Clinician Perspectives on Telemedicine: Observational Cross-sectional Study

Utility of Routine Postoperative Examination for Detecting Vaginal Cuff Dehiscence After Total Laparoscopic Hysterectomy

STUDY OBJECTIVE

To determine the utility of routine postoperative vaginal cuff examination for detection of vaginal cuff dehiscence (VCD) after total laparoscopic hysterectomy (TLH).

DESIGN

Retrospective cohort study.

SETTING

Quaternary care academic hospital in the United States.

PATIENTS

All patients who underwent TLH with a minimally invasive gynecologic surgeon at our institution from 2016 to 2022.

INTERVENTIONS

Laparoscopic hysterectomy with routine vaginal cuff check 6 to 8 weeks postoperatively and laparoscopic hysterectomy without routine vaginal cuff check.

MEASUREMENTS AND MAIN RESULTS

We identified 703 patients who underwent TLH, 216 (30.7%) with routine cuff checks and 487 (69.3%) without. Within the no cuff check group, 287 (58.9%) had entirely virtual follow-up. There was no difference in VCD between the routine cuff check (1.28%, n = 2) and no cuff check groups (0.93%, n = 7, p = .73). Median time to VCD was 70.0 days (27.5-114.0). No VCDs were identified in asymptomatic patients on routine examination, and both patients in the cuff check group with VCD had appropriately healing cuffs on routine examination. In the cuff check group, 7 patients (3.2%) had findings of incomplete healing requiring intervention (silver nitrate, extended pelvic rest), all of whom were asymptomatic at the time of examination. Eight patients (3.7%) in the routine cuff check group and 21 (4.3%) in the no examination group required a nonroutine cuff check owing to symptoms. There was no difference in points of contact for postoperative symptoms between the groups (median 0 [0-1.0] for both groups, p = .778).

CONCLUSION

Routine postoperative vaginal cuff examination does not seem to affect or negate the risk of future VCD. Virtual follow-up for asymptomatic patients may be appropriate after TLH.

Challenges and solutions for implementing telemedicine in Iran from health policymakers' perspective

BACKGROUND

Despite significant progress in health technology and growing interest among countries in incorporating telemedicine into healthcare delivery, its usage remains limited in Iran. The aim of this study is to investigate the challenges related to telemedicine in Iran and pinpoint potential solutions from the viewpoint of health policymakers, marking the first such endeavor.

METHODS

This qualitative study was conducted in Iran in 2022. Data were gathered from 19 health policymakers who were selected using purposeful and snowball sampling techniques via in-depth and semi-structured interviews. The research findings were analyzed using the content analysis technique, with coding performed using MAXQDA software. The content analysis approach developed by Erlingsson was utilized to analyze the data.

RESULTS

The study revealed eight main challenges that inhibit the widespread use of telemedicine in Iran. These challenges include policy weaknesses, uncertainty around operating mechanisms, inadequate communication and telecommunication infrastructure, insufficient cultural infrastructure, lack of electronic requirements, redundant bureaucracies, legal gaps, and economic factors. Furthermore, four key solutions to these challenges were identified. These include a national commitment to the development of telemedicine, the establishment of a telemedicine roadmap, the enhancement of e-health requirements and infrastructure, and the preparation of the community to accept telemedicine as a viable option for healthcare delivery.

CONCLUSION

The implementation of telemedicine in Iran faces significant challenges, some of which are related to the national healthcare system, while others stem from various policy-related institutions and organizations. Addressing these challenges will require extensive inter-organizational cooperation and strong leadership at the governance level. However, it should be noted that fully resolving these issues is a time-consuming process.

Telehealth Competencies: Training Physicians for a New Reality?

In North America, telehealth increased by 40% between 2019 and 2020 and stabilized at 40% in 2021. As telehealth becomes more common, it is essential to ensure that healthcare providers have the required skills to overcome the challenges and barriers of this new modality of care. While the COVID-19 pandemic has accelerated the design and implementation of telehealth curricula in healthcare education programs, its general adoption is still a major gap and an important barrier to ensuring scaling up and sustainability of the telesshealth practice. Lack of experienced faculty and limited curricular time are two of the most common barriers to expanding telehealth education. Overcoming the barriers of telehealth curricula implementation may require moving away from the classic expert model of learning in which novices learn from experts. As the adoption of telehealth curricula is still in its early stages, institutions may need to plan for faculty development and trainee education at the same time. Questions regarding the timing and content of telehealth education, the interprofessional development of curricula, and the identification of optimal pedagogical methods remain open and crucial. This article reflects on these questions and presents telesimulation as an ideal instructional method for the training of telehealth competencies. Telesimulation can provide opportunities for practical training across a range of telehealth competencies, fostering not only technical proficiency but also communication skills and interprofessional collaboration.

