Patient and Health System Experience With Implementation of an Enterprise-Wide Telehealth Scheduled Video Visit Program: Mixed-Methods Study

Short- and intermediate-term impact of DTC telemedicine consultations on subsequent healthcare consumption

AIM

The use of direct-to-consumer (DTC) telemedicine consultations in primary healthcare has increased rapidly, in Sweden and internationally. Such consultations may be a low-cost alternative to face-to-face visits, but there is limited evidence on their effects on overall healthcare consumption. The aim of this study was to assess the short- and intermediate-term impact of DTC telemedicine consultations on subsequent primary healthcare consumption, by comparing DTC telemedicine users to matched controls in a Swedish setting.

METHODS

We constructed a database with individual-level data on healthcare consumption, for all residents of Region Stockholm in 2018, by linking national and regional registries. The study population included all individuals who had ≥ 1 physician consultation (telemedicine or face-to-face) during the first half of 2018. DTC telemedicine users were matched 1:2 to controls who were non-users of DTC telemedicine but who had a traditional face-to-face consultation during the study period. The matching criteria were diagnosis and demographic and socioeconomic variables. An interrupted time series analysis was performed to compare the healthcare consumption of DTC telemedicine users to that of the control group.

RESULTS

DTC telemedicine users increased their healthcare consumption more than controls. The effect seemed to be mostly short term (within a month), but was also present at the intermediate term (2-6 months after the initial consultation). The results were robust across age and disease groups.

CONCLUSION

The results indicate that DTC telemedicine consultations increase the total number of physician consultations in primary healthcare. From a policy perspective, it is therefore important to further investigate for which diagnoses and treatments DTC telemedicine is suitable so that its use can be encouraged when it is most cost-efficient and limited when it is not. Given the fundamentally different models for reimbursement, there are reasons to review and possibly harmonise the incentive structures for DTC telemedicine and traditional primary healthcare.

Assessment of Knowledge and Attitude of Anaesthetists in Utilizing Telehealth-Based Pre-anaesthesia Evaluation

BACKGROUND

This study aims to assess anaesthesiologists' understanding and attitudes toward utilizing telehealth for pre-anaesthesia evaluations (PAEs) in instances where a scheduled surgery is deferred to the procedure day due to hospital or patient-related reasons.

METHODOLOGY

This observational cross-sectional study involved anaesthesiologists with over six months of hospital experience, opting to participate voluntarily. Non-probability sampling was employed for participant selection. The study's objectives were communicated, and consent was obtained. Data were recorded in Microsoft Excel and analyzed using STATA 12.0.

RESULTS

Of the 237 participating anaesthetists, 155 were aged 21 to 40. Notably, 88.6% (n=210) expressed interest in advanced telemedicine learning, and 77.6% (n=184) were keen on its implementation. Common sources of information included tele-diagnosis (n=194), tele-education, counselling (n=147), and tele-surveillance, with additional input from telesurgery, tele-triage, tele-monitoring, and teleradiology.

CONCLUSION

The study highlights anaesthetists' strong enthusiasm for adopting advanced telemedicine and teleconferencing. Predominant information sources included tele-diagnosis, tele-education, tele-counselling, and tele-surveillance. The majority endorsed the potential of telemedicine to aid patients, expressing comfort in using it for pre-anaesthesia examinations.

Telehealth access, willingness, and barriers during the COVID-19 pandemic among a nationally representative diverse sample of U.S. adults with and without chronic health conditions

INTRODUCTION

During the COVID-19 pandemic, telehealth services represented a critical tool in maintaining continuity and access to care for adults in the USA. However, despite improvements in access and utilization during the pandemic, disparities in telehealth utilization have persisted. It is unclear what role access and willingness to use telehealth play in telehealth disparities.

METHODS

We used data from the nationally representative COVID-19's Unequal Racial Burden (CURB) survey, an online survey conducted between December 2020 and February 2021, n = 5500. Multivariable Poisson regression was used to estimate the prevalence of perceived telehealth access and willingness to use telehealth services among adults with and without chronic conditions.

RESULTS

Overall, 60.1% of adults with and 38.7% of adults without chronic conditions reported having access to telehealth. After adjustment, adults with chronic conditions were more likely to report telehealth access (adjusted prevalence ratio [aPR] = 1.35, 95% confidence interval [CI] = 1.21-1.50). Most adults with and without chronic conditions reported being willing to use telehealth services (85.1% and 79.8%, respectively), and no significant differences in willingness were observed across chronic condition status (aPR = 1.03, 95% CI = 0.95-1.13). Perceived telehealth access appeared to be a predictor of telehealth willingness in both groups (chronic conditions: aPR = 1.22, 95% CI = 0.97-1.54; no chronic conditions: aPR = 1.37, 95% CI = 1.22-1.54). The prevalence of perceived barriers to telehealth was low, with the majority reporting no barriers (chronic conditions = 51.4%; no chronic conditions = 61.4%).

DISCUSSION

Perceived access to telehealth was associated with telehealth willingness. Investing in approaches that increase telehealth accessibility and awareness is needed to improve access to telehealth for adults with and without chronic conditions.

Did Access to Ambulatory Care Moderate the Associations Between Visit Mode and Ancillary Services Utilization Across the COVID-19 Pandemic Period?

BACKGROUND/OBJECTIVE

In recent years, 2 circumstances changed provider-patient interactions in primary care: the substitution of virtual (eg, video) for in-person visits and the COVID-19 pandemic. We studied whether access to care might affect patient fulfillment of ancillary services orders for ambulatory diagnosis and management of incident neck or back pain (NBP) and incident urinary tract infection (UTI) for virtual versus in-person visits.

METHODS

Data were extracted from the electronic health records of 3 Kaiser Permanente Regions to identify incident NBP and UTI visits from January 2016 through June 2021. Visit modes were classified as virtual (Internet-mediated synchronous chats, telephone visits, or video visits) or in-person. Periods were classified as prepandemic [before the beginning of the national emergency (April 2020)] or recovery (after June 2020). Percentages of patient fulfillment of ancillary services orders were measured for 5 service classes each for NBP and UTI. Differences in percentages of fulfillments were compared between modes within periods and between periods within the mode to assess the possible impact of 3 moderators: distance from residence to primary care clinic, high deductible health plan (HDHP) enrollment, and prior use of a mail-order pharmacy program.

RESULTS

For diagnostic radiology, laboratory, and pharmacy services, percentages of fulfilled orders were generally >70-80%. Given an incident NBP or UTI visit, longer distance to the clinic and higher cost-sharing due to HDHP enrollment did not significantly suppress patients' fulfillment of ancillary services orders. Prior use of mail-order prescriptions significantly promoted medication order fulfillments on virtual NBP visits compared with in-person NBP visits in the prepandemic period (5.9% vs. 2.0%, P=0.01) and in the recovery period (5.2% vs. 1.6%, P=0.02).

CONCLUSIONS

Distance to the clinic or HDHP enrollment had minimal impact on the fulfillment of diagnostic or prescribed medication services associated with incident NBP or UTI visits delivered virtually or in-person; however, prior use of mail-order pharmacy option promoted fulfillment of prescribed medication orders associated with NBP visits.

Pragmatic randomized trial of a pre-visit intervention to improve the quality of telemedicine visits for vulnerable patients living with HIV

INTRODUCTION

The COVID-19 pandemic has required a shift of many routine primary care visits to telemedicine, potentially widening disparities in care access among vulnerable populations. In a publicly-funded HIV clinic, we aimed to evaluate a pre-visit phone-based planning intervention to address anticipated barriers to telemedicine.

METHODS

We conducted a pragmatic randomized controlled trial of patients scheduled for a phone-based HIV primary care visit at the Ward 86 HIV clinic in San Francisco from 15 April to 15 May 2020. Once reached by phone, patients were randomized to either have a structured pre-visit planning intervention to address barriers to an upcoming telemedicine visit versus a standard reminder call. The primary outcome was telemedicine visit attendance.

RESULTS

Of 476 scheduled telemedicine visits, 280 patients were reached by a pre-visit call to offer enrollment. Patients were less likely to be reached if virally unsuppressed (odds ratio (OR) 0.11, 95% confidence intervals (CI) 0.03-0.48), CD4 < 200 (OR 0.24, 95% CI 0.07-0.85), or were homeless (OR 0.24, 95% CI 0.07-0.87). There was no difference between intervention and control in scheduled visit attendance (83% v. 78%, OR 1.38, 95% CI 0.67-2.81).

CONCLUSIONS

A structured phone-based planning call to address barriers to telemedicine in a public HIV clinic was less likely to reach patients with poorly-controlled HIV and patients experiencing homelessness, suggesting additional interventions may be needed in this population to ensure access to telemedicine-based care. Among patients reachable by phone, telemedicine visit attendance was high and not improved with a structured pre-visit intervention, suggesting that standard reminders may be adequate in this population.

