Qualitative Assessment of Rapid System Transformation to Primary Care Video Visits at an Academic Medical Center

Difference in medical student performance in a standardized patient encounter between telemedicine and in-person environments

INTRODUCTION

Telemedicine is an increasingly common form of healthcare delivery in the United States. It is unclear how there are differences in clinical performance in early learners between in-person and telemedicine encounters.

MATERIALS & METHODS

The authors conducted a single-site retrospective cohort study of 241 second-year medical students to compare performance between in-person and telemedicine standardized patient (SP) encounters. One hundred and twenty medical students in the 2020 academic year participated in a telemedicine encounter, and 121 medical students in the 2022 academic year participated in an in-person encounter. SPs completed a multi-domain performance checklist following the encounter, and the authors performed statistical analyses to compare student performance between groups.

RESULTS

Students who completed in-person encounters had higher mean scores in overall performance (75.2 vs. 69.7, p < 0.001). They had higher scores in physical exam (83.3 vs. 50, p < 0.001) and interpersonal communication domains (95 vs. 85, p < 0.001) and lower scores in obtaining a history (73.3 vs. 80, p = 0.0025). There was no significant difference in assessment and plan scores (50 vs. 50, p = 0.96) or likelihood of appropriately promoting antibiotic stewardship (41.3% vs. 45.8%, p = 0.48).

CONCLUSION

The authors identified significant differences in clinical performance between in-person and telemedicine SP encounters, indicating that educational needs may differ between clinical environments.

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.

Care Integration for Hepatitis C Virus Treatment Through Facilitated Telemedicine Within Opioid Treatment Programs: Qualitative Study

BACKGROUND

Telemedicine has the potential to remove geographic and temporal obstacles to health care access. Whether and how telemedicine can increase health care access for underserved populations remains an open question. To address this issue, we integrated facilitated telemedicine encounters for the management of hepatitis C virus (HCV), a highly prevalent condition among people with opioid use disorder (OUD), into opioid treatment programs (OTPs). In New York State, OTPs are methadone-dispensing centers that provide patient-centered, evidence-based treatment for OUD. We investigated the integration and impact of facilitated telemedicine into OTP workflows in these settings.

OBJECTIVE

This study aims to understand OTP staff experiences with integrating facilitated telemedicine for HCV treatment into OTPs, including best practices and lessons learned.

METHODS

We conducted semistructured interviews with 45 OTP staff members (13 clinical, 12 administrative, 6 physicians, and 14 support staff members) at least one year after the implementation of facilitated telemedicine for HCV management. We used hermeneutic phenomenological analysis to understand OTP staff experiences.

RESULTS

We identified 4 overarching themes illustrating the successful integration of facilitated telemedicine for HCV care into OTPs. First, integration requires an understanding of the challenges, goals, and values of the OTP. As OTP staff learned about new, highly effective HCV therapies, they valued an HCV cure as a "win" for their patients and were excited about the potential to eliminate a highly prevalent infectious disease. Second, the integration of facilitated telemedicine into OTPs fosters social support and reinforces relationships between patients and OTP staff. OTP staff appreciated the ability to have "eyes on" patients during telemedicine encounters to assess body language, a necessary component of OUD management. Third, participants described high levels of interprofessional collaboration as a care team that included the blurring of lines between disciplines working toward a common goal of improving patient care. Study case managers were integrated into OTP workflows and established communication channels to improve patient outcomes. Fourth, administrators endorsed the sustained and future expansion of facilitated telemedicine to address comorbidities.

CONCLUSIONS

OTP staff were highly enthusiastic about facilitated telemedicine for an underserved population. They described high levels of collaboration and integration comparable to relevant integrative frameworks. When situated within OTPs, facilitated telemedicine is a high-value application of telemedicine that provides support for underserved populations necessary for high-quality health care. These experiences support sustaining and scaling facilitated telemedicine in comparable settings and evaluating its ability to address other comorbidities.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02933970; https://clinicaltrials.gov/study/NCT02933970.

