Using Telemedicine in a Private Allergy Practice

Telemedicine and patients with heart failure: evidence and unresolved issues

BACKGROUND

Heart failure is the leading cause of cardiac-related hospitalizations. Limited access to reevaluations and outpatient appointments restricts the application of modern therapies. Telemedicine has become an essential resource in the healthcare system because of its countless benefits, such as higher and more frequent appointments and faster titration of medications. This narrative review aimed to demonstrate the evidence and unresolved issues related to the use of telemedicine in patients with heart failure. No studies have examined heart failure prevention; however, several studies have addressed the prevention of decompensation with positive results. Telemedicine can be used to evaluate all patients with heart failure, and many telemedicine platforms are available. Several strategies, including both noninvasive (phone calls, weight measurement, and virtual visits) and invasive (implantable pulmonary artery catheters) strategies can be implemented. Given these benefits, telemedicine is highly desirable, particularly for vulnerable groups. Although some questions remain unanswered, the development of new technologies can complement remote visits and improve patient care.

Telehealth and Allergy Services in Rural and Regional Locations That Lack Specialty Services

Secondary to the coronavirus disease 2019 pandemic, telehealth quickly peaked as the dominant health care modality and its use still remains high. Although allergists and health care systems adapted quickly to adopt telehealth, its increased use has both highlighted its benefits for patients and allergists and demonstrated known concerns with delivering allergy specialty care to rural and regional patient populations. With increased concentration of both patients and allergists in urban areas, the ability to provide allergy specialty care to the rural and remote population continues to remain a challenge despite the advantages leveraged through telehealth. Herein, we review aspects specific to the rural patient population, tele-allergy outcomes with these patient cohorts, and efforts, both past and present, taken at different levels within the allergy community to promote our specialty through specific telehealth modalities to address and engage the rural and regional patient.

Telemedicine Lessons Learned During the COVID-19 Pandemic

Purpose of Review

Prior to the SARS-CoV-2 novel coronavirus (COVID-19) pandemic, access and utilization of telemedicine in the USA was negligeable, with very little interest from both the public and healthcare sectors. Since that time, telemedicine technology and services have undergone explosive growth and investment and are poised to change the way healthcare is delivered now and in the future. But has telemedicine truly changed the way healthcare is delivered or is it merely a temporary fix for a temporary pandemic?

Recent Findings

This global public health emergency has exposed vulnerabilities in our healthcare system and telemedicine has proven to be an effective tool to help increase access to care and improve affordability for patients across all racial, economic, geographic, and technological demographics.

Summary

Looking back on the last 20 months or so since the pandemic started, this review attempts to summarize what has gone well and what has not in the telehealth space and concludes that while far from perfect, telemedicine is here to stay.

THE IMPACT OF TELEMEDICINE AS A DISRUPTIVE INNOVATION ON ALLERGY/IMMUNOLOGY PRACTICE

BACKGROUND

Urban minority preschool children are disproportionately affected by asthma with increased asthma morbidity and mortality. It is important to understand how families manage asthma in preschool children in order to improve asthma control.

OBJECTIVE

This study examines family asthma management and asthma outcomes among a low-income urban minority population of Head Start preschool children.

METHODS

The Family Asthma Management System Scale (FAMSS) assesses how families manage a child's asthma. 388 caregivers completed the FAMSS at baseline. Asthma outcomes were assessed at baseline and prospectively at 6 months, including asthma control (based on the Test for Respiratory and Asthma Control in Kids), courses of oral corticosteroids required, and caregiver health-related quality of life (Pediatric Asthma Caregiver's Quality of Life Questionnaire (PACQLQ)). Multiple regression models assessed the relationship between the FAMSS Total Score, FAMSS subscales, and asthma outcomes.

RESULTS

Higher FAMSS Total scores were associated with fewer courses of oral corticosteroids required (b=-0.23, p<0.01) and higher PACQLQ scores (b=0.07, p<0.05). At baseline, higher Integration subscale scores (b=-0.19, p<0.05) were associated with fewer courses of oral corticosteroids required, and higher Family Response scores were associate with higher PACQLQ scores (b=0.06, p<0.05). However, higher Collaboration scores were associated with lower PACQLQ at baseline (b=-0.06, p<0.05) and 6 months (b=-0.07, p<0.05).