Adoption of video consultations during the COVID-19 pandemic

BACKGROUND

Video consultations have the potential to play a significant role for the future of healthcare by solving some of the imminently arising healthcare challenges, as pointed by the European Commission in Europe and the National Academy of Medicine in the United States of America. This technology can improve quality, efficiency, and enhance access to healthcare.

OBJECTIVE

The aim of this study is to explore and understand individual video consultations acceptance drivers.

METHODS

An extended technology acceptance model was created based on the diffusion of innovation theory (DOI), unified theory of acceptance and use of technology (UTAUT), health belief model (HBM), and concerns for information privacy framework (CFIP). 346 valid responses were collected through an online questionnaire, and the partial least squares (PLS) modeling approach was used to test the model.

RESULTS

The model explained 77.6 % (R2) of the variance on intention to use, and 71.4 % (R2) of the variance in attitude. The predictors of intention to use are attitude (beta = 0.504, p-value<0.001), performance expectancy (beta = 0.196, p-value = 0.002), and COVID-19 (beta = 0.151, p-value<0.001). The predictors of attitude are performance expectancy (beta = 0.643, p-value>0.001), effort expectancy (beta = 0.138, p-value = 0.001), and COVID-19 (beta = 0.170, p-value<0.001).

CONCLUSIONS

This research model highlights the importance of creating extended acceptance models to capture the specificities of each technology in healthcare. The model created helps to understand the most important drivers of video consultation acceptance, highlighting the importance of the COVID-19 pandemic and perceived health risks.

A Randomized Controlled Trial Comparing Telemedicine Versus In-Person Office Visits for the Follow-Up of Overactive Bladder

IMPORTANCE

Overactive bladder is a condition that may be ideally suited for the use of telemedicine because initial treatment options are behavioral modification and pharmacotherapy.

OBJECTIVE

We sought to evaluate if there was an overall difference in patient follow-up rates between telemedicine and in-person visits.

STUDY DESIGN

New patients presenting with overactive bladder from July 2020 to March 2021 were randomized into telemedicine and in-person visits groups. A prospective database was maintained to compare follow-up rates, satisfaction rates, and time commitment.

RESULTS

Forty-eight patients were randomized, 23 to the telemedicine group and 25 to the in-person visits group. There was no significant difference in follow-up rates between the telemedicine and in-person follow-up groups at 30 days (39% vs 28%, P = 0.41), 60-days (65% vs 56% P = 0.51) or 90 days (78% vs 60%, P = 0.17). There was no significant difference in satisfaction rates between the 2 groups. There was a significant difference between the average telemedicine visit time and in-person visit time (12.1 ± 6.9 minutes vs 22.8 ± 17.1 minutes; P = 0.02). For in-person visits, the average travel time was 49 minutes (interquartile range, 10-90 minutes) and average miles traveled was 22.1 miles (interquartile range, 10-70 miles).

CONCLUSIONS

There was no significant difference in follow-up or satisfaction rates between telemedicine and in-person visits. Telemedicine visits took half the length of time compared with in-person visits. On average, patients in the telemedicine group saved approximately 1 hour per follow-up visit. Telemedicine visits save both the health care provider and patient significant amounts of time without sacrificing patient satisfaction and follow-up rates.

Patient experience and healthcare utilization for a COVID-19 telemedicine home monitoring program offered in English and Spanish

Background

Telemedicine is a vital component of the healthcare system’s response to COVID-19. In March of 2020, Providence health system rapidly implemented a telemedicine home monitoring program (HMP) for COVID-19 patients that included use of at-home pulse oximeters and thermometers and text-based surveys to monitor symptoms. By June 2020, Providence updated the HMP to be offered in Spanish. This program was implemented before COVID-19 testing was readily available and therefore was offered to all patients suspected of having COVID-19. This study examines engagement, experience, and utilization patterns for English and Spanish-speaking patients engaged in the COVID-19 HMP.

Methods

A retrospective review of program data was used to understand HMP patient engagement (responsiveness to three daily text to monitor symptoms), satisfaction with the program (likelihood to recommend the program) as well as comfort using home monitoring devices and comfort recovering from home. To understand impact on care for COVID-19 confirmed cases, we used electronic health records to measure patterns in healthcare use for COVID-19 positive HMP participants and non-HMP propensity weighted controls. All patients enrolled in the COVID-19 HMP from March–October 2020 were included in the study. Patients tested for COVID-19 during the time window and not enrolled in HMP were included in the propensity-weighted comparison group. Descriptive and regression analyses were performed overall and stratified by English and Spanish speakers.

Results

Of the 4,358 HMP participants, 75.5% identified as English speakers and 18.2% identified as Spanish speakers. There was high level of responsiveness to three daily text-based surveys monitoring symptoms engagement (>80%) and a high level of comfort using the home monitoring devices (thermometers and pulse oximeters) for English- and Spanish-speaking participants (97.3% and 99.6%, respectively). The majority of English (95.7%) and Spanish-speaking (100%) patients felt safe monitoring their condition from home and had high satisfaction with the HMP (76.5% and 83.6%, respectively). English and Spanish-speaking COVID-19 positive HMP participants had more outpatient and emergency departments (ED) encounters than non-participants 7 and 30 days after their positive test.

Conclusion

This widely implemented HMP provided participants with a sense of safety and satisfaction and its use was associated with more outpatient care and ED encounters. These outcomes were comparable across English and Spanish-speakers, highlighting the importance and potential impact of language-concordant telemedicine.

Role of nursing in telehealth

ABSTRACT

This article explores the types, features, and benefits of telehealth-including a sample telehealth program-and discusses the role of nurses in the efficient delivery and improvement of telehealth systems.

Challenges and opportunities of telehealth digital equity to manage HIV and comorbidities for older persons living with HIV in New York State

BACKGROUND

Older persons living with HIV (PLWH) need routine healthcare to manage HIV and other comorbidities. This mixed methods study investigated digital equity, constituted as access, use and quality, of HIV and specialty telehealth services for PLWH > 50 years during the initial wave of the COVID-19 pandemic when services transitioned to remote care.

METHODS

A survey of closed and open-ended questions was administered to 80 English (N = 63) and Spanish (N = 17) speaking PLWH receiving HIV care at an Academic Medical Center (N = 50) or a Federally Qualified Health Center (N = 30) in New York State. Quantitative analyses examined characteristics predicting telehealth use and visit quality. Qualitative analyses utilized thematic coding to reveal common experiences. Results were integrated to deepen the interpretation.

RESULTS

Telehealth access and use were shaped by multiple related and unstable factors including devices and connectivity, technology literacy, and comfort including privacy concerns. Participants demonstrated their substantial effort to achieve the visit. The majority of patients with a telehealth visit perceived it as worse than an in-person visit by describing it as less interpersonal, and resulting in poorer outcomes, particularly participants with less formal education. Technology was not only a barrier to access, but also influenced perceptions of quality.

CONCLUSIONS

In the COVID-19 pandemic initial wave, barriers to using telehealth were unequally distributed to those with more significant access and use challenges. Beyond these barriers, examining the components of equity indicate further challenges replicating in-person care using telehealth formats for older PLWH. Work remains to establish telehealth as both equitable and desirable for this population.

Individual's Perceptions as a Substitute for Guidelines and Evidence: A Qualitative Study on How Clinicians Choose Between In-person and Remote Consultation

Background

Video consultation (VC) is increasingly seen as a cost-effective way of providing outpatient care in the face of dwindling resources and growing demand for health care worldwide. Therefore, the sustainable implementation of VC is a phenomenon of interest to medical practitioners, researchers, and citizens alike. Studies are often criticized for not being sufficiently robust because the research settings are mostly small-scale pilot projects and are unable to reflect long-term implementation. The COVID-19 pandemic has compelled clinicians worldwide to conduct remote consultation, creating a favorable context to study large-scale remote consultation implementation.

Objective

The aim of this study was to thoroughly investigate how clinicians reason their choice of different consultation modes in the routine of consultation and what the underlying reasons are for their choices. We posited that a deeper understanding of clinicians’ perceptions of remote consultation is essential to deduce whether and how remote consultation will be adopted on a large scale and sustained as a regular service.

Methods

A qualitative approach was taken, in which the unit of analysis was clinicians in one of the largest university hospitals in Norway. In total, 29 interviews were conducted and transcribed, which were used as the primary data source. Using the performative model of routine as the theoretical framework, data were analyzed using deductive content analysis.

