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Interdisciplinary perspectives on accessing specialty evidence-based treatment for Medicaid-insured adolescents with eating disorders

BackgroundFamily-based treatment (FBT), the leading intervention for adolescents with anorexia nervosa (AN), is severely understudied in outpatient care settings that serve publicly-insured populations. Many individuals with public insurance are lower-income, racially and ethnically diverse, and experience barriers to accessing evidence-based interventions for eating disorders (EDs).MethodsSemi-structured interviews were conducted with ten interdisciplinary providers who provide specialty care to youth with EDs in an inpatient and/or outpatient medical setting. Interview questions were focused on the interdisciplinary providers’ experiences of caring for individuals with EDs, with a focus on differences in care for those with private insurance compared to public insurance. The interviews took place two years after training in FBT was delivered to mental health providers in San Francisco County, which created opportunities to explore provider perspectives on collaborating with newly-trained mental health providers in the community implementing FBT with publicly-insured youth.ResultsContent analysis converged on three themes: the critical importance of supporting mental health treatment within the context of medical care, complex challenges when helping patients and their families navigate publicly-funded health care systems, and the overall positive impact of the FBT rollout in San Francisco County. Participants emphasized greater confidence in patient outcomes when collaborating with FBT providers and noted discord when working with providers not trained in EDs or FBT. Referral systems, weight-based stigma, and a lack of appropriate services were highlighted as significant barriers to care. To facilitate treatment engagement in publicly-insured populations, participants stressed the importance of clinicians providing psychoeducation and providing services with a high degree of cultural competence. Participants expressed that patients’ ability to access FBT and providers’ ability to collaborate on cases markedly improved following the county training, increasing their sense of efficacy in delivering adequate patient care.ConclusionsThe discussed themes highlight the importance of access to FBT for individuals in underserved communities, which can significantly reduce both provider and patient burden. Despite various barriers to utilizing FBT in publicly-funded settings, clinicians stressed that cultural adaptations increase the implementation of and facilitate family engagement in FBT, which is consistent with previous literature examining evidence-based intervention implementation science.

Provider Perspectives and Access to Palliative Care: AnAmerican Head and Neck Society (AHNS) Survey.

To explore provider perspectives about palliative care (PC) in head and neck cancer (HNC) care. A 25-question electronic survey was disseminated to the membership of the American Head and Neck Society (AHNS) from April 10, 2023, through June 13, 2023. Respondents were most likely to refer to PC at symptomatic disease progression (52%) or terminal diagnosis (29%) rather than at initial diagnosis (17%). Participants less likely to refer to PC were less likely to refer to symptomatic progression (8% vs. 39%, p = 0.0006) or address advance directives (62% vs. 87%, p = 0.0406). Symptom burden questionnaires were used by only 29% of respondents. Discordance was identified between self-reported and actual access to local inpatient and outpatient PC services. Barriers to PC identified include a lack of established optimal timing of PC referral, a perceived lack of local access to PC, and a lack of uniform standardized assessment of symptom burden.

Barriers and Facilitators Impacting Lung Cancer Screening Uptake Among Black Veterans: A Qualitative Study.

Racial disparities in lung cancer screening (LCS) are well established. Black Veterans are among those at the highest risk for developing lung cancer but are less likely to complete LCS. We sought to identify barriers and facilitators to LCS uptake among Black Veterans. A qualitative study using semistructured interviews was conducted with 32 Black Veterans to assess for barriers, facilitators, and contextual factors for LCS and strategies to improve screening. Veterans were purposively sampled by age, sex, and LCS participation status (ie, patients who received a low-dose CT [LDCT], patients who contacted the screening program but did not receive an LDCT, and patients who did not connect with the screening program nor receive an LDCT). Interview guides were developed using the Theoretical Domains Framework and Health Belief Model. Data were analyzed using rapid qualitative analysis. Barriers of LCS uptake among Black Veterans include self-reported low LCS knowledge and poor memory, attention, and decision processes associated with the centralized LCS process. Facilitators of LCS uptake among Black Veterans include social/professional role; identity and social influences; perceived susceptibility, threat, and consequences due to smoking status and military or occupational exposures; emotion, behavioral regulation, and intentions; and high trust in providers. Environmental context and resources (eg, transportation) and race and racism serve as contextual factors that did not emerge as having a major impact on LCS uptake. Strategies to improve LCS uptake included increased social messaging surrounding LCS, various forms of information dissemination, LCS reminders, balanced and repeated shared decision-making discussions, and streamlined referrals. We identified addressable barriers and facilitators for LCS uptake among Black Veterans that can help focus efforts to improve disparities in screening. Future studies should explore provider perspectives and test interventions to improve equity in LCS.