Associations of perceived changes in work due to digitalization and the amount of digital work with job strain among physicians: a national representative sample

BACKGROUND

Physicians' work is often stressful. The digitalization of healthcare aims to streamline work, but not all physicians have experienced its realization. We examined associations of perceived changes in work due to digitalization and the amount of digital work with job strain among physicians. The moderating role of the length of work experience was investigated for these associations.

METHODS

We used representative survey data on Finnish physicians' (N = 4271) experiences of digitalization from 2021. The independent variables included perceptions on statements about work transformations aligned with digitalization goals, and the extent that information systems and teleconsultations were utilized. Stress related to information systems (SRIS), time pressure, and psychological stress were the dependent variables. We analyzed the associations using multivariable linear and logistic regressions.

RESULTS

Respondents had a mean SRIS score of 3.5 and a mean time pressure score of 3.7 on a scale of 1-5. Psychological stress was experienced by 60%. Perceptions associated with higher SRIS comprised disagreements with statements asserting that digitalization accelerates clinical encounters (b = .23 [95% CI: .16-.30]), facilitates access to patient information (b = .15 [.07-.23]), and supports decision-making (b = .11 [.05-.18]). Disagreement with accelerated clinical encounters (b = .12 [.04-.20]), and agreements with patients' more active role in care (b = .11 [.04-.19]) and interprofessional collaboration (b = .10 [.02-.18]) were opinions associated with greater time pressure. Disagreeing with supported decision-making (OR = 1.26 [1.06-1.48]) and agreeing with patients' active role (OR = 1.19 [1.02-1.40]) were associated with greater psychological stress. However, perceiving improvements in the pace of clinical encounters and access to patient information appeared to alleviate job strain. Additionally, extensive digital work was consistently linked to higher strain. Those respondents who held teleconsultations frequently and had less than 6 years of work experience reported the greatest levels of time pressure.

CONCLUSIONS

Physicians seem to be strained by frequent teleconsultations and work that does not meet the goals of digitalization. Improving physicians' satisfaction with digitalization through training specific to the stage of career and system development can be crucial for their well-being. Schedules for digital tasks should be planned and allocated to prevent strain related to achieving the digitalization goals.

Healthcare professional and manager perceptions on drivers, benefits, and challenges of telemedicine: results from a cross-sectional survey in the Italian NHS

BACKGROUND

The Covid-19 pandemic provided new challenges and opportunities for patients and healthcare providers while accelerating the trend of digital healthcare transformation. This study explores the perspectives of healthcare professionals and managers on (i) drivers to the implementation of telemedicine services and (ii) perceived benefits and challenges related to the use of telemedicine across the Italian National Health Service.

METHODS

An online cross-sectional survey was distributed to professionals working within 308 healthcare organisations in different Italian regions. Quantitative and qualitative data were collected through a self-administered questionnaire (June-September 2021). Responses were analysed using summary statistics and thematic analysis.

RESULTS

Key factors driving the adoption of telemedicine have been grouped into (i) organisational drivers (reduce the virus spread-80%; enhance care quality and efficiency-61%), (ii) technological drivers (ease of use-82%; efficacy and reliability-64%; compliance with data governance regulations-64%) and (iii) regulatory drivers (regulations' semplification-84%). Nearly all respondents perceive telemedicine as useful in improving patient care (96%). The main benefits reported by respondents are shorter waiting lists, reduced Emergency Department attendance, decreased patient and clinician travel, and more frequent patient-doctor interactions. However, only 7% of respondents believe that telemedicine services are more effective than traditional care and 66% of the healthcare professionals believe that telemedicine can't completely substitute in-person visits due to challenges with physical examination and patient-doctor relationships. Other reported challenges include poor quality and interoperability of telemedicine platforms and scarce integration of telemedicine with traditional care services. Moreover, healthcare professionals believe that some groups of patients experience difficulties in accessing and using the technologies due to socio-cultural factors, technological and linguistic challenges and the absence of caregivers.

CONCLUSIONS

Respondents believe that telemedicine can be useful to complement and augment traditional care. However, many challenges still need to be overcome to fully consider telemedicine a standard of care. Strategies that could help address these challenges include additional regulations on data governance and reimbursements, evidence-based guidelines for the use of telemedicine, greater integration of tools and processes, patient-centred training for clinicians, patient-facing material to assist patients in navigating virtual sessions, different language options, and greater involvement of caregivers in the care process.

Patient and provider perspectives on telemedicine use in an outpatient gynecologic clinic serving a diverse, low-income population

OBJECTIVE

To evaluate patient and provider experiences using telemedicine for gynecologic visits among a diverse, low-income population.

