Provider, Staff, and Patient Perspectives on medical Visits Using Clinical Video Telehealth: A Foundation for Educational Initiatives to Improve Medical Care in Telehealth

Referral of patients from rural primary care clinics to telemedicine vendors for opioid use disorder treatment: A mixed-methods study

INTRODUCTION

Rural primary care clinics can expand their medication treatment for opioid use disorder (MOUD) capacity by coordinating care with external telemedicine (TM) vendors specializing in addiction medicine. This study used mixed methods to identify factors that influence patient referrals from rural primary care clinics to TM vendors for MOUD.

METHODS

Between July/August 2020 and January/February 2021, 582 patients with OUD were identified across six primary care sites; that included 68 referred to an external TM vendor to receive MOUD. Mixed effects logistic regression identified individual and site-level factors associated with being referred to the TM vendor. Clinic providers and staff participated in in-depth interviews and focus groups to discuss their considerations for referring patients to the TM vendor.

RESULTS

Patient referrals were positively associated with local household broadband coverage (OR = 2.55, p < 0.001) and negatively associated with local population density (OR = 0.01, p  =  0.003) and the number of buprenorphine prescribers in the county (OR = 0.85, p < 0.001). Clinic personnel expressed appreciation for psychiatric expertise and the flexibility to access MOUD brought by the TM vendor. Perceived concerns about TM referral included a lack of trust with external providers, uncertainty about TM service quality, workflow delays, and patients' technological and insurance challenges.

CONCLUSION

This study revealed several clinic-level factors that may potentially influence patient referral to TM vendor services for MOUD. To facilitate the referral process and utilization of TM vendors, efforts should be made to foster open communication and trust between clinic providers and TM vendors, streamline workflows, and improve Internet access for patients.

Blood pressure telemonitoring and telemedicine, a Latin America perspective

PURPOSE

To share a Latin-American perspective of the use of telemedicine, together with blood pressure measurements outside the medical office, as a potential contribution to improving access to the health system, diagnosis, adherence, and persistence in hypertension treatment.

MATERIAL AND METHODS

A document settled by a Writing Group of Mexico Hypertension Experts Group, Interamerican Society of Hypertension, Epidemiology and Cardiovascular Prevention Council of the Interamerican Society of Cardiology, and National Cardiologist Association of Mexico.

RESULTS

In almost all Latin American countries, the health sector faces two fundamental challenges: (1) ensure equitable access to quality care services in a growing population that faces an increase in the prevalence of chronic diseases, and (2) optimise the growing costs of health services, maintaining equity, accessibility, universality, and quality. Telehealth proposes an innovative approach to patient management, especially for chronic conditions, intending to provide remote consultation, education, and follow-up to achieve measurements and goals. It is a tool that promises to improve access, empower the patient, and somehow influence their behaviour about lifestyle changes, improving prevention and reducing complications of hypertension. The clinical practitioner has seen increased evidence that the use of out-of-office blood pressure (BP) measurement and telemedicine are helpful tools to keep patients and physicians in contact and promote better pharmacological adherence and BP control. A survey carried out by medical and scientific institutions showed that practitioners are up-to-date with telemedicine, had internet access, and had hardware availability.

CONCLUSIONS

A transcendent issue is the need to make the population aware of the benefits of taking blood pressure to avoid complications of hypertension, and in this scenario, promote the creation of teleconsultation mechanisms for the follow-up of patients diagnosed with hypertension.

APRNs' perception of telehealth use

BACKGROUND

The COVID-19 pandemic resulted in a significant increase in the use of telehealth. Although advanced practice registered nurses (APRNs) play an essential role in improving healthcare accessibility, including the provision of telehealth, for many individuals, few studies examining provider perceptions of telehealth have included APRN participants.

METHODS

This article describes a quantitative, descriptive study involving a survey administered electronically to a convenience sample of APRNs from one state.

RESULTS

Seventy-five APRN participants completed the survey, with NPs comprising nearly 90% of the sample. On average, surveyed APRNs had been conducting telehealth visits for 2.57 years. Most participants were able to develop or maintain rapport with new or established patients using telehealth and felt that their patients were satisfied by these visits. More than one-third of participants reported that new patients seen via telehealth received somewhat worse care than patients seen face to face, and one-quarter reported that established patients seen via telehealth received somewhat worse care.

CONCLUSION

Although some concerns exist, overall, APRNs' perceptions of the use of telehealth were positive, with most wishing to continue providing care via telehealth in the future. This study adds to the literature on providers' perceptions of telehealth by describing the APRN viewpoint.

The Telemedicine Experience in Primary Care Practices in the United States: Insights From Practice Leaders

PURPOSE

The need to rapidly implement telemedicine in primary care during the coronavirus disease 2019 (COVID-19) pandemic was addressed differently by various practices. Using qualitative data from semistructured interviews with primary care practice leaders, we aimed to report commonly shared experiences and unique perspectives regarding telemedicine implementation and evolution/maturation since March 2020.

