Telemedicine Encounters Research Articles

The Impact of International Classification of Disease-Triggered Prescription Support on Telemedicine: Observational Analysis of Efficiency and Guideline Adherence.

Integrating decision support systems into telemedicine may optimize consultation efficiency and adherence to clinical guidelines; however, the extent of such effects remains underexplored. This study aims to evaluate the use of ICD (International Classification of Disease)-coded prescription decision support systems (PDSSs) and the effects of these systems on consultation duration and guideline adherence during telemedicine encounters. In this retrospective, single-center, observational study conducted from October 2021 to March 2022, adult patients who sought urgent digital care via direct-to-consumer video consultations were included. Physicians had access to current guidelines and could use an ICD-triggered PDSS (which was introduced in January 2022 after a preliminary test in the preceding month) for 26 guideline-based conditions. This study analyzed the impact of implementing automated prescription systems and compared these systems to manual prescription processes in terms of consultation duration and guideline adherence. This study included 10,485 telemedicine encounters involving 9644 patients, with 12,346 prescriptions issued by 290 physicians. Automated prescriptions were used in 5022 (40.67%) of the consultations following system integration. Before introducing decision support, 4497 (36.42%) prescriptions were issued, which increased to 7849 (63.57%) postimplementation. The physician's average consultation time decreased significantly to 9.5 (SD 5.5) minutes from 11.2 (SD 5.9) minutes after PDSS implementation (P<.001). Of the 12,346 prescriptions, 8683 (70.34%) were aligned with disease-specific international guidelines tailored for telemedicine encounters. Primary medication adherence in accordance with existing guidelines was significantly greater in the decision support group than in the manual group (n=4697, 93.53% vs n=1389, 49.14%; P<.001). Most of the physicians adopted the PDSS, and the results demonstrated the use of the ICD-code system in reducing consultation times and increasing guideline adherence. These systems appear to be valuable for enhancing the efficiency and quality of telemedicine consultations by supporting evidence-based clinical decision-making.

Characteristics of Patients Utilizing Telemedicine in Hand and Upper-Extremity Surgery.

The impact of social determinants of health on patients' access to medical care and health outcomes is increasingly recognized. Telemedicine's rapid and widespread adoption altered the delivery of care. This study describes the characteristics of patients undergoing telemedicine visits with hand surgeons, without COVID-19 pandemic-related restrictions. All telemedicine encounters for 4 hand surgeons at a single institution between September 2022 and September 2023 were retrospectively reviewed. Patient demographics were recorded as well as the encounter type. The distance of the patients' residential address and the area deprivation index (ADI) were recorded. Sixty patient encounters were recorded. Forty-seven percent were male and 53% were female, 5 (8.3%) were new patients, 44 (73.3%) were established patients, and 11 (18.3%) were postoperative. The mean age was 43, and the mean and median distances from the clinic were 72 and 18 miles, respectively. Forty-three patients (72%) were from high ADI residences. Upon comparison of low ADI (0-50th percentile) and high ADI (50th-100th percentile) patients, no statistically significant differences in age, sex, distance from clinic, or encounter type were found. Telemedicine in hand surgery at this single institution is most frequently used for follow-up encounter types in patients living in high ADI communities, far from clinic sites. Low or high ADI did not correlate with seasonal changes in the use of telemedicine, encounter type, or patient demographics. Telemedicine may improve patient access to hand surgery follow-up care. This may particularly benefit patients facing geographic and economic challenges to healthcare access. Prognostic Level IV.

Understanding Patient Satisfaction: A Comparative Analysis of Telemedicine versus In-person Encounters in Pediatric Plastic Surgery.