Pediatric Primary Care Clinicians' Perspectives on Telemedicine Use, 2020 Versus 2021

Objective: We examined the change in pediatric primary care clinician attitudes and perceptions about telemedicine after one year of telemedicine use. Methods: We administered a survey to pediatric primary care clinicians across 50 primary care practices in Pennsylvania in 2020 and 2021. Surveys were linked using a combination of deterministic and probabilistic matching. We used McNemar's test to compare change in responses from 2020 to 2021. Results: Among pediatric primary care clinicians surveyed in 2020 and 2021 (n = 101), clinicians agreed that telemedicine could always or usually deliver high-quality care for mental health (80% in 2020 and 78% in 2021), care coordination (77% in 2020 and 70% in 2021), acute care (33% in 2020 and 34% in 2021), or preventive care (25% in 2020 and 18% in 2021) and this did not significantly change. Clinician perceptions of usability, while high, declined over time with fewer endorsing ease of use (93% in 2020 and 80% in 2021) and reliability (14% in 2020 and 0% in 2021) over time. Despite this, 62% of clinicians agreed that they were satisfied with their use of telemedicine at both time points. Respondents anticipated positive impact on equity and timeliness of care from telemedicine use but did not anticipate positive impact across child health, health care delivery, or clinician experience. Perceptions across these domains did not change over time. Conclusions: With one year of telemedicine experience, primary care clinicians maintained beliefs that telemedicine could deliver high-quality care for specific clinical needs but had worsening perceptions of usability over time.

Innovations produced in Primary Health Care during the COVID-19 pandemic: an integrative literature review

Primary Health Care (PHC) proved to be an important part of the prevention, control and treatment measures against COVID-19, a situation in which it was challenged to keep up its provision of regular services as well. This article identifies the main arrangements made to provide PHC care in the context of the COVID-19 pandemic. An integrative literature review of articles found in PubMed, SciELO and LILACS databases was performed using the descriptors "Primary Health Care" and "COVID-19". Findings were analyzed considering three questions: Information and Communication Technologies (ICT), Organizations of Work Processes and Non-COVID Chronic Diseases. The use of different forms of ICT to provide PHC is highlighted regarding patients with respiratory symptoms and chronic patients. Changes in team composition, service flows, physical spaces and working hours were also introduced. Although strategies aimed at monitoring chronic patients and at remote care may have helped minimize deterioration of their health, the decrease in the number of visits performed during this period could have resulted in an increased demand for PHC in post-pandemic years.

A Systematic Review of Publications on Perceptions and Management of Chronic Medical Conditions Using Telemedicine Remote Consultations by Primary Healthcare Professionals April 2020 to December 2021 During the COVID-19 Pandemic

Telemedicine technologies allow distribution of health-related services and information and can include electronic and telecommunication technologies, remote patient and clinician contact, referral and prescribing, patient education, and monitoring. This systematic review aimed to evaluate publications on the perceptions and management of chronic medical conditions using telehealth remote consultations by primary healthcare professionals between April 2020 and December 2021 during the COVID-19 pandemic. Electronic databases, including Cinhal, PubMed, Science Direct, and ProQuest were searched to extract qualitative studies relevant to the topic. Inclusion criteria were developed based on the Population, Exposure, and Outcomes scoping framework. The target population was healthcare professionals working in primary care settings. Included studies encompassed various types of telemedicine, such as synchronous telemedicine, video conferencing, telephone conversations, and smart devices. Eight studies were included. Synchronous telemedicine was highly effective in ensuring the continuity of care and treatment, providing patients with convenience, improved access to treatment, and earlier disease management. Video conferencing and telephone consultations were the most common methods used. Challenges included concerns about patient privacy, technology literacy, and acceptance. Telemedicine was commended for its ability to provide access to immediate expert medical advice and eliminate the need for long-distance travel, contributing to increased patient compliance. Synchronous telemedicine is a promising solution for managing chronic conditions during and after the COVID-19 pandemic, offering benefits to patients and healthcare professionals. To maximize its potential, concerns regarding patient privacy, confidentiality, and technology literacy need to be addressed. Proper legislation and regulations are required for long-term success of telemedicine, making it a valuable component of healthcare systems.

Telehealth Implementation Response to COVID-19 in the OneFlorida+ Clinical Research Network: Perspectives of Clinicians and Health Systems Leaders