METHODS

Patients attending telemedicine visits at a resident-run gynecology clinic completed a modified Telemedicine Usability Questionnaire and providers completed a survey addressing satisfaction and barriers for each visit. The Telemedicine Usability Questionnaire included six subscales to assess telemedicine usability with 1-5 Likert-scale responses. Statistical analyses included Chi-square, Fisher's exact, Wilcoxon rank sum, Wilcoxon signed-rank, and two-sample t-test.

RESULTS

Of 192 patients enrolled, 157 (82%) completed the surveys (87% video visits, 13% telephone visits). Most patients were ethnic minorities (non-Hispanic White-16%, Hispanic-32%, Black-28%, Asian-10%), median age was 40 years (range 18-69), and 63% reported income under $40,000. The total mean Telemedicine Usability Questionnaire score was 4.3/5. The reliability subscale score (3.72/5) was lower compared to all other subscales (p < 0.001). Older respondents were more likely to find telemedicine unreliable (mean age >44 vs <39, p = 0.02). Without telemedicine, 54% would have traveled ≥1 h to appointments, with 46% spending over $35 on travel, and 27% missing ≥ 1 workday. Patients preferred telemedicine for follow-up rather than initial visits (81% vs 33%, p < 0.01). Among providers, residents felt less adequately trained in telemedicine compared to nurse practitioners and fellows (54% vs 46%, p = 0.039).

CONCLUSION

Low-income women utilizing telemedicine for outpatient gynecologic care report positive experiences with improved access to healthcare, cost, and time savings compared to in-person visits. Provider experiences were also positive; however, teaching hospitals must evaluate whether trainee providers feel adequately trained to deliver telemedicine visits.

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.

Telehealth Policy, Practice, and Education: a Position Statement of the Society of General Internal Medicine

Telehealth services, specifically telemedicine audio-video and audio-only patient encounters, expanded dramatically during the COVID-19 pandemic through temporary waivers and flexibilities tied to the public health emergency. Early studies demonstrate significant potential to advance the quintuple aim (patient experience, health outcomes, cost, clinician well-being, and equity). Supported well, telemedicine can particularly improve patient satisfaction, health outcomes, and equity. Implemented poorly, telemedicine can facilitate unsafe care, worsen disparities, and waste resources. Without further action from lawmakers and agencies, payment will end for many telemedicine services currently used by millions of Americans at the end of 2024. Policymakers, health systems, clinicians, and educators must decide how to support, implement, and sustain telemedicine, and long-term studies and clinical practice guidelines are emerging to provide direction. In this position statement, we use clinical vignettes to review relevant literature and highlight where key actions are needed. These include areas where telemedicine must be expanded (e.g., to support chronic disease management) and where guidelines are needed (e.g., to prevent inequitable offering of telemedicine services and prevent unsafe or low-value care). We provide policy, clinical practice, and education recommendations for telemedicine on behalf of the Society of General Internal Medicine. Policy recommendations include ending geographic and site restrictions, expanding the definition of telemedicine to include audio-only services, establishing appropriate telemedicine service codes, and expanding broadband access to all Americans. Clinical practice recommendations include ensuring appropriate telemedicine use (for limited acute care situations or in conjunction with in-person services to extend longitudinal care relationships), that the choice of modality be done through patient-clinician shared decision-making, and that health systems design telemedicine services through community partnerships to ensure equitable implementation. Education recommendations include developing telemedicine-specific educational strategies for trainees that align with accreditation body competencies and providing educators with protected time and faculty development resources.

Usability of telehealth among healthcare providers during COVID-19 pandemic in Nineveh Governorate, Iraq

Objectives

To identify the usability of telehealth services and barriers during the coronavirus disease (COVID-19) pandemic among healthcare providers in Nineveh Governorate-Iraq.

Study design

This was a multicenter cross-sectional survey.

Methods

We collected the required data from April to July 2022 using self-administered open-ended questionnaires. The healthcare providers were physicians, pharmacists, and nurses with at least six months of services at hospitals. A modified form of the Telehealth Usability Questionnaire (TUQ) was used to assess the usability of telehealth services.

Results

There were 460 healthcare providers, of which 269/460 (58.5%) were users of telehealth services. These were mostly physicians (n = 167/269, 62.1%), nurses (52/269, 19.3%), and pharmacists (n = 50/269, 18.6%), with a p-value of 0.001. During the COVID-19 pandemic, physicians (n = 100/167, 60.0%) and pharmacists (n = 28/50, 56.0%) increased their provision of telehealth services. Approximately 60% of physicians and nurses preferred to provide telehealth services in a synchronized manner. The participants mostly used smartphones to provide telehealth services through Messenger/Facebook and WhatsApp applications, specifically utilizing voice and/or video messages. There was some agreement among the participants (n = 269) regarding the usability of telehealth services. The overall mean score (±SD) was 4.8 (±0.88). The most reported barriers to telehealth services were poor Internet services, the presence of specific diseases, lack of technical comprehension, and insufficient time allocated to the service.