Results

Clinicians have mixed opinions on the merits and demerits of VC and its position between in-person and telephone consultation. Totally, 6 different planning criteria were identified, and individual clinicians used different combinations of these criteria when choosing a mode of consultation. The ideals that clinicians hold for conducting consultation can be divided into three aspects: clinical, interpersonal, and managerial. VC engenders a new ideal and endangers the existing ideals. VC causes minor changes in the tasks the clinicians perform during a consultation; thus, these changes do not play a significant role in their choice of consultation. Clinicians could not identify any changes in the outcome of consultation as a result of incorporating a remote mode of consultation.

Conclusions

Clinicians feel that there is a lack of scientific evidence on the long-term effect of remote consultation on clinical efficacy and interpersonal and managerial aspects, which are crucial for consultation service. The absence of sufficient scientific evidence and a clear understanding of the merits and demerits of VC and standard practices and shared norms among clinicians regarding the use of video for consultation both create a void in the consultation practice. This void leads clinicians to use their personal judgments and preferences to justify their choices regarding the consultation mode. Thus, diverse opinions emerge, including some paradoxical ones, resulting in an uncertain future for sustainable large-scale implementation, which can reduce the quality of consultation service.

Telemedicine and Telehealth in Urology-What Do the 'Patients' Think About It?

Telemedicine is the delivery of healthcare to patients who are not in the same location as the physician. The practice of telemedicine has a large number of advantages, including cost savings, low chances of nosocomial infection, and fewer hospital visits. Teleclinics have been reported to be successful in the post-surgery and post-cancer therapy follow-up, and in offering consulting services for urolithiasis patients. This review focuses on identifying the outcomes of the recent studies related to the usage of video consulting in urology centers for hematuria referrals and follow-up appointments for a variety of illnesses, including benign prostatic hyperplasia (BPH), kidney stone disease (KSD), and urinary tract infections (UTIs) and found that they are highly acceptable and satisfied. Certain medical disorders can cause embarrassment, social exclusion, and also poor self-esteem, all of which can negatively impair health-related quality-of-life. Telemedicine has proven beneficial in such patients and is a reliable, cost-effective patient-care tool, and it has been successfully implemented in various healthcare settings and specialties.

Virtual Prenatal and Postpartum Care Acceptability Among Maternity Care Providers

Introduction

The Covid-19 pandemic and statewide stay-at-home orders abruptly impacted clinic operations necessitating the incorporation of telehealth. Uptake of telehealth is multifaceted. Clinician acceptance is critical for success. The aim of this study is to understand maternity care providers’ acceptance of and barriers to providing virtual maternity care.

Methods

Providers completed a baseline and 3-month follow up survey incorporating the validated implementation outcome measures, feasibility of intervention measure (FIM), intervention appropriateness measure (IAM), and acceptability of intervention measure (AIM).Statistical analyses evaluated differences between groups in this small convenience sample to understand trends in perceptions and barriers to telehealth. While not intended to be a qualitative study, a code tree was used to evaluate open-ended responses.

Results

Baseline response rate 50.4% (n = 56). Follow-up retention/response-rate 68% (n = 38). Most reported no prior telehealth experience. 94% agreed with the FIM, decreasing to 92% at follow-up. 80% (prenatal) and 84% (postpartum) agreed with the IAM. Agreement with the AIM increased to 83%.Differences in the FIM and AIM found by division (p < 0.01) and years in practice (p < 0.01). Identified barriers included patient lack of essential tools, inadequate clinic support, and patients prefer in person visits. Themes that emerged included barriers, needs, and areas of success.

Discussion

Telehealth was found to be feasible, appropriate, and acceptable across provider types and divisions. Improving patient/provider access to quality equipment is imperative. Future research must address how and when to incorporate telehealth.

Exploring Noona Using Passively-Collected Data and Satisfaction/Loyalty Ratings

Background

Electronic patient-reported outcomes’ real time communication of treatment-related symptoms is increasingly associated with better outcomes including longer survival and less health care resource use, but the primary method of collecting this information, static questionnaires, has not evolved.

Objective

The aim of this paper is to describe the use of Noona’s three methods of communicating treatment-related symptoms, which are as follows: (1) Noona symptom questionnaires (NSQ), which incorporate branching logic; (2) a diary; and (3) secure messaging, the last two of which have NSQ reporting functionality. It also aims to explore, using multivariable analyses, whether patients find value using these features.

Methods

Noona users (N=1081) who have an active account for more than 30 days, who responded to the satisfaction/loyalty item, and who were undergoing active cancer treatment (systemic or radiotherapy) in the United States were included in this study. All study data were collected via software embedded within Noona code. This includes metadata, patient activities (measured in clicks), and responses to a satisfaction/loyalty question (“How likely are you to recommend Noona to another patient”) displayed on the Noona home page.

Results

Noona users expressed a high degree of satisfaction/loyalty when asked to rate how likely they would recommend Noona to another patient. Multivariable analyses indicate small but significant effects for some of the analyses. Use of NSQs were significantly related to satisfaction/loyalty, users of NSQs had significantly higher satisfaction/loyalty than those who did not use any, and secure communication use was significantly higher for those who rated the app highly compared to those who did not. These relationships will likely be further explicated with the use of satisfaction/loyalty questions that focus specifically on feature use.

Conclusions

Noona is well liked by respondents, and exploratory multivariable analyses demonstrate the potential for using passively and minimally invasive data to demonstrate value.

Satisfaction can co-exist with hesitation: qualitative analysis of acceptability of telemedicine among multi-lingual patients in a safety-net healthcare system during the COVID-19 pandemic

Background

The COVID-19 pandemic triggered unprecedented expansion of outpatient telemedicine in the United States in all types of health systems, including safety-net health systems. These systems generally serve low-income, racially/ethnically/linguistically diverse patients, many of whom face barriers to digital health access. These patients’ perspectives are vital to inform ongoing, equitable implementation efforts.

Methods

Twenty-five semi-structured interviews exploring a theoretical framework of technology acceptability were conducted from March through July 2020. Participants had preferred languages of English, Spanish, or Cantonese and were recruited from three clinics (general medicine, obstetrics, and pulmonary) within the San Francisco Health Network. Both deductive and inductive coding were performed. In a secondary analysis, qualitative data were merged with survey data to relate perspectives to demographic factors and technology access/use.

Results

Participants were diverse with respect to language (52% non-English-speaking), age (range 23-71), race/ethnicity (24% Asian, 20% Black, 44% Hispanic/Latinx, 12% White), & smartphone use (80% daily, 20% weekly or less). All but 2 had a recent telemedicine visit (83% telephone). Qualitative results revealed that most participants felt telemedicine visits fulfilled their medical needs, were convenient, and were satisfied with their telemedicine care. However, most still preferred in-person visits, expressing concern that tele-visits relied on patients’ abilities to access telemedicine, as well as monitor and manage their own health without in-person physical evaluation.

Conclusions

High satisfaction with telemedicine can co-exist with patient-expressed hesitations surrounding the perceived effectiveness, self-efficacy, and digital access barriers associated with a new model of care. More research is needed to guide how healthcare systems and clinicians make decisions and communicate about visit modalities to support high-quality care that responds to patients’ needs and circumstances.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07547-9.

Single institution experience with telemedicine for pediatric urology outpatient visits: Adapting to COVID-19 restrictions, patient satisfaction, and future utilization

INTRODUCTION

Widespread utilization of telemedicine in our practice to date has been limited to the evaluation of certain post-surgical patients. The COVID-19 pandemic acutely stressed our established system and required us to enhance our utilization of telemedicine. We hypothesized that expansion of telemedicine to new and follow up patient visits for pediatric urology could be done effectively in a way that satisfied patient and parental expectations.

MATERIALS AND METHODS

Using a pre-COVID-19 established telemedicine program based in our electronic medical record (EMR), patients and providers transitioned to primarily virtual visits when clinically appropriate. Guidelines were formulated to direct patient scheduling, provider and staff education was provided, including a process map designed for multiple providers to complete video visits (VV), and the EMR was redesigned to incorporate telehealth terminology. The number of VV per provider was recorded using the electronic medical record, and patient reported outcomes (PRO) were measured using a standardized questionnaire.

RESULTS

A total of 631 VV met inclusion criteria during the period of May 2018-April 2020. This included 334 follow up, 172 new, and 125 postoperative visits. The median age of patients at time of visit was 7 years (IQR 2-12 years), median visit time was 20 min (IQR 15-30 min), and the median travel distance saved by performing a VV was 12.2 miles (IQR 6.3-26.8 miles). Diagnoses were varied and included the entire breadth of a standard pediatric urology practice. The PRO questionnaire was completed for 325 of those patient visits. Families reported a high overall satisfaction with the video visits (median score of 10 out of 10) and felt that the visit met their child's medical needs. 90% stated that they would strongly recommend a telehealth visit to other families. Patients and parents reported benefits of VV including decreased travel costs and less time taken off from work and school.