Introduction: The COVID-19 pandemic forced health systems worldwide to make rapid adjustments to patient care. Nationwide stay-at-home mandates and public health concerns increased demand for telehealth to maintain patients' continuity of care. These circumstances permitted observation of telehealth implementation in real-world settings at a large scale. This study aimed to understand clinician and health system leader (HSL) experiences in expanding, implementing, and sustaining telehealth during COVID-19 in the OneFlorida+ clinical research network. Methods: We conducted semistructured videoconference interviews with 5 primary care providers, 7 specialist providers, and 12 HSLs across 7 OneFlorida+ health systems and settings. Interviews were audiorecorded, transcribed, and summarized using deductive team-based template coding. We then used matrix analysis to organize the qualitative data and identify inductive themes. Results: Rapid telehealth implementation occurred even among sites with low readiness, facilitated by responsive planning, shifts in resource allocation, and training. Common hurdles in routine telehealth use, including technical and reimbursement issues, were also barriers to telehealth implementation. Acceptability of telehealth was influenced by benefits such as the providers' ability to view a patient's home environment and the availability of tools to enhance patient education. Lower acceptability stemmed from the inability to conduct physical examinations during the shutdown. Conclusions: This study identified a broad range of barriers, facilitators, and strategies for implementing telehealth within large clinical research networks. The findings can contribute to optimizing the effectiveness of telehealth implementation in similar settings, and point toward promising directions for telehealth provider training to improve acceptability and promote sustainability.

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.

Virtual Management of Chronic Conditions During the COVID-19 Pandemic: Insights From Primary Care Providers and Clinical Pharmacists

INTRODUCTION

The abrupt change in care delivery caused by the coronavirus disease 2019 pandemic may have left some patients, particularly those with chronic conditions, unable to receive timely and appropriate routine care. Understanding the effect of the pandemic and the switch to virtual care for patients with chronic conditions requires in-depth qualitative feedback from providers who care for these patients.

MATERIALS AND METHODS

We interviewed 13 primary care providers and clinical pharmacists from the Veterans Health Administration. Interviews elicited experiences managing patients with chronic conditions, specifically diabetes and hypertension, during the coronavirus disease 2019 pandemic. We employed a rapid analytic approach for data analysis.

RESULTS

In general, interview participants maintained that most patients' chronic conditions could be managed remotely without significant disruption. However, patients who lack familiarity with technology and/or reliable broadband access, patients not compliant with recommended self-assessments, and older patients with hearing loss or cognitive disorders may be more difficult to manage virtually. Although providers reported minimal disruptions to care because of the pandemic, they did note that the closure of labs and experiences of social isolation may have negatively impacted patients. Providers suggested optimizing virtual management through more robust patient instruction on virtual care technology, increased use of Veterans Affairs home health services, and removing institutional barriers that may de-incentivize virtual care modalities.

CONCLUSIONS

For many patients with chronic conditions, virtual care is a promising approach to provide ongoing management in primary care. However, more tailored strategies may be needed to care for sicker, more vulnerable patients.

Strategies to Bridge Equitable Implementation of Telehealth

During the COVID-19 pandemic, the rapid scaling of telehealth limited the extent to which proactive planning for equitable implementation was possible. The deployment of telehealth will persist in the postpandemic era, given patient preferences, advances in technologies, growing acceptance of telehealth, and the potential to overcome barriers to serve populations with limited access to high-quality in-person care. However, aspects and unintended consequences of telehealth may leave some groups underserved or unserved, and corrective implementation plans that address equitable access will be needed. The purposes of this paper are to (1) describe equitable implementation in telehealth and (2) integrate an equity lens into actionable equitable implementation.

Opportunities to Enhance the Implementation of Veterans Affairs Video-Based Care: Qualitative Perspectives of Providers from Diverse Specialties

BACKGROUND

Increasing the adoption of digital care tools, including video visits, is a long-term goal for the US Department of Veterans Affairs (VA). While previous work has highlighted patient-specific barriers to the use of video visits, few have examined how clinicians view such barriers and how they have overcome them during the rapid uptake of web-based care.

OBJECTIVE

This study sought input from providers, given their role as critical participants in video visit implementation, to qualitatively describe successful strategies providers used to adapt their practices to a web-based care setting.

METHODS

We conducted interviews with 28 VA providers (physicians and nurse practitioners) from 4 specialties that represent diverse clinical services: primary care (n=11), cardiology (n=7), palliative care (n=5), and spinal cord injury (n=5). All interviews were audio recorded and transcribed, and transcripts were reviewed and coded according to an iteratively created codebook. To identify themes, codes were grouped together into categories, and participant comments were reviewed for repetition and emphasis on specific points. Finally, themes were mapped to Expert Recommendations for Implementing Change (ERIC) strategies to identify evidence-based opportunities to support video visit uptake in the VA.