Conclusion

Healthcare providers demonstrated a tendency towards the usability of telehealth services. Despite the available barriers, triage collaborations among patients, healthcare providers, and healthcare institutions are needed to achieve more successful adoption of these services.

An Educational Needs Assessment of Telehealth in Primary Care Among US Internal Medicine Residents

OBJECTIVES

As a result of the coronavirus disease 2019 pandemic, many Internal Medicine (IM) residency programs converted to telehealth for primary care. Our objectives in this study were to better understand resident past and present telehealth education, their perceived barriers to telehealth practice, and their perceived solutions to improving telehealth use and education.

METHODS

We performed a cross-sectional needs assessment survey between November 2020 and February 2021 among residents at 10 IM residency programs across the United States. Our primary measures were telehealth use in resident continuity clinics before and during the coronavirus disease 2019 pandemic, telehealth training, and confidence and barriers in using telehealth.

RESULTS

Of 857 residents contacted, 314 (36.6%) responded. Residents reported low rates of education in telehealth prepandemic with significant improvements after the start of the pandemic across all visit domains (range of 10.7%-19.6% prepandemic compared with 25.6%-55.7% postpandemic, all P < 0.001). Resident confidence levels were significantly lower (P < 0.001) for video visits and telephone visits compared with in-person visiting across domains of communication, history taking, using an interpreter, making a diagnosis, counseling patients, providing psychosocial support, performing medical management, and coordinating after-visit care. Reported barriers included patient resources, clinic resources, lack of preceptor feedback, and lack of observation. Reported resources for improvement included tutorials on physical examination techniques, clinical space for telehealth, and patient resources for telehealth.

CONCLUSIONS

To effectively address the educational needs for telehealth practice by IM residents, educators must consider not only curricular needs but also clinical, preceptor, and patient barriers to the high-quality use of telehealth for primary care.

Telemedical Consultations in Palliative Care: Benefits through Knowledge Exchange and Intercollegiate Collaboration-Findings from the German oVID Project

(1) Background: As the number of people receiving specialized palliative care (PC) continues to rise, there is a need to ensure the transfer of this expertise from university-based PC departments to primary care hospitals without such in-house access. The present study examines the potential of telemedicine to bridge these gaps. (2) Methods: This is a prospective multi-center feasibility trial. All physicians were appropriately pre-equipped and instructed to conduct telemedical consultations (TCs), which took place within fixed meetings or on-call appointments either related or unrelated to individual patients (allowing TCs also for educational and knowledge exchange purposes). (3) Results: An inquiry for participation was submitted to 11 hospitals, with 5 external hospitals actively cooperating. In the first study section, a total of 57 patient cases were included within 95 patient-related TCs during 80 meetings. Other university disciplines were involved in 21 meetings (26.2%). Therapy adjustments resulted following 25 of 71 affected TCs (35.2%). In 20 cases (21.1%), an on-site consultation at the university hospital was avoided, and in 12 cases (12.6%), a transfer was avoided. Overall, TCs were considered helpful in resolving issues for 97.9% of the cases (n = 93). Yet, technical problems arose in about one-third of all meetings for at least one physician (36.2%; n = 29). Besides, in the second study section, we also conducted 43 meetings between physicians for education and knowledge exchange only. (4) Conclusions: Telemedicine has the potential to transfer university expertise to external hospitals through simple means. It improves collaboration among physicians, may prevent unnecessary transfers or outpatient presentations, and is thus likely to lower costs.

Telemedicine perceptions and experiences of socially vulnerable households during the early stages of the COVID-19 pandemic: a qualitative study

BACKGROUND

Early in the COVID-19 pandemic, efforts to decrease risk of viral transmission triggered an abrupt shift from ambulatory health care delivery toward telemedicine. In this study, we explore the perceptions and experiences of telemedicine among socially vulnerable households and suggest strategies to increase equity in telemedicine access.

METHODS

Conducted between August 2020 and February 2021, this exploratory qualitative study involved in-depth interviews with members of socially vulnerable households needing health care. Participants were recruited from a food bank and primary care practice in Montréal. Digitally recorded telephone interviews focused on experiences and perceptions related to telemedicine access and use. In our thematic analysis, we employed the framework method to facilitate comparison, and the identification of patterns and themes.

RESULTS

Twenty-nine participants were interviewed, 48% of whom presented as women. Almost all sought health care in the early stages of the pandemic, 69% of which was received via telemedicine. Four themes emerged from the analysis: delays in seeking health care owing to competing priorities and perceptions that COVID-19-related health care took precedence; challenges with appointment booking and logistics given complex online systems, administrative inefficiencies, long wait times and missed calls; issues around quality and continuity of care; and conditional acceptance of telemedicine for certain health problems, and in exceptional circumstances.