CONCLUSION

The EMR enabled nimble redirection of clinical care in the setting of a global pandemic. The enhanced use of telemedicine has proved to be an alternative method to provide care for pediatric urology patients. Families indicate a high degree of satisfaction with this technology in addition to significant time and cost savings. Telemedicine should remain a key aspect of medical care and expanded from post-operative visits to new patient and follow up visits, even as we return to our normal practices as the pandemic restrictions soften.

The Effect of 24/7, Digital-First, NHS Primary Care on Acute Hospital Spending: Retrospective Observational Analysis

BACKGROUND

Digital health has the potential to revolutionize health care by improving accessibility, patient experience, outcomes, productivity, safety, and cost efficiency. In England, the NHS (National Health Service) Long Term Plan promised the right to access digital-first primary care by March 31, 2024. However, there are few global, fully digital-first providers and limited research into their effects on cost from a health system perspective.

OBJECTIVE

The aim of this study was to evaluate the impact of highly accessible, digital-first primary care on acute hospital spending.

METHODS

A retrospective, observational analysis compared acute hospital spending on patients registered to a 24/7, digital-first model of NHS primary care with that on patients registered to all other practices in North West London Collaboration of Clinical Commissioning Groups. Acute hospital spending data per practice were obtained under a freedom of information request. Three versions of NHS techniques designed to fairly allocate funding according to need were used to standardize or "weight" the practice populations; hence, there are 3 results for each year. The weighting adjusted the populations for characteristics that impact health care spending, such as age, sex, and deprivation. The total spending was divided by the number of standardized or weighted patients to give the spending per weighted patient, which was used to compare the 2 groups in the NHS financial years (FY) 2018-2019 (FY18/19) and 2019-2020 (FY19/20). FY18/19 costs were adjusted for inflation, so they were comparable with the values of FY19/20.

RESULTS

The NHS spending on acute hospital care for 2.43 million and 2.54 million people (FY18/19 and FY19/20) across 358 practices and 49 primary care networks was £1.6 billion and £1.65 billion (a currency exchange rate of £1=US $1.38 is applicable), respectively. The spending on acute care per weighted patient for Babylon GP at Hand members was 12%, 31%, and 54% (£93, P=.047; £223, P<.001; and £389, P<.001) lower than the regional average in FY18/19 for the 3 weighting methodologies used. In FY19/20, it was 15%, 35%, and 51% (£114, P=.006; £246, P<.001; and £362, P<.001) lower. This amounted to lower costs for the Babylon GP at Hand population of £1.37, £4.40 million, and £11.6 million, respectively, in FY18/19; and £3.26 million, £9.54 million, and £18.8 million, respectively, in FY19/20.

CONCLUSIONS

Patients with access to 24/7, digital-first primary care incurred significantly lower acute hospital costs.

Telehealth was beneficial during COVID-19 for older Americans: A qualitative study with physicians

Background

Individuals aged 65 and older face unique barriers to adoption of telehealth, and the coronavirus disease 2019 pandemic has provided a “natural experiment” in how to meet the health needs of older patients remotely. Physician perspectives on practical considerations surrounding telehealth adoption, motivations of use, and reasons for nonuse are necessary to inform the future of healthcare delivery. The objective is to understand the experiences of physicians using telemedicine for older patients.

Methods

From September to November 2020, we conducted 30‐min semi‐structured interviews using purposeful sampling to identify and enroll participants from diverse settings. We included 48 U.S.‐based physicians (geriatrician, n = 18, primary care, n = 15, emergency, n = 15) from all geographic regions, rural–urban and academic/community settings. Audio‐recorded interviews were professionally transcribed and analyzed using framework analysis. Major themes and subthemes were identified.

Results

Participants had a median (interquartile range) age of 37.5 (34–44.5), 27 (56%) were women. Five major themes emerged: (1) telehealth uptake was rapid and iterative, (2) telehealth improved the safety of medical care, (3) use cases were specialty‐specific (for geriatricians and primary care physicians telehealth substituted for in‐person visits; for emergency physicians it primarily supplemented in‐person visits), (4) physicians altered clinical care to overcome older patient barriers to telehealth use, and (5) telehealth use among physicians declined in mid‐April 2020, due primarily to patient needs and administrator preferences, not physician factors.

Conclusion

In this qualitative analysis, physicians reported a rapid, iterative uptake of telehealth and attenuation of use as coronavirus disease 2019 prevalence declined. Physician experiences during the pandemic can inform interventions and policies to help buoy telehealth for ongoing healthcare delivery and ensure its accessibility for older Americans.

Patient Satisfaction with Telehealth During COVID-19: Experience in a Rural County on the United States-Mexico Border

Background: The aim of this study was to analyze patient satisfaction with telehealth in a rural county on the United States-Mexico border after rapid expansion of telehealth services during the COVID-19 pandemic. Materials and Methods: Chiricahua Community Health Centers, Inc., a federally qualified health center in southeastern Arizona, conducted phone surveys with 562 patients to measure various outcomes related to patient satisfaction and experience with telehealth between June and August 2020. Data from patient surveys were analyzed within the following age categories: <18 years (37%), 18-34 years (19%), 35-54 years (15%), and 55+ years (29%). Results and Discussion: Patients were overall satisfied with telehealth (87%) and believed the quality of care was just as good as or better than in-person appointments (88%). Many would be willing to try telehealth in the future (54%). Distance/convenience (odds ratio [OR] = 5.01, 95% confidence interval [CI] 2.80-8.97), ease of scheduling (OR = 3.82, 95% CI 1.30-11.21), and protection from potential exposure to coronavirus (OR = 3.01, 95% CI 1.57-5.75) were all strongly predictive of overall satisfaction scores. Adults within the 35-54 (OR = 0.29, 95% CI 0.10-0.81) and 55+ (OR = 0.37, 95% CI 0.14-0.95) age groups were overall less satisfied with telehealth compared with younger adults 18-34 years. Underlying health conditions and primary language were not correlated with satisfaction in using telehealth. Conclusions: Telehealth may be an effective tool for overcoming barriers and providing rural patients with access to health care without compromising patient satisfaction.

Digital Health: Unlocking Value in a Post-Pandemic World

The COVID-19 pandemic has forever changed health care, spurring a revolution in digital health technologies. Across the world, hundreds of thousands of health care systems are considering a central question: how do we connect with our patients? Digital health has been used as a stopgap in many cases to continue the essential functions of health systems. As the post-pandemic world and our "new normal" come into focus, further needs will have to be met with a digital patient interaction, with an eye toward value transformation. One barrier to fully leveraging digital tools is the lack of a framework for classifying the type of digital health care. This can limit our ability to design, deploy, evaluate, and communicate through digital means. This article presents 3 categories of digital health and their relationships to value metrics: (1) telehealth or direct care delivery, (2) digital access tools, and (3) digital monitoring. An evidence-based discussion reveals past successes, current promises, and future challenges in reducing defects in value through digital care. In the coming years, value transformation will become more crucial to the success of health care systems. By using the taxonomy in this article, health systems can better implement digital tools with a value-driven purpose. Defining the role of digital health in the post-pandemic world is needed to assist health systems and practices to build a bridge to value-based care.

Considerations When Using Telemedicine As the Advanced Practice Registered Nurse

Accessibility to health care is crucial to management of chronic and acute conditions. Although the severe acute respiratory syndrome coronavirus 2 pandemic significantly impacts the issue of access to health care, with the introduction of Waiver 1135, telehealth has become a positive strategy in increasing safe access to health care. This report addresses considerations to take into account when advanced practice registered nurses use telehealth to facilitate access to care.

Assessing patient usability of video visits

BACKGROUND

Telehealth is being adopted by health systems across the country and many barriers to the expansion of video visit programs have been identified. Our study focused on the usability of video visit technology by examining technical challenges faced by patients over the course of a video visit.

METHODS

We conducted a survey of patients who received care from the Michigan Medicine video visit program from January 31, 2019 to July 31, 2019. The video visit program includes more than 1,300 visits a year across more than 30 specialties. Following the completion of their video visit, all patients were invited to participate in our online survey through the patient portal. The survey included questions on patient satisfaction, motivation and technical challenges.

RESULTS

We received responses from 180 patients (response rate of 26%). Overall patient satisfaction was high; 90% of respondents agreed that their video visit experience was similar to that of in-person visits and 93.3% of respondents would recommend video visits. Despite this high satisfaction rate, 36 out of 180 (20.0%) respondents cited technical issues during their video visit: video issues (n=11), audio issues (n=5), video and audio issues (n=2), slow/dropped connection (n=7), initial set-up issues (n=4), long wait time (n=3), and other (n=4).