CONCLUSION

Among this population of low-income minority preschool children, understanding how a family manages their child's asthma may help identify gaps for education to possibly improve caregiver asthma-related quality of life and reduce courses of oral corticosteroids.

Electronic medication monitoring versus self-reported use of inhaled corticosteroids and short-acting beta2-agonists in uncontrolled asthma

OBJECTIVE

Current standard of care, patient self-report and clinician estimation, overestimates true inhaled corticosteroids (ICS) adherence. We compare self-reported inhaled ICS and short-acting beta 2-agonists (SABA) use with objective data from electronic medication monitors (EMMs).

METHODS

Adults with uncontrolled asthma and prescribed ICS and SABA were enrolled. At visit one, participants' ICS and SABA inhalers were fitted with EMMs to track real-time medication usage over 14 days. Participants were asked to complete paper diaries to self-report medication usage over the same period. Participant self-report of ICS adherence and SABA use versus objective ICS adherence and SABA use was compared using Wilcoxon signed-rank tests.

RESULTS

One hundred participants (80% female, mean age 48.5 years, 60% completed college, 80% privately insured) had complete data. Participant self-report (median (IQR): 0.8 (0.0, 2.0)) was greater than objectively measured (median (IQR): 0.43 (0.1, 2.1)) SABA use, but the difference was not statistically significant (P = 0.64). Participant self-report (median (IQR): 97 (67, 100)) was significantly greater than objectively measured (median (IQR): 75 (54, 93)) ICS adherence (P = 0.002).

CONCLUSIONS

Significant discrepancies between self-report and objective ICS usage were observed. EMM can provide clinicians with accurate data on ICS medication taking behavior, thus reducing medication regimen complexity, side effects, and costs.

The applications of eHealth technologies in the management of asthma and allergic diseases

Portable devices, such as smartphones and mobile Internet access have become ubiquitous in the last decades. The term 'eHealth' stands for electronic health. The tools included in the eHealth concept utilize phones, computers and the Internet and related applications to improve the health care industry. Implementation of eHealth technologies has been documented for the management of different chronic diseases, including asthma and allergic conditions. Clinicians and patients have gained opportunity to communicate in new ways, which could be used cost-effectively to improve disease control and quality of life of those affected. Additionally, these innovations bring new opportunities to academic researchers. For example, eHealth has allowed researchers to compile data points that were previously unavailable or difficult to access, and analyse them using novel tools, collectively described as 'big data'. The role of eHealth become more important since early 2020, due to the physical distancing rules and the restrictions on mobility that have been applied worldwide as a response to the coronavirus disease 2019 pandemic. In this review, we summarize the most recent developments in various eHealth platforms and their relevance to the speciality of allergy and immunology, from the point of view of three major stakeholders: clinicians, patients and researchers.

A Narrative Review of Factors Historically Influencing Telehealth Use across Six Medical Specialties in the United States

Prior to the COVID-19 pandemic, studies in the US have identified wide variations in telehealth use across medical specialties. This is an intriguing problem, because the US has historically lacked a standardized set of telehealth coverage and reimbursement policies, which has posed a barrier to telehealth use across all specialties. Although all medical specialties in the US have been affected by these macro (policy-level) barriers, some specialties have been able to integrate telehealth use into mainstream practice, while others are just gaining momentum with telehealth during COVID-19. Although the temporary removal of policy (coverage) restrictions during the pandemic has accelerated telehealth use, uncertainties remain regarding future telehealth sustainability. Since macro (policy-level) factors by themselves do not serve to explain the variation in telehealth use across specialties, it would be important to examine meso (organizational-level) and micro (individual-level) factors historically influencing telehealth use across specialties, to understand underlying reasons for variation and identify implications for widespread sustainability. This paper draws upon the existing literature to develop a conceptual framework on macro-meso-micro factors influencing telehealth use within a medical specialty. The framework is then used to guide a narrative review of the telehealth literature across six medical specialties, including three specialties with lower telehealth use (allergy-immunology, family medicine, gastroenterology) and three with higher telehealth use (psychiatry, cardiology, radiology) in the US, in order to synthesize themes and gain insights into barriers and facilitators to telehealth use. In doing so, this review addresses a gap in the literature and provides a foundation for future research. Importantly, it helps to identify implications for ensuring widespread sustainability of telehealth use in the post-pandemic future.

