Ensuring Primary Care Diagnostic Quality in the Era of Telemedicine

An electronic trigger to detect telemedicine-related diagnostic errors

INTRODUCTION

The COVID-19 pandemic advanced the use of telehealth-facilitated care. However, little is known about how to measure safety of clinical diagnosis made through telehealth-facilitated primary care.

METHODS

We used the seven-step Safer Dx Trigger Tool framework to develop an electronic trigger (e-trigger) tool to identify potential missed opportunities for more timely diagnosis during primary care telehealth visits at a large Department of Veterans Affairs facility. We then applied the e-trigger algorithm to electronic health record data related to primary care visits during a 1-year period (1 April 2020-31 March 2021). The algorithm identified patients with unexpected visits within 10 days of an index telemedicine visit and classified such records as e-trigger positive. We then validated the e-trigger's ability to detect missed opportunities in diagnosis using chart reviews based on a structured data collection instrument (the Revised Safer Dx instrument).

RESULTS

We identified 128,761 telehealth visits (32,459 unique patients), of which 434 visits led to subsequent unplanned emergency department (ED), hospital, or primary care visits within 10 days of the index visit. Of these, 116 were excluded for clinical reasons (trauma, injury, or childbirth), leaving 318 visits (240 unique patients) needing further evaluation. From these, 100 records were randomly selected for review, of which four were falsely flagged due to invalid data (visits by non-providers or those incorrectly flagged as completed telehealth visits). Eleven patients had a missed opportunity in diagnosis, yielding a positive predictive value of 11%.

DISCUSSION

Electronic triggers that identify missed opportunities for additional evaluation could help advance the understanding of safety of clinical diagnosis made in telehealth-enabled care. Better measurement can help determine which patients can safely be cared for via telemedicine versus traditional in-person visits.

Designing Telemedicine for Older Adults With Multimorbidity: Content Analysis Study

BACKGROUND

Telemedicine is a potential option for caring for older adults with multimorbidity. There is a need to explore the perceptions about telemedicine among older adults with multimorbidity to tailor it to the needs of older adults with multiple chronic conditions.

OBJECTIVE

This study aims to explore the perceptions about telemedicine among older patients with multimorbidity.

METHODS

A qualitative study was conducted using semistructured interviews. The interview questions examined older adults' perspectives about telemedicine, including their expectations regarding telemedicine services and the factors that affect its use. Thematic analysis was performed using NVivo (version 12; Lumivero). The study was reported using the Standards for Reporting Qualitative Research guidelines.

RESULTS

In total, 29 patients with multimorbidity-21 (72%) female patients and 8 (28%) male patients with a mean age of 69 (SD 10.39) years-were included. Overall, 4 themes and 7 subthemes emerged: theme 1-perceived benefit of telemedicine among older adults with multimorbidities, theme 2-appropriate use of telemedicine for multimorbid care, theme 3-telemedicine system catering to the needs of older patients, and theme 4-respect patients' decision to decline to use telemedicine.

CONCLUSIONS

Telemedicine for older adults with multimorbidity should focus on those with stable conditions. This can help increase access to care for those requiring continuous condition monitoring. A structured telemedicine program and patient-centered services can help increase patient acceptance of telemedicine. However, health care providers must accept the limitations of older patients that may prevent them from receiving telemedicine services.

And Still She Rises: Policies for Improving Women's Health for a More Equitable Post-Pandemic World

The COVID-19 pandemic has spawned crises of violence, hunger and impoverishment. Maternal and Infant Health Canada (MIHCan) conducted this policy action study to explore how changes that have arisen during the COVID-19 pandemic may catalyze potential improvements in global women's health toward the creation of a more equitable post-pandemic world. In this mixed methods study, 280 experts in women's health responded to our survey and 65 subsequently participated in focus groups, including professionals from India, Egypt/Sudan, Canada and the United States/Mexico. From the results of this study, our recommendations include augmenting mental health through more open dialogue, valuing and compensating those working on the frontlines through living wages, paid sick leave and enhanced benefits and expanding digital technology that facilitates flexible work locations, thereby freeing time for improving the wellbeing of caregivers and families and offering telemedicine and telecounseling, which delivers greater access to care. We also recommend bridging the digital divide through the widespread provision of reliable and affordable internet services and digital literacy training. These policy recommendations for employers, governments and health authorities aim to improve mental and physical wellbeing and working conditions, while leveraging the potential of digital technology for healthcare provision for those who identify as women, knowing that others will benefit. MIHCan took action on the recommendation to improve mental health through open conversation by facilitating campaigns in all study regions. Despite the devastation of the pandemic on global women's health, implementing these changes could yield improvements for years to come.