INTERPRETATION

Early in the pandemic, participants report telemedicine delivery did not accommodate the diverse needs and capacities of socially vulnerable populations. Patient education, logistical support and care delivery by a trusted provider are suggested solutions, in addition to policies supporting digital equity and quality standards to promote telemedicine access and appropriate use.

Primary Care Physician's Perception and Satisfaction With Telehealth in the National Guard Primary Healthcare Centers in Jeddah, Saudi Arabia in 2022

Background Telehealth is a tool to facilitate the connection between patients and their healthcare providers. With the recent emergence of telehealth, implementation of this service in primary healthcare centers (PHCs) has been accompanied by specific challenges despite the high levels of satisfaction reported. This study aimed to assess the factors that affect clinicians' perceptions and satisfaction with telehealth in National Guard PHCs to help explore and overcome any barriers and challenges. Methods A cross-sectional survey was distributed among primary healthcare physicians using virtual clinics in the National Guard PHCs in Jeddah, Saudi Arabia, in 2022. A validated questionnaire from previous literature was used to evaluate clinicians' perceptions and satisfaction with telehealth. Results The study included 53 primary healthcare physicians, with an overall response rate of 90%. Most physicians (77%) were satisfied with their overall experience with offering virtual visits. Nevertheless, 72% of physicians perceived patients' limited technical knowledge, and 70% considered limited access to technology a significant barrier against virtual visits. Higher satisfaction levels were significantly associated with those who did not consider the lack of integration of virtual visits with current workflow or electronic medical records (EMRs) a significant barrier to conducting virtual visits (p-value = 0.005). Conclusion Despite the undeniable advantages of telehealth, barriers, and challenges remain extant and can influence clinicians' satisfaction. Continuous monitoring for improvements is needed to enhance the telehealth experience.

Can Tele-Neuro-Ophthalmology Be Useful Beyond the Pandemic?

PURPOSE OF THE REVIEW

Neuro-ophthalmologists rapidly adopted telehealth during the COVID-19 pandemic to minimize disruption to patient care. This article reviews recent research on tele-neuro-ophthalmology adoption, current limitations, and potential use beyond the pandemic. The review considers how digital transformation, including machine learning and augmented reality, may be applied to future iterations of tele-neuro-ophthalmology.

RECENT FINDINGS

Telehealth utilization has been sustained among neuro-ophthalmologists throughout the pandemic. Adoption of tele-neuro-ophthalmology may provide solutions to subspecialty workforce shortage, patient access, physician wellness, and trainee educational needs within the field of neuro-ophthalmology. Digital transformation technologies have the potential to augment tele-neuro-ophthalmology care delivery by providing automated workflow solutions, home-based visual testing and therapies, and trainee education via simulators. Tele-neuro-ophthalmology use has and will continue beyond the COVID-19 pandemic. Digital transformation technologies, when applied to telehealth, will drive and revolutionize the next phase of tele-neuro-ophthalmology adoption and use in the years to come.

Endocrinologists' Experiences With Telehealth: A Qualitative Study With Implications for Promoting Sustained Use

OBJECTIVE

Endocrinology is well-suited to telehealth, with high rates of use and known benefits. Clinician attitudes toward telehealth will be critical to ensuring sustained use after the pandemic. We examined endocrinologists' experiences with synchronous telehealth to identify factors affecting experiences with and acceptance of the technology.

METHODS

We conducted qualitative interviews and directed-content analysis with a purposive sample of 26 U.S. endocrinologists. Factors affecting clinicians' experiences were mapped to the human-organization-technology fit (HOT-fit) framework.

RESULTS

We found that clinicians' experiences with synchronous telehealth were influenced by: (1) Clinician factors: Clinicians welcomed telehealth but expressed concerns about patient interest, rapport building, and clinical appropriateness, desiring more data to support its use. Many clinicians feared missing clinical findings on virtual examination, despite no such personal experiences. Effects on professional and personal life contributed to satisfaction, through increased flexibility but also increased workload. (2) Organizational factors: Departmental meetings and trainings supported clinicians' technical, logistical, and clinical needs, reducing resistance to telehealth use. Shifting staff responsibilities in clinical workflows improved clinicians' experiences and supported telehealth use, while mixed telehealth and in-person schedules impeded workflow. (3) Technology factors: Most clinicians preferred video visits to telephone. Usability and reliability of telehealth platforms, integration of patient self-monitoring data, and availability of IT support were crucial to a positive experience.

CONCLUSION

Clinician acceptance of telehealth is influenced by clinician, organizational, and technology factors that can be leveraged to improve buy-in. Organizational leaders' attention to addressing these factors will be critical to support endocrinologists' continued provision of telehealth for their patients.

