Ambulatory Telemedicine Research Articles

Age and sex-related comparison of referral-based telemedicine service utilization during the COVID-19 pandemic in Ontario: a retrospective analysis

BackgroundThe COVID-19 pandemic has led to increased utilization of telemedicine services.MethodsA retrospective analysis of all referral-based ambulatory telemedicine services in Ontario from November 2019 to June 2021 was collected from the Ontario Health Insurance Plan (OHIP) billing database. Only fee-for-service billings were included in the present analysis. Coincident COVID-19 cases were obtained from Public Health Ontario. Comparisons were made based on age bracket, sex, telemedicine and in-person care.ResultsBillings for telemedicine services in Ontario increased from $1.7 million CAD in November 2019 to $64 million CAD in April 2020 and the proportions reached a mean peak of 72% in April 2020 and declined to 46% in June 2021. A positive correlation was found between the use of telemedicine and COVID-19 cases (p = 0.05). The age group with the highest proportion of telemedicine use was the 10–20-year-olds, followed by the 20–50-year-olds (61 ± 9.0%, 55 ± 7.3%, p = 0.01). Both age groups remained above 50% telemedicine services at the end of the study period. There seemed to be higher utilization by females (females 54.2 ± 8.0%, males 47.9 ± 7.7%, ANCOVA p = 0.05) for all specialties, however, after adjusting for male to female ratio m:f of 0.952:1.0 according to the 2016 census, this was no longer significant.ConclusionsThe use of telemedicine services remained at a high level across groups, particularly the 10–50-year-olds. There were clear age preferences for using telemedicine. Studying these differences may provide insights into how the delivery of non-hospital-based medicine has changed during the COVID-19 pandemic.

Provider Perspectives Regarding Ambulatory Telemedicine at a Large Academic Health System During the COVID-19 Pandemic.

Purpose: To understand provider preferences regarding telemedicine across clinical departments and provider demographic groups. Methods: A cross-sectional online survey was distributed to providers at Johns Hopkins Medicine who had completed at least one outpatient telemedicine encounter. The survey included questions about clinical appropriateness and preferred use of telemedicine. Demographic data were obtained from institutional records. Descriptive statistics provided a profile of provider responses. Wilcoxon rank sum tests evaluated departmental and demographic differences. Results: A total of 1,342 of 3,576 providers responded (37.5%). Providers indicated that telemedicine was clinically appropriate for new patients a median of 31.5% of the time (Range: 20% in pediatrics, 80% in psychiatry/behavioral sciences). For existing patients, providers indicated that telemedicine was clinically appropriate a median of 70% of the time (Range: 50% in physical medicine, 90% in psychiatry/behavioral sciences). Providers desired a median of 30% of their schedule template be dedicated to telemedicine (Range: 20% in family medicine, 70% in psychiatry/behavioral sciences). Providers who were female, had fewer than 15 years in practice, or were psychiatrists/psychologists tended to find telemedicine more clinically appropriate (p < 0.05). Conclusions: A majority of providers across clinical departments felt that high-quality care could be delivered through telemedicine, although the amount of care varied widely based on department and patient type. Preferences for future telemedicine similarly showed wide variety across and within departments. These findings indicate that in this early adoption phase of widespread telemedicine integration, there is lack of consensus among providers about the amount of telemedicine appropriate for everyday practice.

Who and How: Telemedicine Eligibility and Participant Guidelines in the Ambulatory Setting

Introduction: Telehealth use has dramatically increased due to the COVID-19 pandemic. Yet there are significant gaps in evidence regarding the clinical appropriateness of synchronous visits for ambulatory telemedicine that are under the umbrella of telehealth and defined as video appointments between patients and providers. As a result, there are few sensible guidelines for day-to-day practice, resulting in a lack of standardization and risk of suboptimal care. Methods: We developed patient inclusion/exclusion guidelines for use in ambulatory telemedicine. Complementary tools included guides on patient preparation, telemedicine physical exam, and provider etiquette. We analyzed telemedicine use by practice type and surveyed a subset of MaineHealth ambulatory practices regarding the applicability of the guidelines. Results: Volume and specialty distribution data show that although telemedicine volume increased significantly, use varied by specialty. Behavioral health providers used telemedicine the most, followed by primary care, medical specialties, and, finally, surgical specialties. Stratification intensified as restrictions on in-person care declined. Discussion: We observed the expected pattern of use by specialty type, given our inclusion/exclusion criteria. Although these criteria may be conceptually straightforward, implementation is not. We operationalized these concepts to ensure individual practices can adapt and implement these insights in a reproducible and predictable way, leading to increased standardization across the health system. Conclusions: Clinical teams need help determining how to best use telemedicine tools. Here, we provide practice-level guidelines focused on practical implementation. We hope this communication advances the effort to develop standards of care for telemedicine indications.