Community Health Care Providers' Perspectives on Human Immunodeficiency Virus Pre-Exposure Prophylaxis Use Among Black Women in Eastern Virginia.

The most at-risk population among women for human immunodeficiency virus (HIV) diagnosis in the United States are Black women, accounting for 61% of all new HIV cases. Pre-exposure prophylaxis (PrEP) is a safe and effective HIV prevention method for people at risk of HIV acquisition. Although disproportionately affected by HIV, Black women's knowledge, perceived benefits, and uptake of PrEP remain low. The socioecological model (SEM) may be useful for understanding why there is a low uptake of PrEP among Black women. The current study used the SEM to explore provider perspectives on the barriers and facilitators of PrEP uptake among Black women in Eastern Virginia. Semistructured interviews were conducted with a total sample of 15 community health care providers. Barriers of PrEP uptake at the societal (e.g., PrEP advertisements focus on gay men), community/organizational (e.g., time constraints in the workplace), interpersonal (e.g., perceived monogamy), and individual (e.g., unmet basic needs) levels were identified. Providers also identified facilitators of PrEP uptake at the societal (e.g., PrEP advertisements that target women), community/organizational (e.g., PrEP education), interpersonal (e.g., HIV-positive partner), and individual (e.g., PrEP awareness and perceived susceptibility to HIV) levels. These findings highlight unique barriers to accessing and taking PrEP for Black women in the United States, and potential factors that could facilitate PrEP use. Both barriers and facilitators may be important targets for interventions to improve PrEP uptake. Future research focused on improving PrEP uptake among Black women in the United States should consider multi-level interventions that target barriers and facilitators to reduce rates of HIV infections.

Perspectives of Certified Nurse-Midwives and Physicians on the Structural and Institutional Barriers that Contribute to the Reproductive Inequities of Black Birthing People in the San Francisco Bay Area.

Black birthing people in the United States disproportionately endure inequitable experiences and outcomes during pregnancy and childbirth via structural, interpersonal, and obstetric racism. In this study, the researchers explore provider perspectives of how racism is perpetuated in institutional perinatal and reproductive health care. Critical Race Theory, Reproductive Justice, and midwifery theory were operationalized through secondary thematic analysis of existing qualitative data from the Community Racial Equity and Training Interventions and Evaluation of Current and Future Healthcare Clinicians Study. Twenty-four perinatal providers (certified nurse-midwives [n = 7] and physicians [n = 17]) voluntarily participated in interviews. A comparative approach was used to determine how professional identity and model of care influence physicians' and certified nurse-midwives' perceptions of equity. Thematic analysis produced 5 themes: racism as a comorbidity, health care systems' inability to address the needs of Black birthing people, health care systems prioritizing providers over patients are failed systems, patients are the experts in the optimal health care model, and benefits of interprofessional teams grounded in Reproductive Justice. Additionally, both physicians and midwives expressed a need for a new care model. With these findings, our team proposes a modification of the midwifery model for application by all provider types that could radically shift the experience and outcomes of perinatal and reproductive health care and reduce mortality. Using a human rights approach to care, a Reproductive Justice-Public Health Critical Race praxis-informed midwifery model may be operationalized by all perinatal and reproductive health care providers. This novel model reflects an iterative process that may offer institutions and providers methods to build on past research supporting midwifery-centered care for improving outcomes for all patients by specifically focusing on improving care of Black birthing people. The implications of this work offer broad application in current clinical practice, quality improvement, research, technology, and patient resources.

Exploring service provider perspectives on service user engagement across service components in coordinated specialty care programs for psychosis.