New Concepts and Technological Resources in Patient Education and Asthma Self-Management

Asthma is a chronic disease that is associated with significant morbidity and mortality. In general, the use of technology resources or electronic health (e-health) has been shown to have beneficial effects on patients with asthma. E-health can impact a broad section of patients and can be cost-effective and associated with high patient satisfaction. E-health may enable remote delivery of care, as well as timely access to health care, which are some of the common challenges faced by patients with asthma. Web-based asthma self-management systems have been found to improve quality of life, self-reported asthma symptoms, lung function, reduction in asthma symptoms/exacerbations, and self-reported adherence for adults. Social media is commonly being used as a platform to disseminate information on asthma to increase public awareness. It can facilitate asthma self-management in a patient friendly manner and has shown to improve asthma control test scores as well as self-esteem. Text massages reminders can increase awareness regarding asthma treatment and control, thus potentially can improve adherence to medications and asthma outcome. Mobile health applications can support asthma self-management, improve a patient's quality of life, promote medication adherence, and potentially reduce the overall costs for asthma care. Inhaler trackers have shown to be beneficial to asthma outcome in various populations by improving adherence to asthma medications. Barriers such as physician financial reimbursement as well as licensing for rendering tele-healthcare services are important concerns. Other limitations of using technology resources in health care are related to liability, professionalism, and ethical issues such as breach of patient confidentiality and privacy. Additionally, there may be less face-to-face interaction and care of the patient when e-health is used.

Telemedicine and emerging technologies for health care in allergy/immunology

Telemedicine (TM) has become a popular method of accessing medical services between providers and patients and is viewed as a cost-effective alternative to more traditional episodic face-to-face encounters. TM overcomes 2 barriers that patients face when seeking health care: distance and time. It is as effective as in-person visits for outpatient treatment of asthma, and it is a convenient way to provide inpatient consultations for patients when the allergist practices outside of the hospital. TM also has been used to manage patients with asthma in schools. Patients tend to be as satisfied with TM or they prefer TM over in-person visits, but infrequently they do prefer in-person visits. In addition to virtual visits using TM, there are several emerging technologies that are relevant to the practice of allergy/immunology including electronic diaries (eg, symptoms and medication use), wearable technology (eg, to monitor activity and vital signs), remote patient monitoring (eg, environmental exposures and medication adherence) as well as electronic medical records augmented with clinical decision support. We believe that the use of TM, particularly when combined with information technologies such as electronic health records, has the potential to cause a transformational change in the way care is delivered by altering the process of interaction between patient and provider. TM addresses the shortage of allergy specialists in rural and underserved urban communities and facilitates patient access to allergy services. As patients take more control of their health care, use of TM is likely to increase because a large part of the move to adopt TM is driven by patient preference.

Work Group Report: COVID-19: Unmasking Telemedicine

Telemedicine adoption has rapidly accelerated since the onset of the COVID-19 pandemic. Telemedicine provides increased access to medical care and helps to mitigate risk by conserving personal protective equipment and providing for social/physical distancing to continue to treat patients with a variety of allergic and immunologic conditions. During this time, many allergy and immunology clinicians have needed to adopt telemedicine expeditiously in their practices while studying the complex and variable issues surrounding its regulation and reimbursement. Some concerns have been temporarily alleviated since March 2020 to aid with patient care in the setting of COVID-19. Other changes are ongoing at the time of this publication. Members of the Telemedicine Work Group in the American Academy of Allergy, Asthma & Immunology (AAAAI) completed a telemedicine literature review of online and Pub Med resources through May 9, 2020, to detail Pre-COVID-19 telemedicine knowledge and outline up-to-date telemedicine material. This work group report was developed to provide guidance to allergy/immunology clinicians as they navigate the swiftly evolving telemedicine landscape.