Impact of Telemedicine Modalities on Equitable Access to Ambulatory Gastroenterology Care

Impact of Telemedicine Modalities on Equitable Access to Ambulatory Gastroenterology Care

Implementing a telemedicine curriculum for internal medicine residents during a pandemic: the Cleveland Clinic experience

Telemedicine training was not a substantial element of most residency programmes prior to the COVID-19 pandemic. Social distancing measures changed this. The Cleveland Clinic Internal Medicine Residency Programme (IMRP) is...

Connecting Through the Screen: Remote Learning and Telehealth During the COVID-19 Pandemic.

To the Editor: Since the beginning of the COVID-19 pandemic, a national consensus on medical student roles has not been established. 1 Students remain eager to participate in patient care, 1 but are distanced from patients, faculty, and rotations. This has prompted medical schools to augment nonclinical clerkship education using remote learning and telehealth. With a faculty mentor, 11 Wake Forest School of Medicine students created a clinical internship program to assist the neurology department’s telehealth response to COVID-19. The objective was to create learning opportunities for students through conversations with patients about their telehealth visit and, in the process, gather after visit data to inform clinical operations. In the first 6 weeks of COVID-19-related ambulatory telehealth, students made 1,600 structured calls and engaged with 583 patients (36.5%). Students learned by connecting with patients—their discussions about telehealth and anxiety regarding current events allowed students to learn from patients’ frontline experiences. Student-generated data contributed to the clinical response to COVID-19. Patients eagerly adopted telehealth, with 75% reporting that “all” their needs were met via televisit and 74% indicating that they would consider future ambulatory telemedicine. 2 Students improved continuity of care by identifying postvisit concerns and refill needs and by facilitating timely physician follow-up. Students gained a window into socioeconomic barriers experienced by patients. One student commented, “we’ve discussed these concepts in a didactic setting, but it is significantly more impactful to understand the effects of social determinants [of health] by speaking with real patients.” Age, financial burden, and the digital divide were prominent barriers even among patients who successfully completed telehealth visits. Students learn best by doing. In this crisis, we have found an opportunity to learn through engaging with patients and have found purpose in contributing to the pandemic response. Here, the need for physical distancing created an opportunity to learn by connecting with patients after their visit. In the future, similar programs could facilitate learning through supporting homebound patients or cancer patients undergoing treatment. Telehealth allows students to expand beyond traditional curricula and support patients in novel ways. Medical education must evolve to reflect this new reality, and we believe that emphasis on patient connection is central to a truly comprehensive medical curriculum. Acknowledgments: The authors wish to thank all the members of the student team for making this project possible including Allysen Schreiber, Alexander Ambrosini, Annie Madeline Thurman, and Dani Smith. The authors also thank Dr. Roy E. Strowd for his mentorship in establishing this clinical internship and comments on earlier drafts of this letter.

