Innovation Through Regulation: COVID-19 and the Evolving Utility of Telemedicine

The Impact of COVID on Health Systems: The Workforce and Telemedicine Perspective

The COVID-19 pandemic significantly strained global health systems, leading to the rapid adoption of telemedicine and changes in workforce management. Previously underused, telemedicine became an essential means of delivering healthcare while adhering to physical distancing guidelines. This transition addressed longstanding barriers like connectivity issues. Simultaneously, the radiology sector innovated by widely implementing remote reading stations, which helped manage exposure risks and conserve human resources. Moreover, the pandemic highlighted the critical role of technological advancements beyond telemedicine, such as the accelerated integration of AI in diagnostics and management. This article examines these comprehensive effects, emphasizing the remote work adaptations and innovations in healthcare systems that have reshaped both healthcare delivery and workforce dynamics during the pandemic.

Telemedicine experiences and perspectives of healthcare providers in long-term care: A scoping review

OBJECTIVE

To consolidate existing evidence on experiences and perspectives of healthcare providers involved in telemedicine services in long-term residential care.

METHODS

A scoping review was conducted. A systematic search for articles published in 2000-2021 was performed in CINAHL, Web of Science, PubMed, EMBASE and Scopus; further, relevant journals and grey literature websites were hand searched. Key search terms included 'telemedicine', 'telehealth' and 'nursing homes'.

RESULTS

Twenty-six articles were included. A narrative synthesis of evidence was conducted. The review identified four themes: (1) Presence of multidisciplinary care, (2) perceived usefulness of telemedicine, (3) perceived ease of use and (4) expanded role of nursing home staff. The presence of multidisciplinary care providers provided a wide range of telemedicine services to residents and promoted interprofessional collaboration between acute and long-term care. Telemedicine was perceived to increase timely onsite management by remote specialists, which enabled care quality improvement. However, technical problems associated with equipment usage reduced the ease of use of telemedicine. Concerns emerged from the expanded role of nursing home staff, which could negatively affect clinical decision-making and create medico-legal risks.

CONCLUSION AND IMPLICATIONS

Telemedicine is valuable in distance-based care, especially in the current 2019 coronavirus pandemic, for supporting continuity of care to nursing home residents. This review provided evidence from multiple healthcare providers' perspectives. Further research can elucidate their specific roles and responsibilities in telemedicine and challenges in work processes, which will facilitate developing evidence-based competencies and improving technical infrastructure, thus contributing to personal and organisational readiness for telemedicine integration.

Telemedicine Visits in US Skilled Nursing Facilities

Importance

Telemedicine in skilled nursing facilities (SNFs) has the potential to improve access and timeliness of care. During the COVID-19 pandemic in 2020 to 2022, telemedicine coverage expanded, but little is known about patterns of use in SNFs.

Objective

To describe patterns of telemedicine use in SNFs.

Design, Setting, and Participants

This cohort study used 2018 to 2022 Medicare fee-for-service claims and Minimum Data Set 3.0 records to identify short- and long-term care SNF residents. Clinician visits were grouped into routine SNF visits (ie, regular primary care within SNF) and other outpatient visits (ie, with non-SNF affiliated primary and specialty care clinicians). Using a difference-in-differences approach, assessments included whether off-hours visits (measured as weekend visits), new specialist visits, psychiatrist visits, or visits for residents with limited mobility changed differentially between 2018 to 2019 and 2020 to 2021 for SNFs with high compared with low telemedicine use in 2020.

Exposure

Telemedicine adoption at SNF after 2020.

Main Outcomes and Measures

Number and proportion of telemedicine SNF and outpatient visits.

Results

Across 15 434 SNFs and 4 463 591 residents from the period January 2019 through June 2022 (mean [SD] age, 79.7 [11.6] years; 61% female in 2020), telemedicine visits increased from 0.15% in January 2019 to February 2020 to 15% SNF visits and 25% outpatient visits in May 2020. By 2022, telemedicine dropped to 2% of SNF visits and 8% of outpatient visits. The proportion of SNFs with any telemedicine visits annually dropped from 91% in 2020 to 61% in 2022. The facilities with high telemedicine use were more likely to be rural (adjusted odds ratio vs urban, 2.06; 95% CI, 1.77 to 2.40). Psychiatry visits differentially increased in high vs low telemedicine-use SNFs (20.2% relative increase; 95% CI, 1.2% to 39.2%). In contrast, there was little change in outpatient visits for residents with limited mobility (7.2%; 95% CI, -0.1% to 14.6%) or new specialist visits (-0.7%; 95% CI, -2.5% to 1.2%).