Telemedicine services experienced unprecedented growth during the coronavirus 2019 pandemic, offering patients remote access to care while minimizing exposures to possible infection. Our institution has one of the country's largest pediatric plastic surgery divisions and serves both a prominent metro area and sprawling rural community. Given the increasing utilization of telemedicine across several surgical subspecialties, this study aims to evaluate patient satisfaction following pediatric plastic surgery telemedicine encounters. Press Ganey surveys were completed by parents or guardians of pediatric plastic surgery patients after in-person or telemedicine encounters with a single surgeon. Surveys were gathered from March 2020 to December 2022. Only 13 of the 25 survey questions were applicable to both in-person and telemedicine encounters and were included for analysis. Top box scores (the proportion of patients who selected the highest rating) were compared using Fisher exact test. Completed surveys were available for both groups from June 2020 to November 2022. A total of 223 surveys met inclusion criteria; there were 159 in-person encounters and 64 telemedicine encounters. Telemedicine encounters consistently had top box scores comparable to, or greater than, in-person encounters for all 13 survey questions. Statistically significant differences were observed for ease of contacting the practice (P = 0.002) and scheduling appointments (P < 0.0001). Pediatric plastic surgery encounters completed via telemedicine demonstrate high patient satisfaction, exceeding in-person encounters for accessibility and convenience. Our study provides objective data about the patient experience and emphasizes the value of integrating telemedicine into pediatric plastic surgery practices.

Telemedical Direction to Optimize Resource Utilization in a Rural Emergency Medical Services System.

Telemedicine remains an underused tool in rural emergency medical servces (EMS) systems. Rural emergency medical technicians (EMT) and paramedics cite concerns that telemedicine could increase Advanced Life Support (ALS) transports, extend on-scene times, and face challenges related to connectivity as barriers to implementation. Our aim in this project was to implement a telemedicine system in a rural EMS setting and assess the impact of telemedicine on EMS management of patients with chest pain while evaluating some of the perceived barriers. This study was a mixed-methods, retrospective review of quality assurance data collected prior to and after implementation of a telemedicine program targeting patients with chest pain. We compared quantitative data from the 12-month pre-implementation phase to data from 15 months post-implementation. Patients were included if they had a chief complaint of chest pain or a 12-lead electrocardiogram had been obtained. The primary outcome was the rate of ALS transport before and after program implementation. Secondary outcomes included EMS call response times and EMS agency performance on quality improvement benchmarks. Qualitative data were also collected after each telemedicine encounter to evaluate paramedic/EMT and EMS physician perception of call quality. The telemedicine pilot project was implemented in September 2020. Overall, there were 58 successful encounters. For this analysis, we included 38 patients in both the pre-implementation period (September 9, 2019-September 10, 2020) and the post-implementation period (September 11, 2020-December 5, 2021). Among this population, the ALS transport rate was 42% before and 45% after implementation (odds ratio 1.11; 95% confidence interval 0.45-2.76). The EMS median out-of-service times were 47 minutes before, and 33 minutes after (P = 0.07). Overall, 64% of paramedics/EMTs and 89% of EMS physicians rated the telemedicine call quality as "good." In this rural EMS system, a telehealth platform was successfully used to connect paramedics/EMTs to board-certified EMS physicians over a 15-month period. Telemedicine use did not alter rates of ALS transports and did not increase on-scene time. The majority of paramedics/EMTs and EMS physicians rated the quality of the telemedicine connection as "good."

Usability And Feasibility of an in-Home Remote Exam Device in Children with Medical Complexity During the COVID-19 Pandemic.

Background: Children with medical complexity (CMC) account for high health care utilization. Telemedicine holds significant potential in CMC, as it allows a provider to engage with CMC in their home environment and can alleviate both financial and transportation burdens. Remote exam devices that enable the performance of a physical exam could expand the ability of providers to clinically assess CMC during a telemedicine visit. In this pilot study, our goal was to develop a process for integrating an in-home remote exam device into a complex care clinic during the COVID-19 pandemic and evaluate the usability and feasibility of this device. Methods: The remote exam device was distributed to caregivers of CMC cared for at a complex care outpatient center. Using deliberate practice framework, our onboarding process provided opportunities for caregivers and providers to learn how to utilize the device. Surveys examining usability and feasibility were administered to both caregivers and providers after each telemedicine encounter. Results: A total of 43 caregivers participated in the onboarding process, which included a total of 83 practice visits. The remote exam device was rated as having excellent usability by caregivers; however, providers rated the device as having lower usability. Feasibility was notable for technology issues contributing to 15% of encounters being cancelled or ending early. Conclusions: The remote exam device was successfully integrated into a complex care clinic. Data from this pilot study supports the usability and feasibility of deploying a remote exam device across a telemedicine platform in a busy and complex outpatient academic practice.