CONCLUSIONS

While most patients report a high degree of satisfaction with their video visit, a meaningful subset of patients continue to experience technical challenges.

The rules for online clinical engagement in the COVID era

Coronavirus disease-2019 (COVID-19) has generated a need to rapidly increase online consulting in secondary care, an area in which it has previously been underutilised. We sought to review the guidance on conducting remote consultations and found that while there is a large amount of information about the implementation of remote consultations at an organisation level, there is a paucity of high-quality papers considering the guidelines for online consultations alongside practical advice for their implementation at the individual level. We reviewed guidelines from reputable medical sources and generated practical advice to assist practitioners to perform safe and effective video consultation. Additionally, we noted reports in the literature of a lack of transparency and resulting confusion regarding the choice of telemedicine platforms. We, therefore, sought to summarise key characteristics of a number of major telemedicine platforms. We recognised a lack of clarity regarding the legal status of performing remote consultations, and reviewed advice from medico-legal sources. Finally, we address the sources of these individual uncertainties, and give recommendations on how these might be addressed systematically, so the practitioners are well trained and competent in the use of online consultations, which will inevitably play an increasingly large role in both primary and secondary care settings in the future.

Telemedicine and Plastic and Reconstructive Surgery: Lessons from the COVID-19 Pandemic and Directions for the Future

Telemedicine holds vast amounts of potential in changing the way outpatient plastic and reconstructive surgery is practiced. Before the coronavirus disease 2019 (COVID-19) pandemic, video conferencing was used by a small fraction of medical specialties. However, since the start of the pandemic, the Centers for Medicare and Medicaid Services and the largest private health insurance companies have relaxed regulations to allow the majority of specialties to use video conferencing in lieu of in-person visits. Most importantly, video conferencing minimizes patient and physician exposure in situations such as these, and decreases risk in the immunocompromised population. Video conferencing, which has been shown to be just as safe and efficacious in treating patients, offers the ability to follow up with physicians while saving travel time and travel-related expenses. This in turn correlates with increased patient satisfaction. Video conferencing also allows physicians to expand their reach to patients in rural areas seeking advanced professional advice. Incorporating video conferencing into existing practices will make for a more efficient practice, improve patient satisfaction, and decrease cost to patients and the health care system.

Private Video Consultation Services and the Future of Primary Care

In many countries, private companies provide primary care services based predominantly on offering video consultations via smartphones. One example is Babylon GP at Hand (BGPaH), which offers video consultations to National Health Service patients, 24 hours a day, and has grown rapidly in London over the last 3 years. The development of this type of service has been controversial, particularly in the United Kingdom, but there has been little formal published evaluation of these services in any country. This paper outlines the main controversies about the use of privately provided video consultation services for primary care and shows how they are informed by the limited evaluations that have been conducted, particularly the evaluation of BGPaH. This paper describes the advantages of these services in terms of convenience, speed of access, the ability to consult without traveling or face-to-face patient-doctor contact, and the possibility of recruiting doctors who cannot work in conventional settings or do not live near the patients. It also highlights the concerns and uncertainties about quality and safety, demand, fragmentation of care, impact on other health services, efficiency, and equity. There are questions about whether private primary care services based on video consultations have a sustainable business model and whether they will undermine other health care providers. During the recent COVID-19 pandemic, the use of video consulting has become more widespread within conventional primary care services, and this is likely to have lasting consequences for the future delivery of primary care. It is important to understand the extent to which lessons from the evaluation of BGPaH and other private services based on a video-first model are relevant to the use of video consulting within conventional general practices, and to consider the advantages and disadvantages of these developments, before video consultation-based services in primary care become more widely established.

Implementation of Video Visits During COVID-19: Lessons Learned From a Primary Care Practice in New York City

Background: During the height of the coronavirus (COVID-19) pandemic, there was an unprecedented demand for “virtual visits,” or ambulatory visits conducted via video interface, in order to decrease the risk of transmission.

Objective: To describe the implementation and evaluation of a video visit program at a large, academic primary care practice in New York, NY, the epicenter of the COVID-19 pandemic.

Design and participants: We included consecutive adults (age > 18) scheduled for video visits from March 16, 2020 to April 17, 2020 for COVID-19 and non-COVID-19 related complaints.

Intervention: New processes were established to prepare the practice and patients for video visits. Video visits were conducted by attendings, residents, and nurse practitioners.

Main measures: Guided by the RE-AIM Framework, we evaluated the Reach, Effectiveness, Adoption, and Implementation of video visits.

Key results: In the 4 weeks prior to the study period, 12 video visits were completed. During the 5-weeks study period, we completed a total of 1,030 video visits for 817 unique patients. Of the video visits completed, 42% were for COVID-19 related symptoms, and the remainder were for other acute or chronic conditions. Video visits were completed more often among younger adults, women, and those with commercial insurance, compared to those who completed in-person visits pre-COVID (all p < 0.0001). Patients who completed video visits reported high satisfaction (mean 4.6 on a 5-point scale [SD: 0.97]); 13.3% reported technical challenges during video visits.

Conclusions: Video visits are feasible for the delivery of primary care for patients during the COVID-19 pandemic.

Infectious Diseases Society of America Position Statement on Telehealth and Telemedicine as Applied to the Practice of Infectious Diseases

Over the last 2 decades, telemedicine has effectively demonstrated its ability to increase access to care. This access has the ability to deliver quality clinical care and offer potential savings to the healthcare system. With increasing frequency, physicians, clinics, and medical centers are harnessing modern telecommunications technologies to manage a multitude of acute and chronic conditions, as well as incorporating telehealth into teaching and research. The technologies spanning telehealth, telemedicine, and mobile health (mHealth) are rapidly evolving, and the Infectious Diseases Society of America (IDSA) has prepared this updated position statement to educate its membership on the use of telemedicine and telehealth technologies. IDSA supports the appropriate and evidence-based use of telehealth technologies to provide up-to-date, timely, cost-effective subspecialty care to resource-limited populations.

An Evaluation of Kiosks for Direct-to-Consumer Telemedicine Using the National Quality Forum Assessment Framework

Background: Evaluation of direct-to-consumer (DTC) telemedicine programs has focused on care delivery via personal electronic devices. Telemedicine kiosks for the delivery of virtual urgent care services have not been systematically described. Introduction: Our institution has placed kiosks for DTC urgent care in pharmacies. These kiosks can be used without a personal electronic device. Materials and Methods: Retrospective review of adult patients using pharmacy-based kiosks (kiosk) or personal electronic devices (app) for DTC evaluation. Data for patient characteristics, wait time, technical quality, visit duration diagnosis codes, follow-up recommendations, and whether the patient was traveling were compared. Results were interpreted using the National Quality Forum framework for telemedicine service evaluation, focused on access, experience, and effectiveness. Comparisons were made using chi-square test, Student's t-test, and Wilcoxon rank-sum tests. Results: Over 1 year there were 1,996 DTC visits; 238 (12%) initiated from kiosks. Kiosk patients were slightly older (mean age 38 ± 13 vs. 35 ± 11; p < 0.001), more likely to be male (52% vs. 39%; p < 0.001), more likely to be remote from home (25% vs. 3%; p < 0.001), and had less technical difficulty (10% vs. 19%; p = 0.003). Referral for urgent in-person evaluation was low in both groups (10% kiosk vs. 16%; app p = 0.017). Discussion: Kiosks may increase access to care and improve technical experience. Low urgent referral rates suggest effective care for both types of visit. Conclusions: Despite their potential advantages, kiosk visits accounted for a minority of overall visits for our DTC telemedicine service line, and daily use of each kiosk location was low.

Assessing the Impact of a Rapidly Scaled Virtual Urgent Care in New York City During the COVID-19 Pandemic

BACKGROUND

The coronavirus disease (COVID)-19 pandemic quickly challenged New York City health care systems. Telemedicine has been suggested to manage acute complaints and divert patients from in-person care.

OBJECTIVES

The objective of this study was to describe and assess the impact of a rapidly scaled virtual urgent care platform during the COVID-19 pandemic.

METHODS

This was a retrospective cohort study of all patients who presented to a virtual urgent care platform over 1 month during the COVID-19 pandemic surge. We described scaling our telemedicine urgent care capacity, described patient clinical characteristics, assessed for emergency department (ED) referrals, and analyzed postvisit surveys.

RESULTS

During the study period, a total of 17,730 patients were seen via virtual urgent care; 454 (2.56%) were referred to an ED. The most frequent diagnoses were COVID-19 related or upper respiratory symptoms. Geospatial analysis indicated a wide catchment area. There were 251 providers onboarded to the platform; at peak, 62 providers supplied 364 h of coverage in 1 day. The average patient satisfaction score was 4.4/5. There were 2668 patients (15.05%) who responded to the postvisit survey; 1236 (49.35%) would have sought care in an ED (11.86%) or in-person urgent care (37.49%).