Engagement in services is a core element to successful outcomes for service users and programs. In coordinated specialty care (CSC) programs, designed for individuals experiencing first-episode psychosis, engagement has only been measured programmatically and not by service component. This qualitative study sought to explore provider perspectives on service user engagement in service components of CSC. Semistructured interviews were conducted with 20 service providers from five community-based early intervention programs for psychosis in the United States. Interviews were recorded and transcribed verbatim, and thematic analysis was used to analyze the data collected. Provider participants described barriers and facilitators that contribute to disengagement or engagement in four service components within early intervention programs: individual psychotherapy, family education and support, medication management, and vocational services. Barriers identified included substance use, stigma, trauma, and external pressures. Identified barriers to engagement in CSC were both unique to individual components and cut across them. By better understanding the complexity of barriers and their intersections within and across CSC components, there can be more effective policy and program development to reduce disengagement and hopefully increase positive outcomes for service users. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Provider Perspectives on Addressing Firearm Safety with Older Adults in Primary Care

ABSTRACT Objectives Chronic conditions, including mild cognitive impairment and depression, place older adults at high risk of firearm suicide. Approximately 40% of older adults have access to a firearm, and many do not store their firearms safely. However, firearm counseling occurs infrequently in clinical settings. Using by the Ottawa Decision Support Framework (ODSF) to conceptualize the decisional support needed by patients and their providers to facilitate firearm counseling, we explore provider perspectives on desired resources for addressing firearm safety with older adult patients. Methods From March – August 2022, we conducted 21 semi-structured interviews with primary care providers caring for older adults. We report deductive concepts as well as emergent themes. Results Major themes were identified from the three components of the ODSF; decisional needs, decision support and decisional outcomes. Themes included: provider self-efficacy to conduct firearm counseling, clinical workflow considerations, stories for change, patient diagnosis implications, and caregiver involvement. Conclusions There is a need for decision aids in the clinical setting that facilitate firearm counseling and promotes shared decision-making about firearm storage. Clinical Implications Implementing a decision aid in the clinical setting can improve provider self-efficacy to conduct firearm counseling and help reduce risk factors associated with firearm-related harm among older adults.

Provider Perspectives on Telehealth Services for Children with Autism Spectrum Disorder During the COVID-19 Pandemic.

The purpose of the current study was to explore provider perspectives on the strengths and challenges of telehealth services (e.g., behavioral interventions, physical, speech, and occupational therapy, medication management) for children with ASD during COVID-19 related shutdowns. From September 2020 to May 2021, we conducted qualitative interviews with 35 providers across multiple disciplines from 17 sites in the Autism Care Network. Qualitative data was analyzed using a framework approach and common themes were identified. Providers across clinical disciplines identified strengths of the virtual model, such as its flexibility and the opportunity it provided to see children in their home environment. They also indicated that some interventions worked better virtually than others, and that there were several factors that impacted their success. Respondents were generally satisfied providing parent-mediated interventions but expressed mixed satisfaction in using telehealth for direct-to-patient care. Results suggest that telehealth services for children with ASD could be a helpful tool in decreasing barriers and improving service delivery, especially when tailored to the individual needs of the patient. More research is needed on the factors contributing to its success in order to eventually inform clinical guidelines regarding the prioritization of children seen for in-person visits.

"How can you kiss and touch this child and show affection towards her? What kind of woman are you?": Provider perspectives on stigma towards native and ethnic minority street-connected youth in the Republic of Georgia.

The Republic of Georgia has experienced a rapid growth in the number of youth working and/or living on the street (YWLS). Although research indicates that YWLS are highly stigmatized, few studies have examined perceptions of stigma among Georgian social service providers who serve YWLS. We conducted in-person in-depth interviews with key informants recruited from governmental institutions and social service organizations in Tbilisi and Rustavi, two large urban areas. A semi-structured interview guide was used to explore provider perspectives on the social contexts surrounding the delivery of services to YWLS. Trained coders conducted a thematic analysis of the data in Dedoose. Twenty-two providers (68% female; 32% male) were interviewed, representing diverse professional roles. Providers perceived that YWLS are subjected to strong public stigma and social exclusion at multiple social-ecological levels, with Roma and Kurdish-Azeri youth experiencing the strongest levels of social hostility, discrimination, and exclusion. Providers perceive that these dynamics prevent YWLS from developing trusting relationships with social service, health and educational institutions. Furthermore, we find that providers report encounters with courtesy stigma, i.e., stigma directed towards the people who serve or are associated with a stigmatized group, when working with YWLS, especially those from ethnic minority groups, which they characterize as a stressor. At the same time, we find that some providers reported negative stereotypes about ethnic minority YWLS. While campaigns have targeted public awareness on the plight of YWLS, study findings suggest that additional efforts are needed to address stigma directed towards YWLS, with a specific need to address stigma directed towards ethnic minority young people who work and/or live on the street.

