Telehealth: Simply a pandemic response or here to stay?

Designing A Blockchain-Empowered Telehealth Artifact for Decentralized Identity Management and Trustworthy Communication: Interdisciplinary Approach

BACKGROUND

Telehealth played a critical role during the COVID-19 pandemic and continues to function as an essential component of health care. Existing platforms cannot ensure privacy and prevent cyberattacks.

OBJECTIVE

The main objectives of this study are to understand existing cybersecurity issues in identity management and trustworthy communication processes in telehealth platforms and to design a software architecture integrated with blockchain to improve security and trustworthiness with acceptable performance.

METHODS

We improved personal information security in existing telehealth platforms by adopting an innovative interdisciplinary approach combining design science, social science, and computer science in the health care domain, with prototype implementation. We used the design science research methodology to implement our overall design. We innovated over existing telehealth platforms with blockchain integration that improves health care delivery services in terms of security, privacy, and efficiency. We adopted a user-centric design approach and started with user requirement collection, followed by system functionality development. Overall system implementation facilitates user requirements, thus promoting user behavior for the adoption of the telehealth platform with decentralized identity management and an access control mechanism.

RESULTS

Our investigation identified key challenges to identity management and trustworthy communication processes in telehealth platforms used in the current health care domain. By adopting distributed ledger technology, we proposed a decentralized telehealth platform to support identity management and a trustworthy communication process. Our design and prototype implementation using a smart contract-driven telehealth platform to provide decentralized identity management and trustworthy communication with token-based access control addressed several security challenges. This was substantiated by testing with 10,000 simulated transactions across 5 peers in the Rahasak blockchain network. The proposed design provides resistance to common attacks while maintaining a linear time overhead, demonstrating improved security and efficiency in telehealth services. We evaluated the performance in terms of transaction throughput, smart contract execution time, and block generation time. To create a block with 10,000 transactions, it takes 8 seconds on average, which is an acceptable overhead for blockchain-based applications.

CONCLUSIONS

We identified technical limitations in current telehealth platforms. We presented several design innovations using blockchain to prototype a system. We also presented the implementation details of a unique distributed architecture for a trustworthy communication system. We illustrated how this design can overcome privacy, security, and scalability limitations. Moreover, we illustrated how improving these factors sets the stage for improving and standardizing the application and for the wide adoption of blockchain-enabled telehealth platforms.

Telehealth uptake among middle-aged and older Americans during COVID-19: chronic conditions, social media communication, and race/ethnicity

OBJECTIVES

This study investigated whether and to what extent constructs of the protection motivation theory of health (PMT)-threat appraisal (perceived vulnerability/severity) and coping appraisal (response efficacy and self-efficacy)-are related to telehealth engagement during the COVID-19 pandemic, and how these associations differ by race/ethnicity among middle-aged and older Americans.

METHODS

Data were from the 2020 Health and Retirement Study. Multivariable ordinary least-squares regression analyses were computed adjusting for health and sociodemographic factors.

RESULTS

Some PMT constructs are useful in understanding telehealth uptake. Perceived vulnerability/severity, particularly comorbidity (b = 0.13, 95% confidence interval (CI) [0.11, 0.15], p < 0.001), and response efficacy, particularly participation in communication via social media (b = 0.24, 95% CI [0.21, 0.27], p < 0.001), were significantly and positively associated with higher telehealth uptake during the COVID-19 pandemic among middle-aged and older Americans. Non-Hispanic Black adults were more likely to engage in telehealth during the pandemic than their non-Hispanic White counterparts (b = 0.20, 95% CI [0.12, 0.28], p < 0.001). Multiple moderation analyses revealed the significant association between comorbidity and telehealth uptake was similar across racial/ethnic groups, whereas the significant association between social media communication and telehealth uptake varied by race/ethnicity. Specifically, the association was significantly less pronounced for Hispanic adults (b = -0.11, 95% CI [-0.19, -0.04], p < 0.01) and non-Hispanic Asian/other races adults (b = -0.13, 95% CI [-0.26, -0.01], p < 0.05) than it was for their non-Hispanic White counterparts.

CONCLUSION

Results suggest the potential of using social media and telehealth to narrow health disparities, particularly serving as a bridge for members of underserved communities to telehealth uptake.