CONCLUSIONS

A virtual urgent care platform was scaled to manage a volume of more than 800 patients a day across a large catchment area during the pandemic surge. About half of the patients would otherwise have presented to an ED or urgent care in person. Virtual urgent care is an option for appropriate patients while minimizing in-person visits during the COVID-19 pandemic.

"I'm Not Feeling Like I'm Part of the Conversation" Patients' Perspectives on Communicating in Clinical Video Telehealth Visits

BACKGROUND

Clinical video telehealth (CVT) offers the opportunity to improve access to healthcare providers in medically underserved areas. However, because CVT encounters are mediated through technology, they may result in unintended consequences related to the patient-provider interaction.

METHODS

Twenty-seven patients with type 2 diabetes mellitus enrolled in Veteran Affairs Health Care and at least one previous telehealth visit experience were interviewed regarding their perspectives on facilitators and barriers to communication with their provider during their CVT visit. The semi-structured telephone interviews were approximately 30 min and were audio-recorded and transcribed. We conducted a thematic content analysis of the interview transcripts. Codes from the transcripts were grouped into thematic categories using the constant comparison method and each theme is represented with illustrative quotes.

RESULTS

We identified several themes related to patients' perspectives on CVT. In general, patients expressed satisfaction with CVT visits including better access to appointments, shorter travel time, and less time in the waiting room. Yet, patients also identified several challenges and concerns about CVT visits compared with in-person visits, including concerns about errors in their care because of perceived difficulty completing the physical exam, perceptions that providers paid less attention to them, barriers to speaking up and asking questions, and difficulty establishing a provider-patient relationship. Patients reported feeling less involved during the visit, difficulty finding opportunities to speak, and feeling rushed by the provider.

CONCLUSIONS

Patients believed that CVT can improve their access to care, but could hinder communication with their provider, and some were concerned about the completeness and accuracy of the physical exam.

The Use of the Net Promoter Score (NPS) in an Outpatient Allergy and Pulmonary Clinic: An Innovative Look into Using Tablet-Based Tool vs Traditional Survey Method

Introduction

Patient satisfaction has become an essential metric in addition to the type of care they receive. Phone calls, emails, and text to patients after their healthcare visit are the typical way of obtaining the data reflecting patient satisfaction. The purpose of this retrospective quality improvement study is to compare the traditional post-outpatient clinic survey method with an onsite concise two-question survey using a tablet method immediately after the patient visit using Net Promoter Score (NPS) questions.

Methods

Data were collected retrospectively from February to August 2018 from an outpatient subspecialty clinic in southern California using an existing database from two different sources: the traditional method (TM) and the tablet-based tool (TBT), using NPS. The TM data were obtained from a third-party company using two questions via phone, email, and text collected 2–4 weeks after the patient’s visit. The TBT has only two questions that were given to patients upon their visit check-out. These two questions assessed both provider and clinic’s performance using the NPS method.

Results

In total, there were 1708 patients seen from February to August 2018. In the TM, the total outgoing messages during this period were 580 (34.0%) with 156 responses (27%). In the TBT, 648 out of 1708 (37.9%) surveys were collected with a 100% response rate. The NPS score showed that 99.2% of the providers were promoters. The NPS score for the clinic was 96% which reflects a promoter score.

Conclusion

Our results indicate that when using the TBT immediately after their visit to the clinic, a higher response rate was noted. In addition, both methods had similar outcomes in terms of patient satisfaction NPS scores. Future prospective studies with a larger sample size are warranted to evaluate the effectiveness of the TBT tool in assessing patient satisfaction.

Improving Well-Being Among Trainees: A Partnership to Reduce Barriers to Primary Care Services

BACKGROUND

Improved well-being is a focus for graduate medical education (GME) programs. Residents and fellows often express difficulty with visiting primary care physicians, and this issue has not been thoroughly investigated.

OBJECTIVE

We reported implementation and utilization of a primary care concierge scheduling service and a primary care video visit service for GME trainees.

METHODS

GME leaders collaborated with Duke Primary Care to offer trainees a concierge scheduling service and opportunity for primary care video visits. This quantitative evaluation included (1) analysis of the institutional GME survey results pre- and post-intervention, and (2) review of use of the concierge scheduling line.

RESULTS

Comparison of the 2018 and 2019 internal GME surveys showed a decrease in perceived barriers accessing primary care (58% to 31%, P < .0001), a decrease in perceived delays to access primary care (27% to 21%, P = .023), and an increase in respondents who reported needing health care services in the past year (37% to 62%, P < .0001). Although increased need for health services was reported, there was no difference in the proportion reporting use of health services (63% and 65%, P = .43). Of the 142 concierge line calls reviewed, 127 (87%) callers requested clinic appointments, and 15 (10%) callers requested video appointments. Of callers requesting clinic appointments, 99 (80%) were scheduled.

CONCLUSIONS

Providing resources to connect trainees to primary care greatly reduces their perception of barriers to health care and may provide a convenient mechanism to schedule flexible primary care appointments.

Patient Uptake, Experience, and Satisfaction Using Web-Based and Face-to-Face Hearing Health Services: Process Evaluation Study

BACKGROUND

Globally, access to hearing health care is a growing concern with 900 million people estimated to suffer from disabling hearing loss by 2050. Hearing loss is one of the most common chronic health conditions, yet access to hearing health care is limited. Incorporating Web-based (voice calling, messaging, or emailing) service delivery into current treatment pathways could improve access and allow for better scalability of services. Current electronic health studies in audiology have focused on technical feasibility, sensitivity, and specificity of diagnostic hearing testing and not on patient satisfaction, experiences, and sustainable models along the entire patient journey.

OBJECTIVE

This study aimed to investigate a hybrid (Web-based and face-to-face) hearing health service in terms of uptake, experience, and satisfaction in adult patients with hearing loss.

METHODS

A nonprofit hearing research clinic using online and face-to-face services was implemented in Durban, South Africa, using online recruitment from the clinic's Facebook page and Google AdWords, which directed persons to an online Web-based hearing screening test. Web-based and face-to-face care pathways included assessment, treatment, and rehabilitation. To evaluate the service, an online survey comprising (1) a validated satisfaction measurement tool (Short Assessment of Patient Satisfaction), (2) a process evaluation of all the 5 steps completed, and (3) personal preferences of communication methods used vs methods preferred was conducted, which was sent to 46 patients who used clinic services.

RESULTS

Of the patients invited, 67% (31/46) completed the survey with mean age 66 years, (SD 16). Almost all patients, 92% (30/31) reported that the online screening test assisted them in seeking hearing health care. Approximately 60% (18/31) of the patients accessed the online hearing screening test from an Android device. Patients stayed in contact with the audiologist mostly through WhatsApp instant messaging (27/31, 87%), and most patients (25/31, 81%) preferred to use this method of communication. The patients continuing with hearing health care were significantly older and had significantly poorer speech recognition abilities compared with the patients who discontinued seeking hearing health care. A statistically significant positive result (P=.007) was found between age and the number of appointments per patient. Around 61% (19/31) of patients previously completed diagnostic testing at other practices, with 95% (18/19) rating the services at the hybrid clinic as better. The net promoter score was 87, indicating that patients were highly likely to recommend the hybrid clinic to friends and family.

CONCLUSIONS

This study applied Web-based and face-to-face components into a hybrid clinic and measured an overall positive experience with high patient satisfaction through a process evaluation. The findings support the potential of a hybrid clinic with synchronous and asynchronous modes of communication to be a scalable hearing health care model, addressing the needs of adults with hearing loss globally.

Opportunities and Challenges of Telehealth in Remote Communities: Case Study of the Yukon Telehealth System

Background

Telehealth has been shown to improve access to health care and to reduce costs to the patient and health care system, especially for patients living in rural settings. However, unique challenges arise when implementing telehealth in remote communities.

Objective

The study aimed to explore the current use, challenges, and opportunities of the Yukon Telehealth System. The lessons learned from this study were used to determine important factors to consider when attempting to advance and expand telehealth programs in remote communities.

Methods

A mixed methods approach was used to evaluate the Yukon Telehealth System and to determine possible future advances. Quantitative data were obtained through usage logs. Web-based questionnaires were administered to nurses in each of the 14 Yukon community health centers outside of Whitehorse and patients who had used telehealth. Qualitative data included focus groups and semistructured interviews with 36 telehealth stakeholders.