179. It’s a Hurdle We Have to Cross, But it’s Just Not a Priority… We Have to Deal With Right Now.” Provider Perspectives on Tobacco Cessation for Young Adults with HIV who Co-use Tobacco and Cannabis

Health conditions related to tobacco use are the leading cause of morbidity among people with HIV (PWH). Twenty to 40% of PWH aged 18-24 use some form of tobacco; more than 50% of daily tobacco-using PWH aged 18-24 also smoke cannabis. Cannabis use can lead to challenges with tobacco cessation and even tobacco re-initiation. This study sought to explore provider perspectives about barriers and facilitators to approaching tobacco cessation in PWH 18-24 years old who co-use tobacco and cannabis.

Provider Attitudes on Regionalization of Maternity Care: A National Survey.

To explore provider perspectives surrounding national guidelines proposing regionalization of maternal care. An 18-item survey focused on provider attitudes and practices surrounding regionalized maternity care was administered to a national sample of practicing obstetricians. We classified respondants reporting less than 500 annual deliveries at their hospital as low-volume providers and those practicing at hospitals performing 500 or more annual deliveries as high-volume providers. We compared responses according to hospital delivery volume using univariate analysis. Of the 497 physicians surveyed, 278 people responded (56%) with 229 currently practicing obstetrics. The median annual delivery volume amongst respondents was 200 (interquartile range 100-1900) with 146 (63.7%) practicing in low-volume delivery centers. The need for medical or surgical expertise was the most commonly reported indication for maternal transfer (19.7%) and independent of practice setting. Ninety-six percent of providers agreed with the concept of regionalization, but respondents in high-volume centers reported higher familiarity with the levels of maternal care paradigm compared to their low-volume counterparts (81.9% v. 62.3%, p < 0.01). Financial factors (60.3%), geography (48.9%), and access to care (43.2%) were the most cited major barriers to regionalization. High-volume providers endorsed geography as a major barrier more often than low-volume providers (57.8% v. 43.8%, p = 0.04). Obstetricians may agree with the concept of regionalized maternity care but also identify significant barriers to its implementation. Early and frequent engagement of providers reflecting the diversity of delivery centers in a region is a simple but necessary step in any attempts to designate levels of maternal care.

Patient-Centred Care for Patients With Diabetes and HIV at a Public Tertiary Hospital in South Africa: An Ethnographic Study.

Background: Healthcare systems across the globe are adopting patient-centred care (PCC) approach to empower patients in taking charge of their illnesses and improve the quality of care. Although models of patient‐centredness vary, respecting the needs and preferences of individuals receiving care is important. South Africa has implemented an integrated chronic disease management (ICDM) which has PCC component. The ICDM aims to empower chronic care patients to play an active role in disease management process, whilst simultaneously intervening at a community/ population and health service level. However, chronic care is still fragmented due to systemic challenges that have hindered the practice of PCC. In this article, we explore provider perspectives on PCC for patients with comorbid type 2 diabetes and HIV at a public tertiary hospital in urban South Africa. Methods: This study utilizes ethnographic methods, encompassing clinical observations, and qualitative interviews with healthcare providers (n=30). Interview recordings were transcribed verbatim and data were analyzed inductively using a grounded theory approach. Results: Providers reported various ways in which they conceptualized and practiced PCC. However, structural challenges such as staff shortages, lack of guidelines for comorbid care, and fragmented care, and patient barriers such as poverty, language, and missed appointments, impeded the possibility of practicing PCC. Conclusion: Health systems could be strengthened by: (i) ensuring appropriate multidisciplinary guidelines for managing comorbidities exist, are known, and available, (ii) strengthening primary healthcare (PHC) clinics by ensuring access to necessary resources that will facilitate successful integration and management of comorbid diabetes and HIV, (iii) training medical practitioners on PCC and structural competence, so as to better understand patients in their sociocultural contexts, and (iv) understanding patient challenges to effective care to improve attendance and adherence.

Provider Perspectives on the Feasibility and Utility of Routine Patient-Reported Outcomes Assessment in Heart Failure: A Qualitative Analysis.