METHODS

We administered a semistructured, 25-minute, virtual interview with 25 primary care practice leaders from 2 health systems in 2 states (New York and Florida) included in PCORnet, the Patient-Centered Outcomes Research Institute clinical research network. Questions were guided by 3 frameworks (health information technology evaluation, access to care, and health information technology life cycle) and involved practice leaders' perspectives on the process of telemedicine implementation in their practice, with a specific focus on the process of maturation and facilitators/barriers. Two researchers conducted inductive coding of qualitative data open-ended questions to identify common themes. Transcripts were electronically generated by virtual platform software.

RESULTS

Twenty-five interviews were administered for practice leaders representing 87 primary care practices in 2 states. We identified the following 4 major themes: (1) the ease of telemedicine adoption depended on both patients' and clinicians' prior experience using virtual health platforms, (2) regulation of telemedicine varied across states and differentially affected the rollout processes, (3) visit triage rules were unclear, and (4) there were positive and negative effects of telemedicine on clinicians and patients.

CONCLUSIONS

Practice leaders identified several challenges to telemedicine implementation and highlighted 2 areas, including telemedicine visit triage guidelines and telemedicine-specific staffing and scheduling protocols, for improvement.

A brief pre-visit educational video improved patient engagement after telehealth visits; results from a randomized controlled trial

Objective

To test an intervention designed to improve patient engagement in telehealth visits by encouraging patients to use active communication behaviors.

Methods

US Veterans with type 2 diabetes mellitus receiving primary care using telehealth were randomized 1:1 to receive both a pre-visit educational video and pamphlet (intervention) or pamphlet alone (control) prior to their scheduled telehealth visit. Data were collected before and after the intervention from the medical record and at telephone interviews (questionnaires). Analyses compared the intervention and control groups using bivariate statistics and multiple regression.

Results

There were no statistically significant differences in baseline Hemoglobin A1c (HbA1c) between intervention and control groups (P > 0.05). Patient's ratings of physicians' communication and post-visit empathy were higher (P ≤ 0.05) in the intervention group than control group and after adjusting for baseline values the intervention group reported higher scores on post-visit therapeutic alliance with the provider and higher patient engagement, compared with the control group, P = 0.01 and P = 0.04, respectively, but post-visit HbA1c was not statistically different.

Conclusions

The educational video was useful as pre-visit preparation for patients prior to a primary care telehealth visit.

Innovation

This study showed the efficacy of a pre-visit video to improve patient engagement and therapeutic alliance after telehealth visits.ClinicalTrials.govIdentifier: NCT02522494.

Understanding opportunities and challenges with telemedicine-delivered buprenorphine during the COVID-19 pandemic

INTRODUCTION

Opioid use disorder (OUD) is a debilitating illness that remains a serious public health issue in the United States. Use of telemedicine to deliver medications for the treatment of OUD (MOUD) was limited until the confluence of the COVID-19 and opioid addiction epidemics in spring 2020. Starting in spring 2020, the Department of Veterans Health Affairs (VHA) transitioned from in-person to mostly telemedicine-delivered OUD care to reduce COVID-19 transmission among veterans and providers. To gain a nuanced understanding of provider perspectives on MOUD care delivery using telemedicine, we conducted semi-structured interviews with VHA providers who were using telehealth to deliver MOUD care.

METHODS

We conducted semi-structed Zoom interviews with VA clinicians at nine VA Medical Centers (VAMCs) in eight states. Potential study participants were identified as providers who were involved in referrals and provision of buprenorphine treatment for chronic pain and opioid addiction. Audio-recordings of all interviews were transcribed and entered into Atlas. Ti qualitative analysis software. The study team analyzed the transcripts for major themes related to tele-prescribing practices for buprenorphine.

RESULTS

Twenty-three VA providers participated in the study, representing 32% of all providers invited to participate in the study. The research team identified the following four themes: (1) COVID-19 spurred a seismic shift in OUD treatment; (2) Video calls provided a rare window into veterans' lives; (3) Providers experienced numerous challenges to virtual visits; and (4) Providers wrestled with paternalism and trust.

CONCLUSIONS

The pandemic accelerated the movement toward harm reduction approaches. Prior to the pandemic, stringent requirements existed for patients receiving MOUD care. Providers in this study reflected on the need for these requirements (e.g., in-person visits, toxicology screens) and how reducing this monitoring implied more trust in patients' autonomous decisions. Providers' observation that videoconferencing offered them a window into patients' lives may offer some ways to improve rapport, and research should explore how best to incorporate the additional information conveyed in virtual visits.