Evaluation of behavioral economic strategies to raise influenza vaccination rates across a health system: Results from a randomized clinical trial

Influenza vaccination rates are low. Working with a large US health system, we evaluated three health system-wide interventions using the electronic health record's patient portal to improve influenza vaccination rates. We performed a two-arm RCT with a nested factorial design within the treatment arm, randomizing patients to usual-care control (no portal interventions) or to one or more portal interventions. We included all patients within this health system during the 2020-2021 influenza vaccination season, which overlapped with the COVID-19 pandemic. Through the patient portal, we simultaneously tested: pre-commitment messages (sent September 2020, asking patients to commit to a vaccination); monthly portal reminders (October - December 2020), direct appointment scheduling (patients could self-schedule influenza vaccination at multiple sites); and pre-appointment reminder messages (sent before scheduled primary care appointments, reminding patients about influenza vaccination). The main outcome measure was receipt of influenza vaccine (10/01/2020-03/31/2021). We randomized 213,773 patients (196,070 adults ≥18 years, 17,703 children). Influenza vaccination rates overall were low (39.0%). Vaccination rates for study arms did not differ: Control (38.9%), pre-commitment vs no pre-commitment (39.2%/38.9%), direct appointment scheduling yes/no (39.1%/39.1%), pre-appointment reminders yes/no (39.1%/39.1%); p > 0.017 for all comparisons (p value cut-off adjusted for multiple comparisons). After adjusting for age, gender, insurance, race, ethnicity, and prior influenza vaccination, none of the interventions increased vaccination rates. We conclude that patient portal interventions to remind patients to receive influenza vaccine during the COVID-19 pandemic did not raise influenza immunization rates. More intensive or tailored interventions are needed beyond portal innovations to increase influenza vaccination.

Synchronous Home-Based Telemedicine for Primary Care: A Review

Synchronous home-based telemedicine for primary care experienced growth during the coronavirus disease 2019 pandemic. A review was conducted on the evidence reporting on the feasibility of synchronous telemedicine implementation within primary care, barriers and facilitators to implementation and use, patient characteristics associated with use or nonuse, and quality and cost/revenue-related outcomes. Initial database searches yielded 1,527 articles, of which 22 studies fulfilled the inclusion criteria. Synchronous telemedicine was considered appropriate for visits not requiring a physical examination. Benefits included decreased travel and wait times, and improved access to care. For certain services, visit quality was comparable to in-person care, and patient and provider satisfaction was high. Facilitators included proper technology, training, and reimbursement policies that created payment parity between telemedicine and in-person care. Barriers included technological issues, such as low technical literacy and poor internet connectivity among certain patient populations, and communication barriers for patients requiring translators or additional resources to communicate.

Perceptions and Use of Telehealth among diverse communities: A Multisite Community Engaged Mixed Methods Study

BACKGROUND

Telehealth has been increasingly adopted by healthcare systems since the start of the COVID-19 pandemic. Although telehealth may provide convenience for patients and clinicians, there are several barriers to accessing it and using it effectively to provide high quality patient care.

OBJECTIVE

This study, was part of a larger multisite community engaged study conducted to understand the impact of COVID-19 on diverse communities. The work described here explored the perceptions of and experience with telehealth use among diverse and underserved community members during COVID-19.

METHODS

We used mixed methods across three regions in the US (Midwest, Arizona, and Florida) from January 2021-November 2021. We promoted our study through social media and community partnerships, disseminating flyers in English and Spanish. We developed a moderator guide and conducted focus groups in English and Spanish mostly using a videoconferencing platform. Participants were placed in focus groups with others who shared similar demographic attributes and geographic location. Focus groups were audio-recorded and transcribed. We analyzed our qualitative data using the framework analytic approach. We developed our broader survey using validated scales and with input from community and scientific leaders and distributed it through social media in English and Spanish. We included a previously published questionnaire which had been used to assess perceptions about telehealth among patients with HIV. We analyzed our quantitative data using SAS software and standard statistical approaches. We examined the effect of region, age, ethnicity/race and education on use and perceptions of telehealth.

RESULTS

We included data from 47 focus groups. Due to our mode of dissemination, we cannot calculate a response rate for the survey. However, we received 3447 English language and 146 Spanish language responses. Over 90% of participants had internet access and 94% had used telehealth. About half of all participants agreed or strongly agreed that telehealth would be beneficial in the future because it better fit their schedules and they would not need to travel. However, about half also agreed or strongly agreed they would not be able to express themselves well and could not be examined when using telehealth. Indigenous participants were especially concerned about these issues when compared to other racial groups.

