Factors to Effective Telemedicine Visits During the COVID-19 Pandemic: Cohort Study

Personal Health Record implementation in rural primary care: A descriptive exploratory study using RE-AIM framework

Demand is emerging for personal health records (PHRs), a patient-centric digital tool for engaging in shared decision-making and healthcare data management. This study uses a RE-AIM framework to explore rural patients and providers' perceptions prior to and following implementation of a PHR. Health care providers and their patients were recruited from early-adopter patient medical home clinics and a local patient advisory group. Focus groups were used to explore patient and provider pre-implementation perceptions of PHRs and post-implementation provider perspectives. Patients were invited through participating clinics to use the PHR. An implementation process evaluation was conducted. Multiple methods and data sources were used and included pre-/post-intervention patient surveys, provider interviews, and PHR/EHR administrative data. Both patient and provider focus groups described PHRs as providing a comprehensive health story and enhanced communication. Patients prioritized collection of health promotion data while providers endorsed health-related, clinical data. Both groups expressed the need for managing expectations and setting boundaries on PHR use. The evaluation indicated Reach: 16% of targeted patients participated and an additional 127 patients used the PHR as a tool during the COVID-19 pandemic. Effectiveness: Patient satisfaction with use was neutral, with no significant changes to quality of life, self-efficacy, or patients' activation. Adoption: 44% of eligible clinics participated, primarily those operated publicly versus privately, in smaller communities, and farther from a regional hospital. Implementation: Despite system interoperability expectations, at time of roll out, information exchange standards had not been reached. Additional implementation complications arose from the onset of the pandemic. One clinic on-boarded additional patients resulting in a rapid spike in PHR use. Maintenance: All clinics discontinued PHR within the study period, citing several key barriers to use. RE-AIM offers a valuable process evaluation framework for a comprehensive depiction of impact, and how to drive future success. Interoperability, patient agency and control, and provider training and support are critical obstacles to overcome in PHR implementation.

Patient portal use: Persistent disparities from pre- to post-onset of the COVID-19 pandemic

INTRODUCTION

The primary objective of this study was to examine patient portal usage from pre- to post-onset of the COVID-19 pandemic to determine what impact the pandemic had on portal usage by patient sub-populations. The second study objective was to assess differences in portal usage by chronic disorders from pre- to post-onset of the pandemic.

METHODS

Patient portal data were extracted and analyzed from a non-profit healthcare system in the Mid-Atlantic region. A total of 153,628 unique patients with patient portal account were included in this study. We assessed patient portal usage from pre-onset (March 2019-February 2020) to post-onset of the COVID-19 pandemic (March 2020-February 2021). We examined usage by patient sub-populations (age, sex, race, ethnicity), comorbid conditions, and health insurance type.

RESULTS

Differences were seen in specific patient portal actions. Increases were seen in immunization views (0.43, 95% CI: 0.39, 0.46) and health record views (0.43, 95% CI: 0.40, 0.46) from post-onset compared to pre-onset. A decrease was noted in prescription renewal (medication) views (-0.07, 95% CI -0.09, -0.05) from pre- to post-onset There was a decrease in both immunization views and health record views among Black patients (-0.07, 95% CI: -0.11, -0.03) in comparison to White patients, but an increase in prescription renewal (medication) views (0.07, 95%CI 0.04, 0.09) amongst Black patients compared to White patients.

CONCLUSIONS

Patient portals are integral to patient care, allowing patients to actively engage in their care and communicate with their healthcare team about ongoing health needs. However, prior disparities in patient portal access have been exacerbated by the COVID-19 pandemic and solutions to address these disparities are urgently needed.

The State-of-the-Art of Patient Portals: Adapting to External Factors, Addressing Barriers, and Innovating

BACKGROUND AND OBJECTIVE

Recent external factors-the 21st Century Cures Act and the coronavirus disease 2019 (COVID-19) pandemic-have stimulated major changes in the patient portal landscape. The objective of this state-of-the-art review is to describe recent developments in the patient portal literature and to identify recommendations and future directions for the design, implementation, and evaluation of portals.

METHODS

To focus this review on salient contemporary issues, we elected to center it on four topics: (1) 21st Century Cures Act's impact on patient portals (e.g., Open Notes); (2) COVID-19's pandemic impact on portals; (3) proxy access to portals; and (4) disparities in portal adoption and use. We conducted targeted PubMed searches to identify recent empirical studies addressing these topics, used a two-part screening process to determine relevance, and conducted thematic analyses.

RESULTS

Our search identified 174 unique papers, 74 were relevant empirical studies and included in this review. Among these papers, we identified 10 themes within our four a priori topics, including preparing for and understanding the consequences of increased patient access to their electronic health information (Cures Act); developing, deploying, and evaluating new virtual care processes (COVID-19); understanding current barriers to formal proxy use (proxy access); and addressing disparities in portal adoption and use (disparities).

CONCLUSION

Our results suggest that the recent trends toward understanding the implications of immediate access to most test results, exploring ways to close gaps in portal adoption and use among different sub-populations, and finding ways to leverage portals to improve health and health care are the next steps in the maturation of patient portals and are key areas that require more research. It is important that health care organizations share their innovative portal efforts, so that successful measures can be tested in other contexts, and progress can continue.