BackgroundPatient‐reported outcomes (PROs) objectively measure health‐related quality of life and provide prognostic information. Advances in technology now allow for rapid, patient‐friendly PRO assessment and scoring, yet the adoption of PROs in clinic has been slow. We conducted a multicenter qualitative study of diverse providers to describe the barriers and facilitators of routine PRO use in heart failure clinics.Methods and ResultsSixty heart failure providers from 5 institutions participated in 8 focus groups to explore provider perspectives on the use of heart failure‐specific and generic PROs in clinical practice. A qualitative editing approach was used to analyze the data, whereby a coding dictionary was iteratively developed and applied using the qualitative software program Altas.ti. Three main themes, supporting and impeding PRO use, emerged: (1) data collection; (2) presentation and interpretation; and (3) utility and value. For each construct, we identified perspectives that highlighted both barriers and facilitators. Providers identified burden, survey fatigue, and language/health literacy barriers as potentially impeding data collection. Optimal workflow, PRO frequency and length, use of PRO translations, and assistance of a patient's proxy were suggested as facilitators. Focus group discussions provided insight on how to display PROs to support its interpretability and sharing. Furthermore, the need to educate providers on the utility and value PROs over and above current clinical approaches emerged.ConclusionsOvercoming the barriers and supporting facilitators of PRO adoption could potentially lead to more successful adoption of PROs in heart failure clinics.

Sources of Distress in Primary Care Opioid Management and the Role of a Controlled Substance Review Group: A Qualitative Study.

The objective of the study was to explore provider perspectives surrounding opioid prescribing in the context of the early implementation of a multidisciplinary group, called the Controlled Substance Review Group, that provided structured opioid case discussion and consultation to primary care providers. A Veterans Health Administration primary care clinic in Portland, Oregon. Participants: 12 members of primary care clinic staff representing multiple disciplines with recent participation in the Controlled Substance Review Group. Six semistructured interviews with primary care providers, one focus group discussion with six Nurse Care Managers, and 28 structured observations of CSRG meetings were conducted. In an iterative process using applied thematic analysis, a trained qualitative researcher reviewed textual data for themes. Four broad domains with associated themes emerged from the analysis: 1) challenges of pain management-objective pain measures, changing guidelines, lack of coordinated approach; 2) patient attachment to opioids-threats, entitlement, abandonment; 3) provider frustration-confrontation in clinic visits, lack of mental health engagement, complex social situation; and 4) role of the Controlled Substance Review Group-communication techniques, supporting mental health engagement, structured backing. Primary care providers experience stress associated with opioid prescribing, including the provision of appropriate pain management using opioid analgesics and difficult patient-provider communication. The Controlled Substance Review Group functions to support providers through assistance with decision-making and shared responsibility for decision outcomes.

Use of electronic dietary assessment tools in primary care: an interdisciplinary perspective.

BackgroundDietary assessment can be challenging for many reasons, including the wide variety of foods, eating patterns and nutrients to be considered. In team-based primary care practice, various disciplines may be involved in assessing diet. Electronic-based dietary assessment (e-DA) instruments available now through mobile apps or websites can potentially facilitate dietary assessment. Providers views of facilitators and barriers related to e-DA instruments and their recommendations for improvement can inform the further development of these tools. The objective of this study was to explore provider perspectives on e-DA tools in mobile apps and websites.MethodsThe exploratory sequential mixed methods design included interdisciplinary focus groups followed by a web-based survey sent to Family Health Teams throughout Ontario, Canada. Descriptive and bivariate analyses were completed. Focus group transcripts contributed to web-survey content, while interpretive themes added depth and context.Results11 focus groups with 50 providers revealed varying perspectives on the use of e-DA for: 1) improving patients’ eating habits; 2) improving the quality of dietary assessment; and, 3) integrating e-DA into the care process. In the web-survey 191 respondents from nine disciplines in 73 FHTs completed the survey. Dietitians reported greater use of e-DA than other providers (63% vs.19%; p = .000) respectively. There was strong interest among disciplines in the use of e-DA tools for the management of obesity, diabetes and heart disease, especially for patient self-monitoring. Barriers identified were: patients’ lack of comfort with using technology, misinterpretation of e-DA results by patients, time and education for providers to interpret results, and time for providers to offer counselling.Conclusionse-DA tools in mobile apps and websites may improve dietary counselling over time. Addressing the identified facilitators and barriers can potentially promote the uptake of e-DA into clinical practice.