Difference in medical student performance in a standardized patient encounter between telemedicine and in-person environments

ABSTRACT Introduction Telemedicine is an increasingly common form of healthcare delivery in the United States. It is unclear how there are differences in clinical performance in early learners between in-person and telemedicine encounters. Materials & Methods The authors conducted a single-site retrospective cohort study of 241 second-year medical students to compare performance between in-person and telemedicine standardized patient (SP) encounters. One hundred and twenty medical students in the 2020 academic year participated in a telemedicine encounter, and 121 medical students in the 2022 academic year participated in an in-person encounter. SPs completed a multi-domain performance checklist following the encounter, and the authors performed statistical analyses to compare student performance between groups. Results Students who completed in-person encounters had higher mean scores in overall performance (75.2 vs. 69.7, p < 0.001). They had higher scores in physical exam (83.3 vs. 50, p < 0.001) and interpersonal communication domains (95 vs. 85, p < 0.001) and lower scores in obtaining a history (73.3 vs. 80, p = 0.0025). There was no significant difference in assessment and plan scores (50 vs. 50, p = 0.96) or likelihood of appropriately promoting antibiotic stewardship (41.3% vs. 45.8%, p = 0.48). Conclusion The authors identified significant differences in clinical performance between in-person and telemedicine SP encounters, indicating that educational needs may differ between clinical environments.

Unveiling the Adoption and Barriers of Telemedicine in US Hospitals: A Comprehensive Analysis (2017-2022).

Telemedicine has emerged as a vital healthcare delivery model, especially pronounced during the COVID-19 pandemic. Our study uniquely focuses on an institutional lens, examining US hospitals to offer targeted policy implications. To investigate the trend in telemedicine adoption across US hospitals from 2017 to 2022 and analyze the institutional challenges they encounter, particularly in the realm of electronic health information exchange. Cross-sectional study leveraging data from the American Hospital Association's (AHA) annual surveys for the years 2017 to 2021 and the 2022 AHA IT Supplement Survey. The study includes a national sample of US hospitals, covering a diverse range of hospital types including large, nonprofit, teaching, and system-affiliated institutions. US hospitals form the study's participants, with a substantial response rate to the surveys. Key metrics include the number of telemedicine patient encounters, percentage of hospitals offering telemedicine services, and institutional challenges to electronic health information exchange. Telemedicine encounters saw a 75% increase, growing from approximately 111.4 million in 2020 to nearly 194.4 million in 2021. The percentage of hospitals offering at least one form of telemedicine service went from 46% in 2017 to 72% in 2021. Larger, nonprofit, and teaching hospitals were more prone to telehealth adoption, without notable urban-rural disparities. While over 90% of hospitals allow patients to view and download medical records, only 41% permit online data submission. Importantly, 25% of hospitals identified Certified Health IT Developers such as EHR vendor as frequent culprits in information blocking, with cost being the primary obstacle. The findings underscore the rapid yet uneven adoption of telemedicine services in U.S. hospitals. The results point to the need for comprehensive policy interventions to address the challenges identified and realize telemedicine's full potential in healthcare delivery and resilience.

An After-Hours Telemedicine Urgent Care Service May Not Improve Access to Care for Underserved Populations.

Background: After-hours telemedicine services for emergency care are thought to offer a solution for patients who live at a distance from traditional face-to-face emergency services. This study evaluates such a service in a Health Maintenance Organization, focusing on the differences between central and peripheral populations. Methods: In this cross-sectional database study, we collected data regarding the encounter and patient characteristics, including prescriptions, referrals for further evaluation in a traditional emergency department (ED), and the distance from a traditional ED. Other outcome measures included health care utilization after the encounter such as primary care physician (PCP) encounters, additional telemedicine encounters, ED visits, and hospitalization. Results: In total, 45,411 patient visits were analyzed. Medication was prescribed in 25% of the encounters, and a referral to an ED was given in 22%. In total, 17.7% of the patients visited an ED within 24 h of the index encounter. In total, 64.8% of patients visited a PCP in the following 30 days. No further care was needed in 32.4% of the encounters. In multivariable logistic regression, the odds of using the service were lower for low socio-economic status groups and inhabitants of the periphery than the central areas. A weak reverse correlation was observed in Jewish sectors regarding distance from traditional ED, whereas no correlation was found in the Arab sector. Conclusion: It is commonly believed that telemedicine overcomes geographical barriers. The results of this research do not support this hypothesis.

