. These findings underscore the need for extensive training and user support in the implementation of the CHADIS program.
Translation of this model to a target population of low-income or non–English-speaking families would require considerable modification of the model. Previous research, however, showed that Medicaid beneficiaries have a very positive attitude toward patient portals and would be willing participants in computer-assisted programs that enhance communication with providers.42 Computer literacy and the ease of use of our program also would affect the generalizability to other populations.
Ultimately, the value of the new model will need to be demonstrated in improved health care outcomes for children with respect to preventive and developmental services. Currently, we are evaluating our model in a controlled trial within Kaiser Permanente Colorado and using a modified version of the model in a safety net Medicaid program in Denver, Colorado (Denver Community Health Network). This evaluation will assess feasibility and acceptance, as well as the impact of the model on important developmental and preventive service outcomes.
We have been able to develop a new model for WCC that builds on previous research in the field and involves Internet-based technologies. We have shown that it is possible to implement the model in an HMO setting and to demonstrate positive effects on provider and family experiences. Future research is needed to assess the impact of our model on preventive and developmental service outcomes for children and to better understand the changes and modifications of the model that will be required for use in different settings and diverse patient populations.
- Accepted February 24, 2009.
- Address correspondence to David Aaron Bergman, MD, Department of Pediatrics, Stanford University School of Medicine, Suite 100, 770 Welch Rd, Palo Alto, CA 94304. E-mail:
Financial Disclosure: The authors have indicated they have no financial relationships relevant to this article to disclose.
What's Known on This Subject:
WCC is not meeting the needs of families. Pediatricians want to do better but are constrained by lack of time and resources. Internet technology offers the opportunity to engage parents in WCC and to extend the encounter.
What This Study Adds:
This study demonstrates the feasibility and acceptance of a new model for WCC that uses the Internet to engage parents and to expand the efficiency and capacity of the WCC visit.
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