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The use of information technology holds significant promise for increasing access to health care when consumers and their providers live and work in different communities. For example, electronic consultations using computer-based patient records can reduce the need for families to travel long distances to consult specialists. The term ''telemedicine" is generally applied to the use of information technology when there is geographic separation or distance between the participants. Telemedicine applications include clinical evaluations, consultations, and supervision of providers in other locations (IOM, 1996).
Computer-based patient records can help to facilitate provider access to records, make transfer of records easier, and increase the availability of clinical information for research (IOM, 1997b). Many other uses of information technology are developing in medicine and health care, including some that are consumer-oriented. For those parents and providers who are able to use computers, an extensive variety of patient education materials are available through the Internet. Electronic parent-support groups, children's advocacy groups, and others are becoming increasingly common.
To provide readers with some examples of the uses of information technology by specialty providers, Box 7.3 includes some scenarios based on the actual clinical experiences of one of the committee members, a pediatric gastroenterologist. Research and evaluation have not caught up with the rapid diffusion or variety of uses of information technology in health care, and standard protocols and guidelines have not been developed, with the exception of the standards for electronic transmission of clinical data that are mandated by the Health Insurance Portability and Accountability Act of 1996.
Medical information systems can cost from $500,000 to several million dollars, depending on their features (Ciotti and Zodda, 1996). The expense of installing new administrative software has slowed its implementation, particularly in public clinics. In the past, insurers and health plans have restricted payments for telemedicine consultations and other electronic applications, such as patient education (IOM, 1996). However, the committee believes strongly in the potential of information technology to improve access and quality in health care for children and their families, and the committee urges insurers and health plans to explore its use further.
Access Under Managed Care
As of the summer of 1997, 36 states had mandated managed care arrangements for at least some children with special needs (Alliance for Health Reform, 1997). Some providers and researchers have expressed serious concerns about the potential for incorporating patients with chronic illnesses and serious medical conditions into the typical capitated managed care model (Hughes et al., 1995; Newacheck et al., 1994). Most managed care organizations (MCOs) have traditionally served working adults, who are generally healthy. Thus, MCOs have not tended to have much experience with low-income, chronically ill, or low-income individuals, although some are gaining experience through Medicaid managed care contracts and through developing programs specifically for these groups (AAHP, 1997).
There are few existing studies of children's access to care under managed care and they show many gaps and inconsistencies, making the evidence difficult to interpret. For example, a few studies have compared access to preventive services for low-income children with managed care and traditional coverage. They have found that children enrolled in Health Maintenance Organizations (HMOs) are more likely than children with traditional coverage to receive preventive medical care such as immunizations, vision and other screening tests, as well as more frequent and complete check-up visits compared with children with traditional coverage (Carey et al., 1990; Szilagyi et al., 1990).
A study comparing immunization rates for inner-city infants in Los Angeles found that they were more likely to have current immunizations if they received care in public health clinics rather than in