Multidrug stewardship and adherence to guidelines in >200,000 direct-to-consumer Telemedicine encounters.

The quality of care and safety for Telemedicine-discharged patients with suspected respiratory infections are closely related to low rates of prescriptions of unjustified and high-risk medications. This retrospective study aimed to assess adherence to the current COVID-19 guidelines in direct-to-consumer telemedicine encounters at a large center using multidrug stewardship protocols. A quarterly electronic survey utilizing medical records of individual physician care assessed various quality indicators. Physicians received ongoing adaptive feedback based on personal metrics, with Telemedicine Center recommendations derived from the 2020 Infectious Diseases Society of America guidelines. The study included all consecutive adults with new respiratory symptoms in the last 14 days who sought spontaneous Telemedicine consultations between March 2020 and August 2021. This study analyzed patients with suspected or confirmed COVID-19 and other airway infections. Of the 221,128 evaluated patients, 42,042 (19%) had confirmed COVID-19; 104,021 (47%) were suspected to have COVID-19; and, 75,065 (33%) had other diagnoses. Patients with suspected or confirmed COVID-19 had a mean (+DP) age of 35±12 years. A total of 125,107 (85.65%) patients were managed at home, 2,552 (1.74%) were referred for non-urgent in-office reassessment, and 17,185 (11.7%) were referred to the emergency department for whom there was no further treatment recommendation. The antibiotic rate in confirmed or suspected COVID-19 cases was 0.46%/0.65% and that for non-evidence-based prescriptions was 0.01%/0.005%. Guideline training and Telemedicine consultation feedback may lead to lower antibiotic and antimicrobial prescriptions in suspected and confirmed COVID-19 cases. Multidrug stewardship protocols may improve guideline adherence and reinforce the quality of care and safety in Telemedicine encounters.

Telemedicine impact on patient disparities and physician practice patterns in cancer rehabilitation: A multicenter retrospective study.

To examine the impact of telemedicine on demographic and practice patterns between outpatients receiving virtual versus in-person cancer rehabilitation physiatry care. Multicenter retrospective study. Outpatient cancer rehabilitation physiatry clinics at four academic medical centers in the United States. Patients with cancer diagnoses or history of cancer diagnosis. Cancer rehabilitation physiatry encounters. Visit mode (in-person, telemedicine); disparities variables (age, race, and gender) by visit mode, and practice interventions (imaging, medications, procedures, other orders, and orders of any type) by visit mode. Among a total of 7004 encounters, 2687 unique patients were found. In-person participants were significantly older than the average telemedicine participant (mean 62.9 vs. 60.7 years; p < .001). A race effect was seen (p = .037) with individuals reporting as Asian or other being more likely to have telemedicine encounters. No gender disparities were seen. Using a random visit analysis model to compare populations receiving in-person versus telemedicine care, a slight majority (53%) of follow-up visits were via telemedicine, versus 40% of new patient visits (p < .001). No significant differences were seen in medication prescribing frequency (38.9% telemedicine vs. 36.7% in-person, adjusted relative risk [RR]: 0.988, confidence interval [CI]: 0.73-1.34; p = .988) or imaging frequency (2.4% telemedicine vs. 7.6%; adjusted RR: 0.784, CI: 0.44-1.39; p = .408) between telemedicine versus in-person visit types. Other orders were significantly less likely to be placed during telemedicine than in-person visits (19.9% telemedicine vs. 28.6% in-person; adjusted RR: 0.623, CI: 0.45-0.86, p = .004). Order(s) of any type were placed in 54% of visits (52% telemedicine vs. 56% in-person; adjusted RR: 0.92 for telemedicine, CI: 0.83-1.01, p = .082). Telemedicine has been integrated into cancer rehabilitation physiatry practices and appears to be conducive for placing many types of orders, especially medications. Age was found to be the only major demographic difference between in-person and telehealth patients.

Care Integration for Hepatitis C Virus Treatment Through Facilitated Telemedicine Within Opioid Treatment Programs: Qualitative Study.