A Digital Telehealth System to Compute the Myasthenia Gravis Core Examination Metrics

Background

Telemedicine practice for neurological diseases has grown significantly during the COVID-19 pandemic.Telemedicine offers an opportunity to assess digitalization of examinations and enhances access to modern computer vision and artificial intelligence processing to annotate and quantify examinations in a consistent and reproducible manner. The Myasthenia Gravis Core Examination (MG-CE) has been recommended for the telemedicine evaluation of patients with myasthenia gravis.

Objective

We aimed to assess the ability to take accurate and robust measurements during the examination, which would allow improvement in workflow efficiency by making the data acquisition and analytics fully automatic and thereby limit the potential for observation bias.

Methods

We used Zoom (Zoom Video Communications) videos of patients with myasthenia gravis undergoing the MG-CE. The core examination tests required 2 broad categories of processing. First, computer vision algorithms were used to analyze videos with a focus on eye or body motions. Second, for the assessment of examinations involving vocalization, a different category of signal processing methods was required. In this way, we provide an algorithm toolbox to assist clinicians with the MG-CE. We used a data set of 6 patients recorded during 2 sessions.

Results

Digitalization and control of quality of the core examination are advantageous and let the medical examiner concentrate on the patient instead of managing the logistics of the test. This approach showed the possibility of standardized data acquisition during telehealth sessions and provided real-time feedback on the quality of the metrics the medical doctor is assessing. Overall, our new telehealth platform showed submillimeter accuracy for ptosis and eye motion. In addition, the method showed good results in monitoring muscle weakness, demonstrating that continuous analysis is likely superior to pre-exercise and post-exercise subjective assessment.

Conclusions

We demonstrated the ability to objectively quantitate the MG-CE. Our results indicate that the MG-CE should be revisited to consider some of the new metrics that our algorithm identified. We provide a proof of concept involving the MG-CE, but the method and tools developed can be applied to many neurological disorders and have great potential to improve clinical care.

Pandemic-Triggered Adoption of Telehealth in Underserved Communities: Descriptive Study of Pre- and Postshutdown Trends

Background

The adoption of telehealth services has been a challenge in rural communities. The reasons for the slow adoption of such technology-driven services have been attributed to social norms, health care policies, and a lack of infrastructure to support the delivery of services. However, the COVID-19 pandemic–related shutdown of in-person health care services resulted in the usage of telehealth services as a necessity rather than a choice. The pandemic also fast-tracked some needed legislation to allow medical cost reimbursement for remote examination and health care services. As services return to normalcy, it is important to examine whether the usage of telehealth services during the period of a shutdown has changed any of the trends in the acceptance of telehealth as a reliable alternative to traditional in-person health care services.

Objective

Our aim was to explore whether the temporary shift to telehealth services has changed the attitudes toward the usage of technology-enabled health services in rural communities.

Methods

We examined the Medicaid reimbursement data for the state of Alabama from March 2019 through June 2021. Selecting the telehealth service codes, we explored the adoption rates in 3 phases of the COVID-19 shutdown: prepandemic, pandemic before the rollout of mass vaccination, and pandemic after the rollout of mass vaccination.

Results

The trend in telemedicine claims had an opposite pattern to that in nontelemedicine claims across the 3 periods. The distribution of various characteristics of patients who used telemedicine (age group, gender, race, level of rurality, and service provider type) was different across the 3 periods. Claims related to behavior and mental health had the highest rates of telemedicine usage after the onset of the pandemic. The rate of telemedicine usage remained at a high level after the rollout of mass vaccination.

Conclusions

The current trends indicate that adoption of telehealth services is likely to increase postpandemic and that the consumers (patients), service providers, health care establishments, insurance companies, and state and local policies have changed their attitudes toward telehealth. An increase in the use of telehealth could help local and federal governments address the shortage of health care facilities and service providers in underserved communities, and patients can get the much-needed care in a timely and effective manner.

Patient Preferences for Patient Portal-Based Telepsychiatry in a Safety Net Hospital Setting During COVID-19: Cross-sectional Study

BACKGROUND

Patient portals are a safe and secure way for patients to connect with providers for video-based telepsychiatry and help to overcome the financial and logistical barriers associated with face-to-face mental health care. Due to the COVID-19 pandemic, telepsychiatry has become increasingly important to obtaining mental health care. However, financial and technological barriers, termed the "digital divide," prevent some patients from accessing the technology needed to use telepsychiatry services.

OBJECTIVE

As an extension to a clinic's outreach project during COVID-19 to improve patient engagement with video-based visits through the hospital's patient portal among adult behavioral health patients at an urban safety net hospital, we aim to assess patient preference for patient portal-based video visits or telephone-only visits and to identify the demographic variables associated with their preference.

METHODS

Patients in an outpatient psychiatry clinic were contacted by phone, and preference for telepsychiatry by phone or video through a patient portal, as well as device preference for video-based visits, were documented. Patient demographic characteristics were collected from the electronic medical record.

RESULTS

A total of 128 patients were reached by phone. A total of 79 (61.7%) patients chose video-based visits, and 69.6% (n=55) of these patients preferred to access the patient portal through a smartphone. Older patients were significantly less likely to agree to video-based visits.

CONCLUSIONS

Among behavioral health patients at a safety net hospital, there was relatively low engagement with video-based visits through the hospital's patient portal, particularly among older adults.