Access to traumatic spinal cord injury care in Saskatchewan, Canada: A qualitative study on community healthcare provider perspectives

Healthcare provider experiences with access to care for disabled patient populations may inform healthcare system change and improve health outcomes. Persons with spinal cord injury often require access to life-long care. The objective of this study was to explore healthcare provider perspectives on client access to care in traumatic spinal cord injury. We used an interpretive qualitative study with semi-structured interviews and focus groups to explore provider perspectives on five access dimensions: availability, accessibility, affordability, accommodation, and acceptability. Volunteer (n=23) healthcare providers (therapists, physicians, nurses, home care workers and managers) working with traumatic spinal cord injury clients in Saskatchewan participated. Nine healthcare providers serviced rural areas. Healthcare providers felt restricted in their ability to ensure availability of services. In rural areas, therapy and counselling services were often not available. Parking and transportation barriers severely impacted the accessibility of services. Inconsistencies related to the affordability of equipment and accessible housing were expressed. Efforts to accommodate clients to remain in their home communities were apparent. Night time or early morning care seemed impossible to accommodate. Healthcare providers accepted that attitudes and efforts concerning health advocacy among clients, families, and other care providers impacted access. Barriers related to availability, accessibility, and affordability were perceived to affect traumatic spinal cord injury care. Healthcare providers identified the need to accommodate clients’ needs by assuming different healthcare and advocacy roles, especially in the face of service shortages. However, restrictions imposed by administrative guidelines, policies or cost were perceived to limit the ability to fully accommodate client’s needs.

Lessons on Measuring e-Government Satisfaction

This paper summarises lessons learned in relation to an ongoing study to collect feedback on e-government systems that have been implemented to e-enable several core administrative functions in the UK as part of the I-MEET project. Previous work summarises findings from surveys of users of such systems and this paper reports on the experience of surveying providers. An extensive survey was designed and administered to explore provider perspectives on the e-government application in general, system aspects, cost, implementation, prerequisites (e.g. policy support), various dimensions of effects, and the respondent's overall opinion of the system. The survey found a complex mix of internal and external contacted service providers and commissioners, each of whom has a different set of success measures for a service, and shared services (such as common web site providers) that were not obvious but could result in correlated observations. These findings provide signposts for future researchers to potential pitfalls. Nevertheless, when complete, the integration by the I-MEET project of user and provider perspectives will give policy makers the opportunity to balance the scale, complexity and expense of electronically delivered transactions on the government side with the usability and satisfaction from the user perspective, revealing linkages between aspects of both.

The VISYTER Telerehabilitation System for Globalizing Physical Therapy Consultation: Issues and Challenges for Telehealth Implementation

Background and Purpose. There are substantive issues to address in physical therapist education programs facing obstacles related to faculty funding for educational endeavors, identification of optimal pedagogies, and consideration of global and national health concerns. Educational technologies may serve as tools to expand the delivery of high-quality, efficient health care education to address current, evolving, and future needs of physical therapist students and the patients they will serve. The purpose of this case report is to describe the Versatile and Integrated System for Telerehabilitation (VISYTER) and its use for physical therapy telehealth consultation in an international setting, as well as its use to measure patient satisfaction and explore provider perspectives on the experience. Case Description. Three pediatric patients, 1 male and 2 females, with a mean age of 5 years (SD=3), and located in Mexico, participated in a telehealth session with academic and clinical faculty in the United States using the VISYTER telerehabilitation system. A patient satisfaction survey and user perspectives were collected and analyzed. Key themes were identified from semi-structured interviews with patients, family members, and health care providers. Outcomes. Patient satisfaction was high for utilizing the VISYTER telerehabilitation system. A key theme was that technology-assisted collaboration between the health care team members and patients may further education, research, and practice in Mexico and the United States. Discussion and Conclusion. Several challenges must be addressed when considering telehealth implementation internationally. Overall, the VISYTER telerehabilitation software, using lowbandwidth Internet connections (384 kbps) and aggressive compression with low resolution (320 x 240), allowed for a stable telehealth physical therapy consultation between Mexico to the United States.