Telemedicine has the potential to remove geographic and temporal obstacles to health care access. Whether and how telemedicine can increase health care access for underserved populations remains an open question. To address this issue, we integrated facilitated telemedicine encounters for the management of hepatitis C virus (HCV), a highly prevalent condition among people with opioid use disorder (OUD), into opioid treatment programs (OTPs). In New York State, OTPs are methadone-dispensing centers that provide patient-centered, evidence-based treatment for OUD. We investigated the integration and impact of facilitated telemedicine into OTP workflows in these settings. This study aims to understand OTP staff experiences with integrating facilitated telemedicine for HCV treatment into OTPs, including best practices and lessons learned. We conducted semistructured interviews with 45 OTP staff members (13 clinical, 12 administrative, 6 physicians, and 14 support staff members) at least one year after the implementation of facilitated telemedicine for HCV management. We used hermeneutic phenomenological analysis to understand OTP staff experiences. We identified 4 overarching themes illustrating the successful integration of facilitated telemedicine for HCV care into OTPs. First, integration requires an understanding of the challenges, goals, and values of the OTP. As OTP staff learned about new, highly effective HCV therapies, they valued an HCV cure as a "win" for their patients and were excited about the potential to eliminate a highly prevalent infectious disease. Second, the integration of facilitated telemedicine into OTPs fosters social support and reinforces relationships between patients and OTP staff. OTP staff appreciated the ability to have "eyes on" patients during telemedicine encounters to assess body language, a necessary component of OUD management. Third, participants described high levels of interprofessional collaboration as a care team that included the blurring of lines between disciplines working toward a common goal of improving patient care. Study case managers were integrated into OTP workflows and established communication channels to improve patient outcomes. Fourth, administrators endorsed the sustained and future expansion of facilitated telemedicine to address comorbidities. OTP staff were highly enthusiastic about facilitated telemedicine for an underserved population. They described high levels of collaboration and integration comparable to relevant integrative frameworks. When situated within OTPs, facilitated telemedicine is a high-value application of telemedicine that provides support for underserved populations necessary for high-quality health care. These experiences support sustaining and scaling facilitated telemedicine in comparable settings and evaluating its ability to address other comorbidities. ClinicalTrials.gov NCT02933970; https://clinicaltrials.gov/study/NCT02933970.

Outcome After Self-Triage App Referral in Urgent Direct-to-Consumer Telemedicine Encounter.

Background: The quantification of self-triage effectiveness, guided by mobile applications, in urgent direct-to-consumer telemedicine (TM) encounters requires further investigation. The objective of this study was to evaluate the outcomes of referral guidance provided by a symptom-based self-management mobile application decision algorithm in the context of remote urgent care assessments. Methods: An observational retrospective single-center study was conducted from May 2022 to December 2023. The inclusion criteria encompassed individuals aged >18 years old, and those spontaneously seeking virtual emergency care through the EINSTEIN CONECTA application. Patients experiencing connectivity issues, preventing completion of the encounter, were excluded. The primary outcomes included the rate of patient concurrence with the algorithm's recommendation for seeking in-person emergency care and the referral rate to face-to-face assessment among cases evaluated through TM. The application's algorithm employs scientific evidence based on symptoms to recommend referrals to emergency departments (EDs). Results: Out of 88,834 patients connected to the TM Center, self-triage obviated the need for virtual physician assessment in 53,302 (60%) encounters. A total of 35,532 patients were remotely evaluated by 316 on-duty physicians, resulting in 1,125 ICD-coded diagnoses. Among these, 21,722 (61.1%) were initially advised by self-triage to visit the ED, with subsequent medical assessment leading to in-person referrals in 6,354 (29.3%) of the evaluations. Of the 13,810 patients recommended to continue with virtual care post-self-triage, 157 (1.1%) were referred for in-person assessment. Conclusions: Self-triage effectively reduced the need for physician encounters in approximately three-fifths of TM consultations. Despite being based on scientific evidence, symptom-based referral algorithms demonstrated high sensitivity but poor correlation with physician decision-making.

Telemedicine Quality Improvement during the Corona Virus 2019 Pandemic Increases Pediatric Weight Management Access.