"It Took Away and Stripped a Part of Myself": Clinician Distress and Recommendations for Future Telepalliative Care Delivery in the Cancer Context

BACKGROUND

The COVID-19 pandemic has led to the rapid expansion of telehealth service delivery. We explored the experiences of a multidisciplinary palliative care team delivering telepalliative care for oncology inpatients during a 10-weeks COVID-19 surge in New York City.

METHODS/PARTICIPANTS

We conducted semi-structured qualitative interviews with a targeted sample, employing a phenomenological approach with applied thematic text analysis. An interdisciplinary coding team iteratively coded data using a mix of a priori and inductive codes. Team members first independently reviewed each category, then met to reach consensus on recurring themes. The sample (n = 11) included a chaplain (n = 1), social worker (n = 1), pharmacist (n = 1), physicians (n = 3), physician assistant (n = 1), and nurse practitioners (n = 4).

RESULTS

Participants described multidimensional clinician distress as a primary experience in delivering telepalliative care during the COVD-19 surge, characterized by competing loyalties (e.g., institutional obligations, ethical obligations to patients, resentment and distrust of leadership) and feelings of disempowerment (e.g., guilt in providing subpar support, decisional regret, loss of identity as a provider). Participants provided explicit recommendations to improve telepalliative care delivery for acute oncology inpatients in the future.

CONCLUSION

Palliative care clinicians experienced personal and professional distress providing inpatient telepalliative care during this COVID-19 surge. Clinician strain providing telehealth services must be explored further as the pandemic and utilization of telehealth evolves. Telepalliative care planning must include attention to clinician wellbeing to sustain the workforce and promote team cohesion, and a focus on infrastructure needed to deliver high-quality, holistic care for oncology patients and their families when in-person consultation is impossible.

Enablers and barriers to nurse-facilitated geriatric teleconsultations in nursing homes: a qualitative descriptive multi-site study

BACKGROUND

Nurses play a major role in facilitating teleconsultations in nursing homes with remote physicians. Currently, evidence explicating their role in teleconsultations is lacking. As telemedicine usage grows, understanding the factors that enable or impede nurses' role in teleconsultations allows for more support in the provision of patient care through this modality.

OBJECTIVE

This study sought to explore enablers and barriers nurses faced in facilitating geriatric teleconsultations in nursing homes.

METHODS

A qualitative descriptive study using semi-structured interviews was conducted in Singapore, from July to November 2021. Purposive sampling of nursing home nurses was undertaken. Data were inductively analysed using Braun and Clarke's thematic analysis approach.

RESULTS

Twenty-two nursing home nurses participated in the study. Six key themes were identified as enablers and barriers in nurse-facilitated geriatrics teleconsultations. Enablers included nurses' acknowledgement of teleconsultations as needs-orientated service, close partnership with the hospital-based geriatric service for training and workflow support and nurses' sense of empowerment in teleconsultation involvement. Barriers that existed were the nurses' lack of confidence in physical assessment and communication competencies, role conflict due to nurses' perceived inability to meet physicians' expectations and limited scope of practice in performing teleconsultation-related tasks and the presence of technology-related challenges.

CONCLUSION

The identification of enablers and barriers in teleconsultations for nursing home residents provides insights for future research and development in telemedicine-related implementation and educational interventions in long-term care. Developing strong partnerships between telemedicine providers and nursing homes, further enhancement of nurses' telemedicine competencies and optimising digital infrastructure are warranted.

Factors Associated With Telemedicine Use Among German General Practitioners and Rheumatologists: Secondary Analysis of Data From a Nationwide Survey

Background

Previous studies have demonstrated telemedicine (TM) to be an effective tool to complement rheumatology care and address workforce shortage. With the outbreak of the SARS-CoV-2 pandemic, TM experienced a massive upswing. However, in rheumatology care, the use of TM stagnated again shortly thereafter. Consequently, the factors associated with physicians’ willingness to use TM (TM willingness) and actual use of TM (TM use) need to be thoroughly investigated.

Objective

This study aimed to identify the factors that determine TM use and TM willingness among German general practitioners and rheumatologists.

Methods

We conducted a secondary analysis of data from a German nationwide cross-sectional survey with general practitioners and rheumatologists. Bayesian univariate and multivariate logistic regression analyses were applied to the data to determine which factors were associated with TM use and TM willingness. The predictor variables (covariates) that were studied individually included sociodemographic factors (eg, age and sex), work characteristics (eg, practice location and medical specialty), and self-assessed knowledge of TM. All the variables positively and negatively associated with TM use and TM willingness in the univariate analysis were then considered for Bayesian model averaging analysis after a selection based on the variance inflation factor (≤2.5). All analyses were stratified by sex.