Patient Characteristics Associated With Telemedicine Access for Primary and Specialty Ambulatory Care During the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has required a shift in health care delivery platforms, necessitating a new reliance on telemedicine. To evaluate whether inequities are present in telemedicine use and video visit use for telemedicine visits during the COVID-19 pandemic. In this cohort study, a retrospective medical record review was conducted from March 16 to May 11, 2020, of all patients scheduled for telemedicine visits in primary care and specialty ambulatory clinics at a large academic health system. Age, race/ethnicity, sex, language, median household income, and insurance type were all identified from the electronic medical record. A successfully completed telemedicine visit and video (vs telephone) visit for a telemedicine encounter. Multivariable models were used to assess the association between sociodemographic factors, including sex, race/ethnicity, socioeconomic status, and language, and the use of telemedicine visits, as well as video use specifically. A total of 148 402 unique patients (86 055 women [58.0%]; mean [SD] age, 56.5 [17.7] years) had scheduled telemedicine visits during the study period; 80 780 patients (54.4%) completed visits. Of 78 539 patients with completed visits in which visit modality was specified, 35 824 (45.6%) were conducted via video, whereas 24 025 (56.9%) had a telephone visit. In multivariable models, older age (adjusted odds ratio [aOR], 0.85 [95% CI, 0.83-0.88] for those aged 55-64 years; aOR, 0.75 [95% CI, 0.72-0.78] for those aged 65-74 years; aOR, 0.67 [95% CI, 0.64-0.70] for those aged ≥75 years), Asian race (aOR, 0.69 [95% CI, 0.66-0.73]), non-English language as the patient's preferred language (aOR, 0.84 [95% CI, 0.78-0.90]), and Medicaid insurance (aOR, 0.93 [95% CI, 0.89-0.97]) were independently associated with fewer completed telemedicine visits. Older age (aOR, 0.79 [95% CI, 0.76-0.82] for those aged 55-64 years; aOR, 0.78 [95% CI, 0.74-0.83] for those aged 65-74 years; aOR, 0.49 [95% CI, 0.46-0.53] for those aged ≥75 years), female sex (aOR, 0.92 [95% CI, 0.90-0.95]), Black race (aOR, 0.65 [95% CI, 0.62-0.68]), Latinx ethnicity (aOR, 0.90 [95% CI, 0.83-0.97]), and lower household income (aOR, 0.57 [95% CI, 0.54-0.60] for income <$50 000; aOR, 0.89 [95% CI, 0.85-0.92], for $50 000-$100 000) were associated with less video use for telemedicine visits. These results were similar across medical specialties. In this cohort study of patients scheduled for primary care and medical specialty ambulatory telemedicine visits at a large academic health system during the early phase of the COVID-19 pandemic, older patients, Asian patients, and non-English-speaking patients had lower rates of telemedicine use, while older patients, female patients, Black, Latinx, and poorer patients had less video use. Inequities in accessing telemedicine care are present, which warrant further attention.

Quality and Safety Analysis of 2,999 Telemedicine Encounters During the COVID-19 Pandemic

To examine whether telemedicine remains safe and of high quality despite rapid expansion of services by comparing telemedicine encounters before and during the COVID-19 pandemic. Pre-post study investigating 2,999 telemedicine encounters: February 1, 2020-May 15, 2020, was performed. A total of 2,919 completed visits before and after strict social distancing implementation were analyzed for patient and provider characteristics, encounter characteristics (e.g., history and physical examination), and quality and safety metrics (phone calls ≤ 7 days postvisit, visit-cause-specific hospital admission or mortality ≤ 30 days after visit). Stratified analysis of 3 groups for outcomes (young age, neuromuscular diagnosis, and new encounters) was performed. Patients ranging from 1 month to 33 years of age were seen. Rural patients were less likely to be seen during the pandemic compared with urban patients (8% vs 90%; p < 0.0001); teaching clinic and specialty clinic encounters increased significantly during the pandemic (8% vs 3%; p = 0.005), and documentation of at least 2 systems on examination was noted significantly more frequently during the pandemic (13% vs 7%; p = 0.009). No deaths were reported. There were no differences before/during the pandemic in safety or telemedicine failure metrics within the entire group and high-risk subgroups. Despite a markedly and rapidly expanded scope of ambulatory telemedicine care during the COVID-19 pandemic, telemedicine remained a safe and high-quality option for pediatric neurology patients. In addition, populations perceived as high risk for telemedicine (the very young, new patients, and those with neuromuscular diagnoses) can benefit from telemedicine visits, particularly when access to in-person care is limited.

Medical Undistancing Through Telemedicine: A Model Enabling Rapid Telemedicine Deployment in an Academic Health Center During the COVID-19 Pandemic.