The corona virus 2019 pandemic disrupted care for pediatric patients with chronic conditions, including those with childhood obesity. Lockdowns forced providers to create new ways of caring for this population. Telemedicine was a promising but previously unavailable solution. This quality improvement report details how the Healthy and Fit Children's Clinic transitioned and improved care via telemedicine. Between March 2020 and April 2021, the quality improvement project team incorporated the Model for Improvement to transition the clinic to telemedicine. The team tracked Healthy and Fit Children's Clinic appointments, no-shows, billing and reimbursement data, and noted unintended consequences or unanticipated barriers. Patients and their families were given a satisfaction survey at the end of each telemedicine encounter. Compared with pre-telemedicine implementation, there was a 120% increase in completed patient clinic visits per week and a sustained positive shift above the established baseline. Telemedicine no-show rates achieved <10%, with an average sustained rate of <20%, compared with unchanged in-person no-show rates of >50% pre- and post-telemedicine implementation. There was a 74% increase in monthly billing and a sustained positive shift above the pre-telemedicine baseline. On average, patients rated all six satisfaction questions ≥92 on the 100-point scale (compared with 83 pre-telemedicine). This transition to telemedicine was successful and could be translatable to other clinic sites. Patients attended their clinic visits more consistently and were highly satisfied with their care. In a population where continuity of care is paramount, telemedicine shows promise as a tool to treat childhood obesity.

Abstract WP52: Evaluation of Post Stroke Telehealth Services in Texas (Vast-1)

Background: Shortly after AHA/ASA released an updated policy on stroke care systems, COVID-19 disrupted these systems. Lockdowns and social distancing were considered critical to mitigate COVID-19 transmission but altered public perceptions about stroke medical care. As a result, telehealth expanded rapidly across Texas. However, little is known how to optimally integrate telehealth services into the continuum of stroke care. Methods: To identify barriers and facilitators of post-acute stroke telehealth services among stroke survivors’ facilities of the Lone Star Stroke Consortium (LSSC) Research Consortium, we conducted semi-structured interviews with stroke providers and focus groups with patients. Audiotapes were transcribed, and files prepared for analysis. Using a grounded theory approach, we performed data analysis to allow theory to emerge from data. Two independent reviewers read transcripts, developed coding using an iterative consensus building, verified codes, developed concepts, and created categories. Constant comparison process found emerging themes within each category. Results: We enrolled 23 providers and 34 patients. Access, telemedicine encounter and technology were revealed as major categories of post-acute stroke telehealth among providers and patients. Facilitators of access included increased accessibility and elimination of barriers. Reliable internet connection and technological skills were barriers for both groups. Patients and providers identified virtual visits as good. However, full medical exam, including cognitive evaluation, was a barrier for patients and providers. Technology increased ability to communicate with patients and providers. Barriers included constrains of internet services, lack of documentation for virtual visits, and lack of telemedicine platform. Conclusion: Our study will contribute to future telehealth services integration into continuum of stroke care.

A Digital Camera-Based Eye Movement Assessment Method for NeuroEye Examination

The ability to perform quantitative and automated neurological assessment could enhance diagnosis and treatment in the pre-hospital setting, such as during telemedicine or emergency medical services (EMS) encounters. Such a tool could be developed by adapting clinically significant information such as symmetry of eye movement or conjugate eye movement. Here we describe a digital camera-based eye tracking method “NeuroGaze” to capture the symmetry of eye movement while performing neurological eye examination. The proposed method was developed based on detecting the center of the pupil for both eyes from a given video and measuring eye conjugacy by transforming the pupil center coordinates to relative gaze. The method was tested on healthy volunteers while performing three neurological eye examinations <xref ref-type="fn" rid="fn1" xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">¹</xref> <fn id="fn1" xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink"><label>¹</label> The NeuroEye dataset is made available at <uri>https://www.kaggle.com/datasets/mahassan8/neuroeye</uri> </fn> . We also compared our proposed approach to state-of-the-art digital camera-based eye-tracking methods and commercial off-the-shelf (COTS) eye trackers. NeuroGaze outperformed digital camera-based eye tracking methods by reporting a mean Spearman rank-order correlation coefficient of 0.86 for the H-test, 0.87 for the Dot-test, and 0.56 for the OKN-Test, and shows similarity in trends for the relative gaze trajectories with a noticeable offset in the scale of the relative gaze angle compared to COTS eye tracker (see Fig. 1). The study demonstrates that by using a pupil-center-based eye-tracking method, a digital camera can measure clinically relevant information regarding eye movement.