Results

Univariate analysis revealed that out of 83 variables, 36 (43%) and 34 (41%) variables were positively or negatively associated (region of practical equivalence≤5%) with TM use and TM willingness, respectively. The Bayesian model averaging analysis allowed us to identify 13 and 17 factors of TM use and TM willingness, respectively. Among these factors, being female, having very poor knowledge of TM, treating <500 patients per quarter, and not being willing to use TM were negatively associated with TM use, whereas having good knowledge of TM and treating >1000 patients per quarter were positively associated with TM use. In addition, being aged 51 to 60 years, thinking that TM is not important for current and future work, and not currently using TM were negatively associated with TM willingness, whereas owning a smart device and working in an urban area were positively associated with TM willingness.

Conclusions

The results point to the close connection between health care professionals’ knowledge of TM and actual TM use. These results lend support to the integration of digital competencies into medical education as well as hands-on training for health care professionals. Incentive programs for physicians aged >50 years and practicing in rural areas could further encourage TM willingness.

Does it get better? An ongoing exploration of physician experiences with and acceptance of telehealth utilization

INTRODUCTION

COVID-19 forced health systems to rapidly implement telehealth for routine practice, often without sufficient training or standards. We conducted a longitudinal survey of physicians to explore changes in their perceptions of the challenges and benefits of telehealth and identify recommendations for future practice.

METHODS

An anonymous online survey was distributed to a cohort of internal medicine physicians in May to June 2020 and March to June 2021. Changes in responses between 2020 and 2021 and by site (private vs. public) were described. These findings, along with those of a thematic analysis of open-ended responses to questions on telehealth experiences, informed a set of recommendations.

RESULTS

The survey response rate was 111/391 in 2021 compared to 122/378 in 2020. Fewer physicians reported that telehealth was more difficult than in person with regards to taking a history (49% in 2020, 33% in 2021, p= 0.015), maximizing patient adherence (33% in 2020, 19% in 2021, p = 0.028), and maintaining patient relationships (31%, 25%, p = 0.009) in 2021. Similar proportions of physicians reported continued challenges with building new patient relationships (75%, 77%, p = 0.075), educating patients (40%, 32%, p = 0.393), and working collaboratively with their team (38%, 41%, p = 0.794). Physicians reported increased satisfaction with tele-visits over in-person visits (13%, 27%, p = 0.006) and less worry over doing future tele-visits (45%, 31%, p = 0.027). Physicians' open-ended responses identified recommendations for further improving the design and use of telehealth.

DISCUSSION

Results suggest that physician experience with telehealth improved but opportunities for training and improved integration remain. Longitudinal assessment can deepen understanding of the evolution of telehealth care.

How can equitable video visit access be delivered in primary care? A qualitative study among rural primary care teams and patients

OBJECTIVE

The COVID-19 pandemic sparked exponential growth in video visit use in primary care. The rapid shift to virtual from in-person care exacerbated digital access disparities across racial groups and rural populations. Moving forward, it is critical to understand when and how to incorporate video visits equitably into primary care. We sought to develop a novel clinical algorithm to guide primary care clinics on how and when to employ video visits as part of care delivery.

DESIGN

Qualitative data collection: one team member conducted all patient semistructured interviews and led all focus groups with four other team members taking notes during groups.

SETTING

3 rural primary care clinics in the USA.

PARTICIPANTS

24 black veterans living in rural areas and three primary care teams caring for black veterans living in rural areas.

PRIMARY AND SECONDARY OUTCOME MEASURES

Findings from semistructured interviews with patients and focus groups with primary care teams.

RESULTS

Key issues around appropriate use of video visits for clinical teams included having adequate technical support, encouraging engagement during video visits and using video visits for appropriate clinical situations. Patients reported challenges with broadband access, inadequate equipment, concerns about the quality of video care, the importance of visit modality choice, and preferences for in-person care experience over virtual care. We developed an algorithm that requires input from both patients and their care team to assess fit for each clinical encounter.

CONCLUSIONS

Informed matching of patients and clinical situations to the right visit modality, along with individual patient technology support could reduce virtual access disparities.

Factors That Influence How Providers Assess the Appropriateness of Virtual Visits: A Qualitative Investigation (Preprint)

Background

The rapid implementation of virtual care (ie, telephone or video-based clinic appointments) during the COVID-19 pandemic resulted in many providers offering virtual care with little or no formal training and without clinical guidelines and tools to assist with decision-making. As new guidelines for virtual care provision take shape, it is critical that they are informed by an in-depth understanding of how providers make decisions about virtual care in their clinical practices.

Objective

In this paper, we sought to identify the most salient factors that influence how providers decide when to offer patients video appointments instead of or in conjunction with in-person care.

Methods

We conducted semistructured interviews with 28 purposefully selected primary and specialty health care providers from the US Department of Veteran’s Affairs health care system. We used an inductive approach to identify factors that impact provider decision-making.