CONCLUSIONS

This work describes findings from a mixed methods community engaged research study about telehealth including perceived benefits and concerns. Although participants enjoyed the benefits of telehealth (not having to travel and easier scheduling) they also had concerns (not being able to express themselves well and not having a physical exam) about telehealth.. These sentiments were especially notable among the Indigenous population. Our work highlights the importance of fully understanding the impact of these novel health delivery modalities on the patient experience and actual or perceived quality of care received.

CLINICALTRIAL

Informatics and data science perspective on Future of Nursing 2020-2030: Charting a pathway to health equity

The Future of Nursing 2020 to 2030 report explicitly addresses the need for integration of nursing expertise in designing, generating, analyzing, and applying data to support initiatives focused on social determinants of health (SDOH) and health equity. The metrics necessary to enable and evaluate progress on all recommendations require harnessing existing data sources and developing new ones, as well as transforming and integrating data into information systems to facilitate communication, information sharing, and decision making among the key stakeholders. We examine the recommendations of the 2021 report through an interdisciplinary lens that integrates nursing, biomedical informatics, and data science by addressing three critical questions: (a) what data are needed?, (b) what infrastructure and processes are needed to transform data into information?, and (c) what information systems are needed to "level up" nurse-led interventions from the micro-level to the meso- and macro-levels to address social determinants of health and advance health equity?

Social Work's Response during the COVID-19 Pandemic: A Systematic Literature Review-Balancing Telemedicine with Social Work Self-Care during A Pandemic

Before the COVID-19 pandemic, questions about the increased use of telemedicine had become common in conversations among medical providers. With the onset of the pandemic, these questions became more pronounced, and quick implementation became the key. New and historic barriers to telemedicine began to emerge at a dramatically increased rate during its rapid mobilization. However, considering how quickly telemedicine has been implemented, the impact on frontline workers, such as social workers, has not been specifically explored. We wondered how the change from face-to-face care to using digital platforms for care delivery has affected social work. Could social work ensure the fluid rollout of digital treatment platforms for care management? Could social work balance the increased number of digital treatment platforms with self-care for social workers during the COVID-19 crisis? What were some history social- work-preparedness plans used for other pandemics, and would those plans work for the COVID-19 pandemic? What were some of the self-care techniques employed by social workers? What were the emerging best practices of social workers at the Department of Veterans Affairs (VA) health care system in the U.S. South? We needed to explore these questions to formulate knowledge that could be beneficial for VA health care. This literature review assesses the current responses from the field of social work during the COVID-19 pandemic, leveraging telemedicine, social work self-care, and the fluidity of VA services.

Missed appointments during COVID-19: The impact of telehealth for persons experiencing homelessness with substance use disorders

We examined the impact of telehealth on appointment retention among individuals with substance use disorder (SUD) by housing status. We evaluated appointment status using multivariate logistic regression with primary predictor variables of visit modality, patient's housing status and interaction between these two variables. Between March 1 and September 30, 2020, there were 18,206 encounters among 1,626 clients with SUD. For telehealth encounters, the probability of an appointment no-show was significantly higher for persons experiencing homelessness compared to stably housed (37% versus 25%, p < 0.001). Housing status influences the effectiveness of telehealth as a modality of healthcare delivery for individuals with SUD.

Supporting Retention in HIV Care: Comparing In-Person and Telehealth Visits in a Chicago-Based Infectious Disease Clinic

The COVID-19 pandemic has created increased need for telehealth appointments. To assess differences in appointment adherence for telehealth compared to in-person HIV medical care visits, we conducted a cross-sectional study of patients receiving HIV care in a safety-net hospital-based outpatient infectious disease clinic in a large urban area (Chicago, IL). The sample (N = 347) was predominantly Black (n = 251) and male (62.5%, n = 217); with a mean age of 44.2 years. Appointment attendance was higher for telehealth (78.9%) compared to in-person (61.9%) appointments. Compared to patients without drug use, those with drug use had 19.4 percentage point lower in-person appointment attendance. Compared to those with stable housing, those in unstable housing arrangements had 15.0 percentage point lower in-person appointment attendance. Telehealth as a modality will likely have some staying power as it offers patients newfound flexibility, but barriers to telehealth need to be assessed and addressed.

Effect of Personalized Messages Sent by a Health System's Patient Portal on Influenza Vaccination Rates: a Randomized Clinical Trial

BACKGROUND

Adult influenza vaccination rates are low. Tailored patient reminders might raise rates.

OBJECTIVE

Evaluate impact of a health system's patient portal reminders: (1) tailored to patient characteristics and (2) incorporating behavioral science strategies, on influenza vaccination rates among adults.