Telemedicine in urologic oncology care: Will telemedicine exacerbate disparities?

IntroductionDisparities in prostate, bladder, and kidney cancer outcomes are associated with access to care. Telemedicine can improve access but may be underutilized by certain patient populations. Our objective was to determine if the patient populations who suffer worse oncologic outcomes are the same as those who are less likely to use telemedicine. MethodsUsing an institutional database, we identified all prostate, bladder and kidney cancer encounters from March 14, 2020 to October 31, 2021 (n = 15,623; n = 4, 14; n = 3,830). Telemedicine was used in 13%, 8%, and 12% of these encounters, respectively. We performed random effects modeling analysis to examine patient and provider characteristics associated with telemedicine use. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were reported as measures of association. ResultsAmong prostate, bladder, and kidney cancer patients, Black patients had lower odds of a telemedicine encounter (OR 0.51, 95% CI 0.37–0.69; OR 0.22, 95% CI 0.07–0.70; OR 0.46, 95% CI 0.24–0.86), and patients residing in small and isolated small rural towns areas had higher odds of a telemedicine encounter (OR 1.44, 95% CI 1.09–1.91; OR 2.12, 95% CI 1.14–3.94; OR 1.89, 95% CI 1.12–3.19). Compared to providers in practice ≤5 years, providers in practice for 6 to 15 years had significantly higher odds of a telemedicine encounter for prostate and bladder cancer patients (OR 4.10, 95% CI 1.4511.58; OR 3.42, 95% CI 1.09–10.77). ConclusionThe lower rates of telemedicine use among Black patients could exacerbate pre-existing disparities in prostate, bladder, and kidney cancer outcomes.

The Development and Use of a New Visual Tool (REVISIT) to Support Participant Recall: Web-Based Interview Study Among Older Adults.

Qualitative health services research often relies on semistructured or in-depth interviews to develop a deeper understanding of patient experiences, motivations, and perspectives. The quality of data gathered is contingent upon a patient's recall capacity; yet, studies have shown that recall of medical information is low. Threats to generating rich and detailed interview data may be more prevalent when interviewing older adults. We developed and studied the feasibility of using a tool, Remembering Healthcare Encounters Visually and Interactively (REVISIT), which has been created to aid the recall of a specific telemedicine encounter to provide health services research teams with a visual tool, to improve qualitative interviews with older adults. The REVISIT visual appointment summary was developed to facilitate web-based interviews with our participants as part of an evaluation of a geriatric telemedicine program. Our primary aims were to aid participant recall, maintain focus on the index visit, and establish a shared understanding of the visit between participants and interviewers. The authors' experiences and observations developing REVISIT and using it during videoconference interviews (N=16) were systematically documented and synthesized. We discuss these experiences with REVISIT and suggest considerations for broader implementation and future research to expand upon this preliminary work. REVISIT enhanced the interview process by providing a focus and catalyst for discussion and supporting rapport-building with participants.REVISIT appeared to support older patients' and caregivers' recollection of a clinical visit, helping them to share additional details about their experience. REVISIT was difficult to read for some participants, however, and could not be used for phone interviews. REVISIT is a promising tool to enhance the quality of data collected during interviews with older, rural adults and caregivers about a health care encounter. This novel tool may aid recall of health care experiences for those groups for whom it may be more challenging to collect accurate, rich qualitative data (eg, those with cognitive impairment or complex medical care), allowing health services research to include more diverse patient experiences.

Implementing a Patient-Reported Outcome Dashboard in Oncology Telemedicine Encounters: Clinician and Patient Adoption and Acceptability.