Results

Qualitative analysis revealed distinct clinical, patient, and provider factors that influence provider decisions to initiate or continue with virtual visits. Clinical factors include patient acuity, the need for additional tests or labs, changes in patients’ health status, and whether the patient is new or has no recent visit. Patient factors include patients’ ability to articulate symptoms or needs, availability and accessibility of technology, preferences for or against virtual visits, and access to caregiver assistance. Provider factors include provider comfort with and acceptance of virtual technology as well as virtual physical exam skills and training.

Conclusions

Providers within the US Department of Veterans Affairs health administration system consider a complex set of factors when deciding whether to offer or continue a video or telephone visit. These factors can inform the development and further refinement of decision tools, guides, and other policies to ensure that virtual care expands access to high-quality care.

Virtual care in ontario community health centres: A Cross-Sectional study to understand changes in care delivery

BACKGROUND

Virtual delivery of primary care has seen a massive adoption as a result of the COVID-19 pandemic.

AIM

In this descriptive study, we use an equity lens to explore the impact of transitioning to greater use of virtual care in community health centres (CHCs) across Ontario, Canada.

DESIGN & SETTING

We administered a cross-sectional survey and extracted electronic medical record (EMR) data from thirty-six CHCs.

METHOD

The survey captured CHC's experience with the increased adoption of virtual care. A longitudinal analysis of the EMR data was conducted to evaluate changes in health service delivery. EMR data was extracted monthly for a period of time prior to the pandemic (April 2019 - February 2020) and during (April 2020 - February 2021).

RESULTS

In comparison to the pre-pandemic period, CHCs experienced a moderate decline in visits made (11%), patients seen (9%), issues addressed (9%), and services provided (15%). During the pandemic period, an average of 54% of visits were conducted virtually with phone as the leading virtual modality (96%). Drops in service types ranged from 82% to 28%. The distribution of virtual modalities varied according to the provider type. Access to in-person and virtual care did not vary across patient characteristics.

CONCLUSION

Our results demonstrate a large shift towards virtual delivery while maintaining in-person care. We found no meaningful differences in virtual versus in-person care related to patient characteristics or rurality of centres. Future studies are needed to explore how to best select the appropriate modality for patients and service types.

Provider Evaluation of a Novel Virtual Hybrid Hospital at Home Model

Background

Healthcare provider’s experience with new models of care is crucial for long-term success. In July 2020, Mayo Clinic implemented a novel virtual hybrid hospital at home program called Advanced Care at Home (ACH). This model allows virtual providers in a command center to care for high-acuity patients in the home setting through collaboration with a vendor-mediated supply chain. This study aims to describe the outcomes obtained from a survey applied to the ACH providers to determine their acceptance of the quality and safety of the virtual hybrid care model, their perception towards the decision-making and teamwork between the command center and supplier network, and determine if the overall experience with ACH was rewarding.

Methods

A 15-question anonymous survey was distributed via email quarterly to all the physicians and nurse practitioners registered in ACH program at Mayo Clinic. The survey encompassed questions related to the overall experience in ACH concerning work environment, quality of care, service reliability, teamwork, decision-making, and satisfaction. All the questions were Likert-like scale choice, and a descriptive analysis using frequency distribution and percentages of the data was performed.

Results

Between September 1, 2020 and April 30, 2021, three quarterly surveys were sent to a total of 21 physicians and nurse practitioners caring for patients virtually in ACH. The response rate reported was 72%, 33%, and 66%, respectively, at the first, second, and third quarters. Eighty percent or more of providers consistently gave positive scores to all three areas analyzed throughout the 8-month study.

Conclusion

Providers found the ACH virtual hybrid model of home hospital care very rewarding. They were able to deliver high-quality and safe care to their patients through positive teamwork with a vendor-mediated supply chain. This novel model of hospital at home has the potential to be a great provider satisfier moving forward.

Effects of Telemedicine on Pediatric Clinical Care During COVID-19

Coronavirus disease 2019 (COVID-19) has provided unprecedented opportunity for the growth of telemedicine in pediatrics. Clinics rapidly expanded their telemedicine capabilities and converted in-person visits to virtual visits to offer patients continued care while limiting infection risks. Although the transition to video visits has several benefits-patient convenience, versatility of care, ease of follow up, and management of chronic conditions-these gains are only available to those who have the requisite technology access and literacy needed to conduct a video visit. The need for technology-dependent care stands to further widen preexisting disparities in access to care for those who cannot use or afford the necessary technology. Our article explores some of these benefits and challenges and reminds us that although telemedicine has proven to have high utility for many patients, there are improvements that must still be made to ensure equitable accessibility and durability of virtual visits. [Pediatr Ann. 2021;50(12):e503-e508.].