Results

Since 2008, there has been a consistent number of telehealth sessions of about 1000 per year, with clinical care as the main use (69.06% [759/1099] of all sessions in 2015). From the questionnaire (11 community nurses and 10 patients) and the interview data, there was a consensus among the clinicians and patients that the system provided timely access and cost savings from reduced travel. However, they believed that it was underutilized, and the equipment was outdated. The following 4 factors were identified, which should be considered when trying to advance and expand a telehealth program: (1) patient and clinician buy-in: past telehealth experiences (eg, negative clinician experiences with outdated technology) should be considered when advancing the system. Expansion of services in orthopedics, dermatology, and psychiatry were found to be particularly feasible and beneficial in Yukon; (2) workflow: the use and scheduling of telehealth should be streamlined and automated as much as possible to reduce dependencies on the single Yukon telehealth coordinator; (3) access to telehealth technology: clinicians and patients should have easy access to up-to-date telehealth technology. The use of consumer products, such as mobile technology, should be leveraged as appropriate; and (4) infrastructure: the required human resources and technology need to be established when expanding and advancing telehealth.

Conclusions

While clinicians and patients had generally positive perceptions of the Yukon Telehealth System, there was consensus that it was underutilized. Many opportunities exist to expand the types of telehealth services and the number of telehealth sessions, including the expansion of services in several new specialty areas, updating telehealth equipment to streamline workflows and increase convenience and uptake, and integrating novel technologies. The identified barriers and recommendations from this evaluation can be applied to the development and expansion of telehealth in other remote communities to realize telehealth’s potential for providing efficient, safe, convenient, and cost-effective care delivery.

Acceptability, benefits, and challenges of video consulting: a qualitative study in primary care

Background

People increasingly communicate online, using visual communication mediums such as Skype and FaceTime. Growing demands on primary care services mean that new ways of providing patient care are being considered. Video consultation (VC) over the internet is one such mode.

Aim

To explore patients’ and clinicians’ experiences of VC.

Design and setting

Semi-structured interviews in UK primary care.

Method

Primary care clinicians were provided with VC equipment. They invited patients requiring a follow-up consultation to an online VC using the Attend Anywhere web-based platform. Participating patients required a smartphone, tablet, or video-enabled computer. Following VCs, semi-structured interviews were conducted with patients (n = 21) and primary care clinicians (n = 13), followed by a thematic analysis.

Results

Participants reported positive experiences of VC, and stated that VC was particularly helpful for them as working people and people with mobility or mental health problems. VCs were considered superior to telephone consultations in providing visual cues and reassurance, building rapport, and improving communication. Technical problems, however, were common. Clinicians felt, for routine use, VCs must be more reliable and seamlessly integrated with appointment systems, which would require upgrading of current NHS IT systems.

Conclusion

The visual component of VCs offers distinct advantages over telephone consultations. When integrated with current systems VCs can provide a time-saving alternative to face-to-face consultations when formal physical examination is not required, especially for people who work. Demand for VC services in primary care is likely to rise, but improved technical infrastructure is required to allow VC to become routine. However, for complex or sensitive problems face-to-face consultations remain preferable.

Comparing the content and quality of video, telephone, and face-to-face consultations: a non-randomised, quasi-experimental, exploratory study in UK primary care

BACKGROUND

Growing demands on primary care services have led to policymakers promoting video consultations (VCs) to replace routine face-to-face consultations (FTFCs) in general practice.

AIM

To explore the content, quality, and patient experience of VC, telephone (TC), and FTFCs in general practice.

DESIGN AND SETTING

Comparison of audio-recordings of follow-up consultations in UK primary care.

METHOD

Primary care clinicians were provided with video-consulting equipment. Participating patients required a smartphone, tablet, or computer with camera. Clinicians invited patients requiring a follow-up consultation to choose a VC, TC, or FTFC. Consultations were audio-recorded and analysed for content and quality. Participant experience was explored in post-consultation questionnaires. Case notes were reviewed for NHS resource use.

RESULTS

Of the recordings, 149/163 were suitable for analysis. VC recruits were younger, and more experienced in communicating online. FTFCs were longer than VCs (mean difference +3.7 minutes, 95% confidence interval [CI] = 2.1 to 5.2) or TCs (+4.1 minutes, 95% CI = 2.6 to 5.5). On average, patients raised fewer problems in VCs (mean 1.5, standard deviation [SD] 0.8) compared with FTFCs (mean 2.1, SD 1.1) and demonstrated fewer instances of information giving by clinicians and patients. FTFCs scored higher than VCs and TCs on consultation-quality items.

CONCLUSION

VC may be suitable for simple problems not requiring physical examination. VC, in terms of consultation length, content, and quality, appeared similar to TC. Both approaches appeared less 'information rich' than FTFC. Technical problems were common and, though patients really liked VC, infrastructure issues would need to be addressed before the technology and approach can be mainstreamed in primary care.

Potential for Integrating Mental Health Specialist Video Consultations in Office-Based Routine Primary Care: Cross-Sectional Qualitative Study Among Family Physicians

BACKGROUND

Although real-time mental health specialist video consultations have been proposed as an effective care model for treating patients with mental health conditions in primary care, little is known about their integration into routine practice from the perspective of family physicians.

OBJECTIVE

This study aimed to determine the degree to which family physicians advocate that mental health specialist video consultations can be integrated into routine primary care, where most patients with mental health conditions receive treatment.

METHODS

In a cross-sectional qualitative study, we conducted 4 semistructured focus groups and 3 telephonic interviews in a sample of 19 family physicians from urban and rural districts. We conducted a qualitative content analysis applying the Tailored Implementation in Chronic Diseases framework in a combined bottom-up (data-driven) and top-down strategy for deriving key domains.

RESULTS

Family physicians indicated that mental health specialist video consultations are a promising and practical way to address the most pressing challenges in current practice, that is, to increase the accessibility and co-ordination of specialized care. Individual health professional factors were the most frequently discussed topics. Specifically, family physicians valued the anticipated clinical outcomes for patients and the anticipated resources set for the primary care practice as major facilitators (16/19, 84%). However, family physicians raised a concern regarding a lack of facial expressions and physical interaction (19/19, 100%), especially in emergency situations. Therefore, most family physicians considered a viable emergency plan for mental health specialist video consultations that clearly delineates the responsibilities and tasks of both family physicians and mental health specialists to be essential (11/19, 58%). Social, political, and legal factors, as well as guideline factors, were hardly discussed as prerequisites for individual family physicians to integrate mental health specialist video consultations into routine care. To facilitate the implementation of future mental health specialist video consultation models, we compiled a checklist of recommendations that covers (1) buy-in from practices (eg, emphasizing logistical and psychological relief for the practice), (2) the engagement of patients (eg, establishing a trusted patient-provider relationship), (3) the setup and conduct of consultations (eg, reliable emergency plans), and (4) the fostering of collaboration between family physicians and mental health specialists (eg, kick-off meetings to build trust).

CONCLUSIONS

By leveraging the primary care practice as a familiar environment for patients, mental health specialist video consultations provide timely specialist support and potentially lead to benefits for patients and more efficient processes of care. Integration should account for the determinants of practice as described by the family physicians.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00012487; https://www.drks.de/drks_web/navigate.do? navigationId=trial.HTML&TRIAL_ID=DRKS00012487.

Current use of telehealth in urology: a review

PURPOSE

Applications of telehealth have been growing in popularity. However, there is little information on how telehealth is being used in Urology. In this review, we examine current applications of telehealth in urological practices as well as barriers to implementation.

METHODS

A review was conducted of original research within the past 10 years describing telehealth applications in urology. Articles on telehealth as applied to other specialties were reviewed for discussion on real or perceived barriers to implementation.

RESULTS

Twenty-four articles met the inclusion criteria. The most common application of telehealth was using a video visit to assess or follow-up with patients. The second most commonly described applications of telehealth were telementorship, or the use of telehealth technology to help train providers, and telemedicine used in diagnostics. Studies consistently stated the effectiveness of the telehealth applications and the high level of patient and provider satisfaction.

CONCLUSIONS

Telehealth is sparingly used in urology. Barriers to implementation include technological literacy, reimbursement uncertainties, and resistance to change in workflow. When used, telehealth technologies are shown to be safe, effective, and satisfactory for patients and providers. Further investigation is necessary to determine the efficacy of telehealth applications.