Background: The authors draw upon their experience with a successful, enterprise-level, telemedicine program implementation to present a "How To" paradigm for other academic health centers that wish to rapidly deploy such a program in the setting of the COVID-19 pandemic. The advent of social distancing as essential for decreasing viral transmission has made it challenging to provide medical care. Telemedicine has the potential to medically undistance health care providers while maintaining the quality of care delivered and fulfilling the goal of social distancing. Methods: Rather than simply reporting enterprise telemedicine successes, the authors detail key telemedicine elements essential for rapid deployment of both an ambulatory and inpatient telemedicine solution. Such a deployment requires a multifaceted strategy: (1) determining the appropriateness of telemedicine use, (2) understanding the interface with the electronic health record, (3) knowing the equipment and resources needed, (4) developing a rapid rollout plan, (5) establishing a command center for post go-live support, (6) creating and disseminating reference materials and educational guides, (7) training clinicians, patients, and clinic schedulers, (8) considering billing and credentialing implications, (9) building a robust communications strategy, and (10) measuring key outcomes. Results: Initial results are reported, showing a telemedicine rate increase to 45.8% (58.6% video and telephone) in just the first week of rollout. Over a 5-month period, the enterprise has since conducted over 119,500 ambulatory telemedicine evaluations (a 1,000-fold rate increase from the pre-COVID-19 time period). Conclusion: This article is designed to offer a "How To" potential best practice approach for others wishing to quickly implement a telemedicine program during the COVID-19 pandemic.

Letter: Emergency Response Plan During the COVID-19 Pandemic: The University of Alabama at Birmingham Experience.

Letter: Emergency Response Plan During the COVID-19 Pandemic: The University of Alabama at Birmingham Experience.

Patient Perceptions of Head and Neck Ambulatory Telemedicine Visits: A Qualitative Study.

During the COVID-19 pandemic, there has been unprecedented use of telemedicine for otolaryngology ambulatory visits. Patient satisfaction with telemedicine is an important metric, but survey-based questionnaires do not capture the nuances of the patient experience. This study aims to understand head and neck patients' perceptions about telemedicine clinic visits during COVID-19. Fifty-six established patients who had video-based telemedicine visits with an otolaryngology-head and neck surgery faculty member between March 25, 2020, and April 24, 2020, completed unstructured telephone interviews. Conventional content analysis was used to analyze the interview data. Retrospective chart reviews were conducted to determine the patients' demographic, disease, and treatment information. The primary benefits of telemedicine were accessibility and cost and time savings. Primary limitations included the ability to perform a physical examination. Most patients expressed a willingness to participate in future remote visits if appropriate or necessitated by social circumstances. Telemedicine is a disruptive process, and long-term adoption requires understanding patient perception of and satisfaction with telemedicine. Head and neck cancer patients were generally satisfied with telemedicine. The study elucidated patient perceived benefits and limitations of telemedicine. Continued implementation of telemedicine in otolaryngology-head and neck ambulatory clinics will require consideration of contextual features surrounding the virtual delivery of care, with particular attention to visit appropriateness for telemedicine and social circumstances.

Rapid Implementation of Outpatient Teleneurology in Rural Appalachia: Barriers and Disparities.

To describe rapid implementation of telehealth during the COVID-19 pandemic and assess for disparities in video visit implementation in the Appalachian region of the United States. A retrospective cohort of consecutive patients seen in the first 4 weeks of telehealth implementation was identified from the Neurology Ambulatory Practice at a large academic medical center. Telehealth visits defaulted to video, and when unable, phone-only visits were scheduled. Patients were divided into 2 groups based on the telehealth visit type: video or phone only. Clinical variables were collected from the electronic medical record including age, sex, race, insurance status, indication for visit, and rural-urban status. Barriers to scheduling video visits were collected at the time of scheduling. Patient satisfaction was obtained by structured postvisit telephone call. Of 1,011 telehealth patient visits, 44% were video and 56% phone only. Patients who completed a video visit were younger (39.7 vs 48.4 years, p < 0.001), more likely to be female (63% vs 55%, p < 0.007), be White or Caucasian (p = 0.024), and not have Medicare or Medicaid insurance (p < 0.001). The most common barrier to scheduling video visits was technology limitations (46%). Although patients from rural and urban communities were equally likely to be scheduled for video visits, patients from rural communities were more likely to consider future telehealth visits (55% vs 42%, p = 0.05). Rapid implementation of ambulatory telemedicine defaulting to video visits successfully expanded video telehealth. Emerging disparities were revealed, as older, male, Black patients with Medicare or Medicaid insurance were less likely to complete video visits.

Effectiveness of Ambulatory Telemedicine Care in Older Adults: A Systematic Review.