Telemedicine provides numerous benefits to patients, yet effective communication and symptom assessment remain a concern. The recent uptake of telemedicine provided an opportunity to use a newly developed dashboard with patient-reported outcome (PRO) information to enhance communication and shared decision making (SDM) during telemedicine appointments. The objective of this study was to identify barriers to using the dashboard during telemedicine, develop implementation strategies to address barriers, and pilot test use of this dashboard during telemedicine appointments in two practice settings to evaluate acceptability, adoption, fidelity, and effectiveness. Patients and clinicians were interviewed to identify determinants to dashboard use in telemedicine. Implementation strategies were designed and refined through iterative feedback from stakeholders. A pilot study of dashboard use was conducted from March to September 2022. Acceptability, adoption, and fidelity were evaluated using mixed methods. SDM was evaluated using the collaboRATE measure. One hundred two patient encounters were evaluated. Most patients (62; 60%) had completed some PRO data at the time of their telemedicine encounter. Most (82; 80%) encounters had clinician confirmation that PRO data had been reviewed; however, collaborative review of the dashboard was documented in only 27%. Degree of SDM was high (mean collaboRATE score 3.40; SD, 0.11 [95% CI, 3.17 to 3.63] out of a maximum score of 4). Implementation strategies focused on patient engagement, education, and remote PRO completion. Clinician-facing strategies included education, practice facilitation, and small tests of change. This study demonstrated that implementation of a PRO-based dashboard into telemedicine appointments was feasible and had acceptable adoption and acceptability by patients and clinicians when several strategies were used to engage end users. Strategies targeting both patients and clinicians are needed to support routine and effective PRO integration in telemedicine.

Integrating Telemedicine Training into the Graduate Medical Education Curriculum

Objectives The primary objective of this study was to examine current emergency medicine resident knowledge of telemedicine, expose residents to standardized telemedicine patients virtually, and analyze the effectiveness of telemedicine training on completing a successful encounter. Methods emergency medicine residents first underwent a virtual standardized telemedicine encounter using the ZoomTM telecommunications application without prior training in telemedicine. Standardized patients were then queried on resident success during this untrained encounter using a survey with aspects of a successful telemedicine encounter. The following session involved a lecture by a telemedicine physician. After this intervention, the residents underwent a repeat virtual encounter, with standardized patients responding to the same questions on the fundamental aspects of a successful interview. Residents also underwent a post-survey on their experiences with the training. Results Statistically significant differences were noted on aspects of the encounter related to obtaining informed consent (0% vs. 61%, p = 0.00012), asking about privacy in the patient’s environment (6% vs. 87%, p &lt;0.00001), verifying name and/or date of birth (29% vs. 94%, p =0.00014), explaining the telehealth process and expectations to the patient (0% vs. 94%, p &lt;0.00001). No statistical significance was seen with: resident introducing themselves (94% vs. 100%, p =.31732), asking focused questions about medical condition (100% vs. 100% p = 1), closing the encounter by explaining care plan (94% vs. 94%, p = 1). Conclusions Overall, emergency medicine residents had significant improvement on aspects of an encounter with a standardized patient that were unique to telemedicine after undergoing training from an expert in the field. Similar training could easily be utilized across the country in emergency medicine residencies. This training could prove to be essential in the future because of the global health crisis of the COVID-19 pandemic, but also for rural emergency patient care and remote educational programs.

Experiences of Residents and Fellows at Mayo Clinic After the Rapid Implementation of Telemedicine During the COVID-19 Pandemic.

The COVID-19 pandemic led to many changes across medical organizations and graduate medical education programs nationwide including the rapid implementation of telemedicine as a modality for delivering health care. The purpose of this study was to investigate the telemedicine experiences of residents and fellows with their self-reported level of preparedness, impact on their education including precepting, skill development, and patient-physician relationships, and perceptions of telehealth platforms and curricula in the future. A total of 365 Mayo Clinic residents and fellows across three sites (Florida, Arizona, and Minnesota) were identified as trainees who conducted at least one telemedicine encounter from January 1, 2020 to June 30, 2020 and were sent an electronic survey by e-mail. There was a total of 103 completed surveys across various specialties with 58.3% female respondents, 63.1% residents, 35.0% fellows and 77.7% of respondents who attended medical school in the United States. Most trainees reported having very little to no exposure to telemedicine in their medical careers before the pandemic. The majority were satisfied with their first telemedicine encounter and found precepting comparable to in-person visits. The trainees in this study had a favorable view with 98.1% believing telemedicine will play a more prevalent role in the future and most agreed this should be included in medical school and residency training. Our survey found that after the implementation of telemedicine during the COVID-19 pandemic, the experiences of trainees at a multi-site academic center were overall positive. More research is needed on the perceptions of skill development (physical exam and history taking) during a telemedicine encounter and outlining an optimal telemedicine curriculum that can improve confidence in trainees.