Challenges And Opportunities Faced By Large Health Systems Implementing Telehealth

Executives at large health systems across the United States have an interest in developing or expanding telehealth programs. While interest is increasing, telehealth implementation teams (or e-health teams) often face challenges that can hinder the successful transition from pilot to full-scale implementation. Here we share lessons learned by four large health systems that have faced and largely surmounted these challenges. For e-health teams to successfully engage senior leaders in new telehealth initiatives, it is essential to align proposals with the strategic goals of the institution and use patient stories to highlight the benefits of telehealth. To manage the demand for telehealth offerings from patients and dozens of clinical departments, e-health teams should develop a framework for deciding what's most important. To get large medical staffs to adopt telehealth workflows, e-health teams should nurture telehealth champions at each staff level and incentivize them with career development opportunities and rewards. To enroll a heterogeneous population of patients in telehealth programs, e-health teams should use multiple methods of education to accommodate different learning styles. And finally, health systems should develop telehealth-specific outcome measures and repeatedly use them to motivate improvement.

Use of Telemedicine to Screen Patients in the Emergency Department: Matched Cohort Study Evaluating Efficiency and Patient Safety of Telemedicine

BACKGROUND

Early efforts to incorporate telemedicine into Emergency Medicine focused on connecting remote treatment clinics to larger emergency departments (EDs) and providing remote consultation services to EDs with limited resources. Owing to continued ED overcrowding, some EDs have used telemedicine to increase the number of providers during surges of patient visits and offer scheduled "home" face-to-face, on-screen encounters. In this study, we used remote on-screen telemedicine providers in the "screening-in-triage" role.

OBJECTIVE

This study aimed to compare the efficiency and patient safety of in-person screening and telescreening.

METHODS

This cohort study, matched for days and proximate hours, compared the performance of real-time remote telescreening and in-person screening at a single urban academic ED over 22 weeks in the spring and summer of 2016. The study involved 337 standard screening hours and 315 telescreening hours. The primary outcome measure was patients screened per hour. Additional outcomes were rates of patients who left without being seen, rates of analgesia ordered by the screener, and proportion of patients with chest pain receiving or prescribed a standard set of tests and medications.

RESULTS

In-person screeners evaluated 1933 patients over 337 hours (5.7 patients per hour), whereas telescreeners evaluated 1497 patients over 315 hours (4.9 patients per hour; difference=0.8; 95% CI 0.5-1.2). Split analysis revealed that for the final 3 weeks of the evaluation, the patient-per-hour rate differential was neither clinically relevant nor statistically discernable (difference=0.2; 95% CI -0.7 to 1.2). There were fewer patients who left without being seen during in-person screening than during telescreening (2.6% vs 3.8%; difference=-1.2; 95% CI -2.4 to 0.0). However, compared to prior year-, date-, and time-matched data on weekdays from 1 am to 3 am, a period previously void of provider screening, telescreening decreased the rate of patients LWBS from 25.1% to 4.5% (difference=20.7%; 95% CI 10.1-31.2). Analgesia was ordered more frequently by telescreeners than by in-person screeners (51.2% vs 31.6%; difference=19.6%; 95% CI 12.1-27.1). There was no difference in standard care received by patients with chest pain between telescreening and in-person screening (29.4% vs 22.4%; difference=7.0%; 95% CI -3.4 to 17.4).

CONCLUSIONS

Although the efficiency of telescreening, as measured by the rate of patients seen per hour, was lower early in the study period, telescreening achieved the same level of efficiency as in-person screening by the end of the pilot study. Adding telescreening during 1-3 am on weekdays dramatically decreased the number of patients who left without being seen compared to historic data. Telescreening was an effective and safe way for this ED to expand the hours in which patients were screened by a health care provider in triage.

Clinicians' Selection Criteria for Video Visits in Outpatient Care: Qualitative Study

Background

Video visits with patients were introduced into outpatient care at a hospital in Sweden. New behaviors and tasks emerged due to changes in roles, work processes, and responsibilities. This study investigates the effects of the digital transformation—in this case, how video visits in outpatient care change work processes and introduce new tasks—to further improve the concept of video visits. The overarching goal was to increase the value of these visits, with a focus on the value of conducting the treatment for the patient.

Objective

Through the real-time, social interactional features of preparing for and conducting video visits with patients with obesity, this study examines which patients the clinicians considered suitable for video visits and why. The aim was to identify the criteria used by clinicians when selecting patients for video visits to understand what criteria the clinicians used as the grounds for their selection.

Methods

Qualitative methods were used, including 13 observations of video visits at 2 different clinics and 14 follow-up interviews with clinicians. Transcripts of interviews and field notes were thematically analyzed, discussed, and synthesized into themes.

Results

From the interviews, 20 different arguments for selecting a specific patient for video visits were identified. Analyzing interviews and field notes also revealed unexpressed arguments that played a part in the selection process. The unexpressed arguments, as well as the implicit reasons, for why a patient was given the option of video visits can be understood as the selection criteria for helping clinicians in their decision about whether to offer video visits or not. The criteria identified in the collected data were divided into 3 themes: practicalities, patient ability, and meeting content.

Conclusions

Not all patients with obesity undergoing treatment programs should be offered video visits. Patients’ new responsibilities could influence the content of the meeting and the progress of the treatment program. The selection criteria developed and used by the clinicians could be a tool for finding a balance between what the patient wants and what the clinician thinks the patient can manage and achieving good results in the treatment program. The criteria could also reduce the number and severity of disturbances and limitations during the meeting and could be used to communicate the requirements they represent to the patient. Some of the criteria are based on facts, whereas others are subjective. A method for how and when to involve the patient in the selection process is recommended as it may strengthen the patient’s sense of responsibility and the relationship with the clinician.

Effects of the Digital Transformation: Qualitative Study on the Disturbances and Limitations of Using Video Visits in Outpatient Care

Background

Video mediated meetings with patients were introduced in outpatient care at a hospital in Sweden. New behaviours and tasks emerged due to changes of roles, work processes and responsibilities. The study investigates effects of digital transformation, in this case how video visits in outpatient care change work processes and introduces new tasks, in order to further improve the concept of video visits.

Objective

Through real-time, social interactional features of preparing for and conducting video visits, the study examines clinicians’ perceived limitations and disturbances, and how the conditions between patients and clinicians may change when using video visits instead of face-to-face meetings in outpatient care.

Methods

Qualitative methods have been used including 14 observations of video visits at two different clinics and 14 followup interviews with clinicians. Transcriptions of interviews and field notes were thematically analysed, discussed and synthesised into themes.

Results

Disturbances and limitations related to the technology were related to time; a flexibility to schedule the meeting unbound of place, frustrations when the other part was late for the scheduled meeting, and that more experienced users of video visits usually waited longer before logging in. They were also related to sound; problems getting the sound to work satisfactory during the video visits, and problems with the image. Disturbances and limitations related to the surroundings were related to both the patient’s and the clinician’s environment; the principle of video technology in itself may affect the experience and the content of the consultation, and the surrounding chosen changes the conditions for and reduces the participants’ field of view.

Conclusions

We could see 1) a transformation of roles and responsibilities when turning from face-to-face meetings to video visits, 2) that video visits add new circumstances, with a risk of introducing disturbances and limitations, that in turn affects the content of the meeting, 3) that avoiding negative disturbances during a video visit, requires a sensibility from the clinician’s side as well as a trust in the patient’s judgement, 4) that both expected and unexpected disturbances and limitations during a video visit affect the clinician’s behaviour, feelings, the content of the meeting and how the clinician’s relate to the different components of the concept, and 5) that there is a change of roles introduced when conducting video visits, eg, the clinician taking the first line support if both (s)he and the patient encounter problems with the technology.

Evaluating the patient experience with urological video visits at an academic medical center

BACKGROUND

Telemedicine utilization, including use of video visits, is growing rapidly. While much enthusiasm surrounds telemedicine, the successful implementation of video visits within health systems requires providers to evaluate patient's experience with the implemented technology and workflow.

METHODS

Twenty patients who completed a video visit in the Department of Urology at Michigan Medicine were contacted and asked if they would be willing to share their experience. Patients underwent a semi-structured telephone interview. Using an interview guide, patients were asked questions about the enrollment process, their overall impression of the visit, and feedback to improve the visit. Interview comments were categorized into three primary themes: usability, quality of the visit, and comparison to a traditional in-clinic visit.

RESULTS

Most patients who underwent a urological video visit were highly satisfied with their experience. Most patients also reported being able to join the video visit with minimal issues. However, some patients expressed issues downloading the application and interpreting our educational materials. In regard to quality of the visit, most patients were impressed and pleased. While there was no criticism regarding the picture-quality of the video visit, a few patients reported issues with the audio. It was apparent that quality of video was dependent on quality of the patient's internet connection. When comparing the video visit to a traditional in-clinic visit, patients-especially parents with children at home-found the video visit to be more efficient.

CONCLUSIONS

Our study found that patients were pleased with their urological video visit experience, and there were details about our workflow that would not have been evident without interviews. These findings suggest that while video visits are suitable alternatives to in-clinic appointments at academic medical centers, it is important for providers to obtain direct feedback from patients to identify workflow and technical issues.