DESIGN

Pragmatic 6-arm randomized trial across a health system during the 2019-2020 influenza vaccination season. The setting was one large health system-53 adult primary care practices.

PARTICIPANTS

All adult patients who used the patient portal within 12 months, stratified by the following: young adults (18-64 years, without diabetes), older adults (≥65 years, without diabetes), and those with diabetes (≥18 years).

INTERVENTIONS

Patients were randomized within strata to either (1) pre-commitment reminder alone (1 message, mid-October), (2) pre-commitment + loss frame messages, (3) pre-commitment + gain frame messages, (4) loss frame messages alone, (5) gain frame messages alone, or (6) standard of care control. Patients in the pre-commitment group were sent a message in mid-October, asking if they planned on getting an influenza vaccination. Patients in loss or gain frame groups were sent up to 3 portal reminders (late October, November, and December, if no documented influenza vaccination in the EHR) about importance and safety of influenza vaccine.

MAIN MEASURES

Receipt of 1 influenza vaccine from 10/01/2019 to 03/31/2020.

KEY RESULTS

196,486 patients (145,166 young adults, 29,795 older adults, 21,525 adults with diabetes) were randomized. Influenza vaccination rates were as follows: for young adults 36.8%, for older adults 55.6%, and for diabetics 60.6%. On unadjusted and adjusted (for age, gender, insurance, race, ethnicity, and prior influenza vaccine history) analyses, influenza vaccination rates were not statistically different for any study group versus control.

CONCLUSIONS

Patient reminders sent by a health system's patient portal that were tailored to patient demographics (young adults, older adults, diabetes) and that incorporated two behavioral economic messaging strategies (pre-commitment and loss/gain framing) were not effective in raising influenza vaccination rates.

TRIAL REGISTRATION

This trial was registered with ClinicalTrials.gov (NCT04110314).

Assessment of virtual healthcare: predictors of access and utilization before, during, and after the COVID-19 pandemic

Background: Societal needs highlighted by the ongoing COVID-19 pandemic have resulted in rapid telehealth development and implementation. The broadening of guidelines for practice by regulatory bodies have allowed providers to employ video-capable devices in the virtual delivery of services to physical- and mentalhealth clients located across a broad range of settings. Aim of the study: This study examined use of synchronous, video-based, virtual healthcare before and during the COVID-19 pandemic. This included a comparison of: access for physical and mental health needs; differential assessment of service provision by professionals; consumer satisfaction; and, anticipated future use of virtual healthcare. Material and Methods: An online survey link was sent to three participant groups: college-aged students, adults, and retirement-aged persons. A total of 685 participants, varying in age, gender, ethnicity, and experience using tele-healthcare provided usable data for this study. Results: Half of participants (49.2%; n=337) used virtual healthcare; more people used it during the pandemic (87.2%; n=294) than before (26.4%; n=89). Physical services (86.8%; n=291; primarily physicians) were more common than mental health services (25.6%; n=86; primarily counselors). Access was most common through laptop computers (60.7%; n=204). Participants were satisfied with virtual healthcare experiences (Mdn=5). Almost all participants (94.2%; n=645) believed that virtual healthcare would continue after the pandemic, but only two-thirds (61.3%; n=420) reported they would use virtual healthcare if available in the future. Both previous experience with (p<0.001) and satisfaction with (p<0.001) virtual healthcare positively predicted anticipated future use. Conclusions: Tele-healthcare has experienced significant growth in the COVID-19 era. Emergency policy changes have resulted in services being developed and offered in the medical and mental health realms in conjunction with ongoing empirical evaluations of what does and does not work.

Using a Real-Time Locating System to Evaluate the Impact of Telemedicine in an Emergency Department During COVID-19: Observational Study

BACKGROUND

Telemedicine has been deployed by health care systems in response to the COVID-19 pandemic to enable health care workers to provide remote care for both outpatients and inpatients. Although it is reasonable to suspect telemedicine visits limit unnecessary personal contact and thus decrease the risk of infection transmission, the impact of the use of such technology on clinician workflows in the emergency department is unknown.

OBJECTIVE

This study aimed to use a real-time locating system (RTLS) to evaluate the impact of a new telemedicine platform, which permitted clinicians located outside patient rooms to interact with patients who were under isolation precautions in the emergency department, on in-person interaction between health care workers and patients.