Conclusions and Relevance

In this cohort study of SNF residents, telemedicine was rapidly adopted in early 2020 but subsequently stabilized at a low use rate that was nonetheless higher than before 2020. Higher telemedicine use in SNFs was associated with improved access to psychiatry visits in SNFs. A policy to encourage continued telemedicine use may facilitate further access to important services as the technology matures.

Perspectives of Physicians with Experience in Nursing Home Care on Telehealth Use During the COVID-19 Public Health Emergency

BACKGROUND

Despite expanded access to telehealth services for Medicare beneficiaries in nursing homes (NHs) during the COVID-19 public health emergency, information on physicians' perspectives on the feasibility and challenges of telehealth provision for NH residents is lacking.

OBJECTIVE

To examine physicians' perspectives on the appropriateness and challenges of providing telehealth in NHs.

PARTICIPANTS

Medical directors or attending physicians in NHs.

APPROACH

We conducted 35 semistructured interviews with members of the American Medical Directors Association from January 18 through January 29, 2021. Outcomes of the thematic analysis reflected perspectives of physicians experienced in NH care on telehealth use.

MAIN MEASURES

The extent to which participants used telehealth in NHs, the perceived value of telehealth for NH residents, and barriers to telehealth provision.

KEY RESULTS

Participants included 7 (20.0%) internists, 8 (22.9%) family physicians, and 18 (51.4%) geriatricians. Five common themes emerged: (1) direct care is needed to adequately care for residents in NHs; (2) telehealth may allow physicians to reach NH residents more flexibly during offsite hours and other scenarios when physicians cannot easily reach patients; (3) NH staff and other organizational resources are critical to the success of telehealth, but staff time is a major barrier to telehealth provision; (4) appropriateness of telehealth in NHs may be limited to certain resident populations and/or services; (5) conflicting views about whether telehealth use will be sustained over time in NHs. Subthemes included the role of resident-physician relationships in facilitating telehealth and the appropriateness of telehealth for residents with cognitive impairment.

CONCLUSIONS

Participants had mixed views on the effectiveness of telehealth in NHs. Staff resources to facilitate telehealth and the limitations of telehealth for NH residents were the most raised issues. These findings suggest that physicians in NHs may not view telehealth as a suitable substitute for most in-person services.

Remote treatment of pectus carinatum (Telepectus) during the COVID-19 pandemic

BACKGROUND/PURPOSE

To report telemedicine's feasibility and satisfaction rates for treating patients with pectus carinatum using a dynamic compressor system. We analyzed treatment adherence in comparison with the previous, non-pandemic year.

MATERIALS AND METHODS

Retrospective analysis including patients with pectus carinatum under treatment with a dynamic compressor system using telemedicine at the chest wall centers from two hospitals, private and public, between April and July 2020. A free video conference platform for teleconsultations was employed. We evaluated the incidence of pectus cases with telemedicine, the number of dynamic compressor system prescriptions, the number of patients in the correction phase, and the number who ended treatment. To assess adherence, we compared our cohort with an in-person cohort during the same time frame of the previous, non-pandemic year. In addition, we performed a patient satisfaction survey comprising questions related to socioeconomic status, the likeability of telemedicine, simplicity of modification of the system, and desire to continue with telepectus after the pandemic.

RESULTS

One hundred and thirty-six telepectus consultations were performed in 76 patients. During this time frame, 15 patients started using the dynamic compressor system. Compared to the previous, non-pandemic year, the number of consultations per patient was similar (2019: 1.92 ± 1 .0 vs. 2020: 1.79 ± 0.8, p = 0.32), and there was a significant reduction in the number of dropouts with the use of telemedicine (9% vs. 1%, p = 0.025). Fifty-nine patients answered the satisfaction survey. All of them solved their doubts through telemedicine. Overall, 95% found telemedicine comfortable. Of note, those with a lower income evidenced the highest intention in continuing with telemedicine.

CONCLUSIONS

We demonstrated the feasibility of remote care of patients with pectus carinatum using a dynamic compressor system with a similar frequency of consultations compared to in-person medical care. Telepectus patients revealed a high rate of satisfaction irrespective of their socioeconomic status.