Disparities in healthcare access and delivery, caused by transportation and health workforce difficulties, negatively impact individuals living in rural areas. These challenges are especially prominent in older adults. We systematically evaluated the feasibility, acceptability, and effectiveness in providing telemedicine (TMed), searching the English-language literature for studies (January 2012 to July 2018) in the following databases: Medline (PubMed); Cochrane Library (Wiley); Web of Science; CINAHL; EMBASE (Ovid); and PsycINFO (EBSCO). Older adults (mean age = 65 years or older, and none were younger than 60 years). Interventions consisted of live, synchronous, two-way videoconferencing communication in nonhospital settings. All medical interventions were included. Quality assessment, using the Cochrane Collaboration's Risk-of-Bias Tool, was applied on all included articles, including a qualitative summary of all articles. Of 6616 citations, we reviewed the full text of 1173 articles, excluding 1047 that did not meet criteria. Of the 17 randomized controlled trials, the United States was the country with the most trials (6 [35%]), with cohort sizes ranging from 3 to 844 (median = 35) participants. Risk of bias among included studies varied from low to high. Our qualitative analysis suggests that TMed can improve health outcomes in older adults and that it could be used in this population. TMed is feasible and acceptable in delivering care to older adults. Research should focus on well-designed randomized trials to overcome the high degree of bias observed in our synthesis. Clinicians should consider using TMed in routine practice to overcome barriers of distance and access to care. J Am Geriatr Soc 67:1737-1749, 2019.

Establishing an Ambulatory Telemedicine Service in a Urology Practice

Introduction: It is estimated that 75% of households in the United States have access to broadband Internet,1 of which, 81% of those utilizing internet services access online health information.2 As such, with the rising costs of healthcare, there has been a catalyzed interest in the development of efficient and effective healthcare delivery models.3 One such initiative has been the establishment of telemedicine.4–6 Specifically, in a urology practice, evidence suggests that ambulatory video-visits are well accepted by patients7 and provide a means for equivalent efficiency and satisfaction with significantly reduced patient-related costs.8 Herein then, we describe a step-by-step process for establishing an ambulatory telemedicine service in a urology practice. Materials and Methods: This video is a review of current literature with a step-by-step process to establish a telemedicine service within a urology practice. Results: Several unique considerations exist in establishing an effective telemedicine practice in urology. Modifiable features that may enhance patient acceptance include providing previsit education regarding the ability of the video-visits to deliver care equivalent to a traditional encounter and offering access to video-visit consultations in the presence of the patient's local referring provider. Patient technical considerations include access to broadband Internet, a smart mobile device, or personal computer, as well as speakers and a microphone. Minimum operating system requirements include Microsoft XP, Vista, or 7; or Apple OS 10.7 or greater. Accordingly, before implementing a telemedicine practice, it is important that the urologist ensures compliance with state-specific medical licensure, credentialing, and reimbursement laws. Specific physician technical considerations include the use of a secure, private, HIPAA-compliant licensed medical consultation software, providing supplemental patient education through a virtual platform and offering technical assistance when needed. For patient safety, the provider should identify and screen for indication-specific exclusion criteria, which may require a physical examination. Video-visits can be integrated into a traditional ambulatory clinic; however, to improve efficiency, we encourage the patient to perform a “test” call before their appointment and offer video-visits greater than 1 month before the anticipated visit to allow for patient accommodations. Conclusions: Establishing a telemedicine service in a urology practice is an effective and efficient way of delivering care to established patients while requiring minimal modifications to a traditional clinic model. Nevertheless, to establish a successful telemedicine practice, several important considerations do exist, including patient and provider technical requirements, compliance with state-specific telemedicine laws, and identifying patients in whom a physical examination can be safely omitted. No competing financial interests exist. Runtime of video: 5 mins 33 secs

Ambulatory Telemedicine and Article 44 of the Emergency Life-Saving Technician's Act and Article 20 of the Medical Practitioner's Act

This paper shall discuss the legal bases for mobile telecommunications-based medical supervision in Japan and bulletin from the Ministry of Health, Labour and Welfare. According to Article 44 of the Emergency Life-Saving Technician’s Act, an emergency technician shall not perform certain emergency medical procedures unless specifically authorized to do so by a medical practitioner. Actual conditions make these requirements unwieldy to put into practice. When requested to provide medical control in response to a cell phone call inquiry from an ambulance, a medical practitioner (i.e., a licensed physician), has no choice but to allow the emergency technician to administer medical care, despite the lack of the information needed to grasp actual conditions within the ambulance. These circumstances expose medical practitioners (licensed physicians) to significant legal risks and societal ramifications.

Sustaining and realizing the promise of telemedicine.

Sustaining and realizing the promise of telemedicine.