METHODS

A pre-post analysis was conducted using a badge-based RTLS platform to collect movement data including entrances and duration of stay within patient rooms of the emergency department for nursing and physician staff. Movement data was captured between March 2, 2020, the date of the first patient screened for COVID-19 in the emergency department, and April 20, 2020. A new telemedicine platform was deployed on March 29, 2020. The number of entrances and duration of in-person interactions per patient encounter, adjusted for patient length of stay, were obtained for pre- and postimplementation phases and compared with t tests to determine statistical significance.

RESULTS

There were 15,741 RTLS events linked to 2662 encounters for patients screened for COVID-19. There was no significant change in the number of in-person interactions between the pre- and postimplementation phases for both nurses (5.7 vs 7.0 entrances per patient, P=.07) and physicians (1.3 vs 1.5 entrances per patient, P=.12). Total duration of in-person interactions did not change (56.4 vs 55.2 minutes per patient, P=.74) despite significant increases in telemedicine videoconference frequency (0.6 vs 1.3 videoconferences per patient, P<.001 for change in daily average) and duration (4.3 vs 12.3 minutes per patient, P<.001 for change in daily average).

CONCLUSIONS

Telemedicine was rapidly adopted with the intent of minimizing pathogen exposure to health care workers during the COVID-19 pandemic, yet RTLS movement data did not reveal significant changes for in-person interactions between staff and patients under investigation for COVID-19 infection. Additional research is needed to better understand how telemedicine technology may be better incorporated into emergency departments to improve workflows for frontline health care clinicians.

Incorporating Medical Students Into Primary Care Telehealth Visits: Tutorial

BACKGROUND

The COVID-19 pandemic has brought about sweeping change in health care delivery, which has shifted from in-person consultations to a web-based format. Few medical schools provide web-based medicine or telemedicine training to their learners, though this is likely to be important for future medical practice.

OBJECTIVE

This tutorial communicates a framework for incorporating medical students into primary care telemedicine clinics.

METHODS

A third-year medical student and internal medicine attending physician from the Johns Hopkins University completed telemedicine clinic visits in April 2020 by using a variety of video platforms and via telephone calls.

RESULTS

Nine telemedicine visits were completed over 4 clinic days. Our patients were, on average, aged 68 years. The majority of patients were female (6/9, 67%), and most appointments were completed via a video platform (6/9, 67%). Additionally, our experience is summarized and describe (1) practical tips for how to prepare for a telehealth visit; (2) technology considerations; (3) recommendations for participation during a telehealth visit; (4) debriefing and feedback; (5) challenges to care; and (6) student, care provider, and patient reactions to telemedicine visits.

CONCLUSIONS

Telemedicine clinics have been successfully used for managing patients with chronic conditions, those who have attended low-risk urgent care visits, and those with mental health concerns. Patients have reported high patient satisfaction scores for telemedicine visits, and the majority of patients are comfortable with having medical students as part of their care team. Moving forward, telemedicine will remain a popular method for receiving health care. This study has highlighted that medical students can successfully be integrated into telemedicine clinics and that they should be exposed to telehealth whenever possible prior to residency.

Telemedicine for Acute Conditions During COVID-19: A Nationwide Survey Using Crowdsourcing

Background: COVID-19 has resulted in a rapid and significant adoption of telemedicine for acute conditions. Understanding whether patient demand will last after the pandemic helps providers and payers make informed decisions about whether to continue adopting telemedicine. Objective: We examine user experience as well as process and patient outcomes of using telemedicine for acute conditions during COVID-19 and assess how patient outcomes are affected by waiting times and demographics. Materials and Methods: A survey was conducted via Amazon Mechanical Turk during June 17-29, 2020. Inclusion criteria were: (1) ≥18 years old, (2) residing in the United States, (3) used telemedicine for acute conditions after January, and 4) a human intelligence task approval rate of >95%. Process outcomes included patient waiting time with patient outcomes being satisfaction and future use intention. Bivariate analysis and regressions of the data were performed. Results: On average, respondents reported appointment wait time of 2.76 days and virtual office wait time of 19.44 min. Overall, respondents reported moderate satisfaction (mean 5.08-5.35 of 7) and future use intention (mean 5.10-5.32 of 7). Over 72% of the respondents were satisfied and had future use intention. Females, heavier internet users, and those on the higher/lower ends of the education spectrum reported better patient outcomes. Patients "visiting" a doctor experiencing eye problems, vis-à-vis other ailments, reported lower satisfaction and intention. Waiting time negatively associates with satisfaction. Conclusions: Given the satisfactory outcomes, the high demand for telemedicine may continue after the COVID-19 pandemic. However, whether providers will continue to offer telemedicine visits may require more evidence.