LEVEL OF EVIDENCE

IV.

TYPE OF STUDY

Retrospective study.

Is Avoidable Hospitalization Experienced Prior to Infection Associated With COVID-19-Related Deaths?

Objectives: This study aimed to determine the effect of the presence or absence of avoidable hospitalization before acquiring coronavirus disease (COVID-19) on COVID-19-related deaths.

Methods: This study used the total NHIS-COVID-19 dataset comprising domestic COVID-19 patients, provided by the National Health Insurance Service (NHIS) in South Korea. We conducted logistic regression and double robust estimation (DRE) to confirm the effect of avoidable hospitalization on COVID-19-related deaths.

Results: Logistic regression analysis confirmed that the odds ratio (OR) of death due to COVID-19 was high in the group that experienced avoidable hospitalization. DRE analysis showed a higher OR of death due to COVID-19 in the group that experienced avoidable hospitalization compared to the group that did not experience avoidable hospitalization, except in the subgroup aged ≤69 years.

Conclusion: The effect of avoidable hospitalization on COVID-19-related deaths was confirmed. Therefore, continued health care, preventive medicine, and public health management are essential for reducing avoidable hospitalizations despite the COVID-19 pandemic. Clinicians need to be informed about the importance of continuous disease management.

There and back again: the shape of telemedicine in U.S. nursing homes following COVID-19

Introduction

Telemedicine use in nursing homes (NHs) expanded during the COVID-19 pandemic. The objectives of this study were to characterize plans to continue telemedicine among newly adopting NHs and identify factors limiting its use after COVID-19.

Methods

Key informants from 9 Wisconsin NHs that adopted telemedicine during COVID-19 were recruited. Semi-structured interviews and surveys were employed to identify participant perceptions about the value of telemedicine, implementation challenges encountered, and plans and barriers to sustaining its delivery after COVID-19. Directed content analysis and a deductive thematic approach using the Systems Engineering Initiative for Patient Safety (SEIPS) model was used during analyses. Quantitative and qualitative data were integrated to identify participant views on the value of telemedicine and the tools and work system enhancements needed to make telemedicine easier and more effective.

Results

All participating NHs indicated a preference to continue telemedicine after COVID-19. Urgent assessments of resident change-in-condition and cognitively based sub-specialty consultations were identified as the encounter types most amenable to telemedicine. Reductions in resident off-site encounters and minimization of resident therapy interruptions were identified as major benefits of telemedicine. Twelve work system enhancements needed to better sustain telemedicine were identified, including improvements to: 1) equipment/IT infrastructure; 2) scheduling; 3) information exchange; and 4) telemedicine facilitators.

Discussion

NHs that adopted telemedicine during COVID-19 wish to continue its use. However, interventions that enhance the integration of telemedicine into NH and off-site clinic work systems require changes to existing regulations and reimbursement models to sustain its utilization after COVID-19.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03046-y.

Video-telehealth to support clinical assessment and management of acutely unwell older people in Residential Aged Care: a pre-post intervention study

BACKGROUND

Older people living in Residential Aged Care (RAC) are at high risk of clinical deterioration. Telehealth has the potential to provide timely, patient-centred care where transfer to hospital can be a burden and avoided. The extent to which video telehealth is superior to other forms of telecommunication and its impact on management of acutely unwell residents in aged care facilities has not been explored previously.

METHODS

In this study, video-telehealth consultation was added to an existing program, the Aged Care Emergency (ACE) program, aiming at further reducing Emergency Department (ED) visits and hospital admissions. This controlled pre-post study introduced video-telehealth consultation as an additional component to the ACE program for acutely unwell residents in RACs. Usual practice is for RACs and ACE to liaise via telephone. During the study, when the intervention RACs called the ED advanced practice nurse, video-telehealth supported clinical assessment and management. Five intervention RACs were compared with eight control RACs, all of whom refer to one community hospital in regional New South Wales, Australia. Fourteen months pre-video-telehealth was compared with 14 months post-video-telehealth using generalized linear mixed models for hospital admissions after an ED visit and ED visits. One thousand two hundred seventy-one ED visits occurred over the 28-month study period with 739 subsequent hospital admissions.

RESULTS

There were no significant differences in hospital admission or ED visits after the introduction of video-telehealth; adjusted incident rate ratios (IRR) were 0.98 (confidence interval (CI) 0.55 to 1.77) and 0.89 (95% CI 0.53 to 1.47) respectively.

CONCLUSIONS

Video-telehealth did not show any incremental benefit when added to a structured hospital avoidance program with nursing telephone support.

TRIAL REGISTRATION

The larger Aged Care Emergency evaluation is registered with ANZ Clinical Trials Registry, ACTRN12616000588493.

Characterizing the direct care health workforce in the United States, 2010-2019

BACKGROUND

To describe the growth and characteristics of the direct care health workforce, encompassing home health aides, personal care aides, nursing assistants, and orderlies and psychiatric aides from 2010 to 2019 in the United States.

METHODS

Using nationally representative data from the 2010 to 2019 American Community Survey, we described the growth in the direct care health workforce overall and by type of direct care health worker. In addition, we examined the distribution of direct care workers by geographic region of the country, age categories, citizenship, world area of birth, income, health insurance status, and other characteristics.

RESULTS

From 2010 to 2019, the number of direct care health workers in the United States per 10,000 individuals decreased slightly from 135.81 in 2010 to 133.78 in 2019. Personal care aides made up 42.1% of the direct care health workforce in 2019, followed by nursing assistants (39.5%) and home health aides (16.3%). In 2019, the number of direct care health workers who were not U.S. citizens accounted for roughly 10% of all workers in each year. The relative percentage of direct care health workers that were not a citizen of the United States was highest among home health aides (16.3%). Among workers born outside of the United States, the majority were from Latin America, followed by Asia.

CONCLUSION

From 2010 to 2019, there was little growth in the direct care health workforce despite growing demand for direct care health workers. In the midst of the current and projected shortage of direct care health workers-particularly during the COVID-19 pandemic, longer-term solutions to improve retention of direct care health workers and increase the supply of direct care health workers may be needed.

COVID-19 preparedness in aged care: A qualitative study exploring residential aged care facility managers experiences planning for a pandemic

AIMS AND OBJECTIVES

The study aims to understand the changing context of RACFs and the role of RACF managers in preparing to confront the COVID-19 pandemic and to provide insights into how the use of visual telehealth consultation might be incorporated to assist with managing whatever might arise.

DESIGN

An interpretive descriptive study design was employed, and data were collected using semi-structured interviews conducted via telephone or videoconference. Purposive recruitment targeted clinical managers responsible for the COVID-19 response in RACFs.

METHODS

RACF clinical managers were invited to discuss their responses to COVID-19 including the management of RACF and staff. Semi-structured interviews explored the COVID-19-related challenges, the response to these challenges and how telehealth might assist in overcoming some of these challenges. This study followed Thorne's (2008) three-stage process of interpretive description. The COREQ checklist was used in preparing this manuscript.

RESULTS

Two main themes were identified. The first theme 'keeping people safe' was comprised of three subthemes; fear and uncertainty, managing the risks and retaining and recruiting staff. The second theme was 'keeping people connected', had two subthemes; being disconnected and isolated and embracing technology.

CONCLUSION

Findings from this study provide valuable insight into understanding the context and the challenges for RACFs and the staff as they attempt to keep residents safe and connected with healthcare providers and the outside world.

RELEVANCE TO CLINICAL PRACTICE

Understanding the experiences of RACF managers in preparing to respond to the pandemic will better inform practice development in aged care in particular the use of telehealth and safe practices during COVID-19. Increased awareness of the challenges faced by RACFs during a pandemic provides policymakers with valuable insights for future planning of pandemic responses.

Maximizing Efficiency of Telemedicine in the Skilled Nursing Facility during the Coronavirus Disease 2019 Pandemic

Telemedicine has rapidly become a significant component of healthcare during the coronavirus disease 2019 pandemic, and is particularly beneficial in delivering care to vulnerable populations in skilled nursing facilities (SNFs). To limit coronavirus disease 2019 exposure, our team developed a quality improvement (QI) project to identify common telemedicine-related disruptions and their solutions, and created a streamlined protocol to maximize the efficiency of virtual rounding in the SNF. Through 9 Plan-Do-Study-Act cycles, we revised our protocol to decrease the percentage of rounding time spent troubleshooting telemedicine-related problems (“nonclinical care time”) and were able to demonstrate repeatability at three checkpoints. Our QI project offers a framework for SNF providers and staff to deliver telemedicine-driven patient care.