RESULTS

Interviewees were mostly female (57%, 16/28), with an average age of 49 years and with 2-20 years of experience working in the VA across 16 unique VA facilities. Most providers (82%, 23/28) worked in urban facilities. Many interviewees (78%, 22/28) had some experience with video visits prior to the COVID-19 pandemic, though a majority (61%, 17/28) had conducted fewer than 50 video visits in the quarter prior to recruitment. We identified four primary themes related to how providers adapt their practices to a web-based care setting: (1) peer-based learning and support improved providers' perceived value of and confidence in video visits, (2) providers developed new and refined existing communication and clinical skills to optimize video visits, (3) providers saw opportunities to revisit and refine team roles to optimize the value of video visits for their care teams, and (4) implementing and sustaining web-based care requires institutional and organizational support. We identified several ERIC implementation strategies to support the use of video visits across the individual-, clinic-, and system-levels that correspond to these themes: (1) individual-level strategies include the development of educational materials and conducting education meetings, (2) clinic-level strategies include identifying champions and revising workflows and professional roles, and (3) system-level strategies include altering incentive structures, preparing implementation blueprints, developing and implementing tools for quality monitoring, and involving executive leadership to encourage adoption.

CONCLUSIONS

This work highlights strategies to support video visits that align with established ERIC implementation constructs, which can be used by health care systems to improve video visit implementation.

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.

Synchronous Home-Based Telemedicine for Primary Care: A Review

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

The challenges of telephone consultation program during severe acute respiratory syndrome-coronavirus-2 epidemic in Iran: A qualitative study

Introduction

With the spread of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) disease and its potential risks for vulnerable groups such as the elderly with chronic diseases, telehealth appointments gained more attention around the world. However, using such a system brought about challenges to patients and service providers that need to be addressed by policymakers for system improvement.

Purpose

The present study was conducted with the aim of investigating the challenges of the telephone consultation program, which was run by the Social Security Insurance Organization of Iran during the epidemic of SARS-CoV-2.

Methods

This qualitative study was conducted through semi-structured interviews with physicians who participated in the program, using a purposive sampling approach. The interviews were recorded, transcribed verbatim, and analyzed through conventional content analysis by ATLAS.ti9 software.

Findings

Based on the results of the qualitative content analysis, the challenges in three categories, including program development, implementation, and evaluation and monitoring, and with 10 themes (planning challenges, infrastructure provision, education and culture building, legal issues, motivational mechanisms, effective communication, efficiency, and effectiveness of care, organization, monitoring, and evaluation) and 26 sub-themes were extracted.

Conclusion

Telephone appointments allow medical centers to serve some patients better. However, properly implementing the telephone consultation program requires better planning, training, appropriate infrastructure, and continuous evaluation and improvement of processes.

Approaches to enabling rapid evaluation of innovations in health and social care: a scoping review of evidence from high-income countries

OBJECTIVE

The COVID-19 pandemic increased the demand for rapid evaluation of innovation in health and social care. Assessment of rapid methodologies is lacking although challenges in ensuring rigour and effective use of resources are known. We mapped reports of rapid evaluations of health and social care innovations, categorised different approaches to rapid evaluation, explored comparative benefits of rapid evaluation, and identified knowledge gaps.

DESIGN

Scoping review.

DATA SOURCES

MEDLINE, EMBASE and Health Management Information Consortium (HMIC) databases were searched through 13 September 2022.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included publications reporting primary research or methods for rapid evaluation of interventions or services in health and social care in high-income countries.

DATA EXTRACTION AND SYNTHESIS

Two reviewers developed and piloted a data extraction form. One reviewer extracted data, a second reviewer checked 10% of the studies; disagreements and uncertainty were resolved through consensus. We used narrative synthesis to map different approaches to conducting rapid evaluation.

RESULTS

We identified 16 759 records and included 162 which met inclusion criteria.We identified four main approaches for rapid evaluation: (1) Using methodology designed specifically for rapid evaluation; (2) Increasing rapidity by doing less or using less time-intensive methodology; (3) Using alternative technologies and/or data to increase speed of existing evaluation method; (4) Adapting part of non-rapid evaluation.The COVID-19 pandemic resulted in an increase in publications and some limited changes in identified methods. We found little research comparing rapid and non-rapid evaluation.

CONCLUSIONS

We found a lack of clarity about what 'rapid evaluation' means but identified some useful preliminary categories. There is a need for clarity and consistency about what constitutes rapid evaluation; consistent terminology in reporting evaluations as rapid; development of specific methodologies for making evaluation more rapid; and assessment of advantages and disadvantages of rapid methodology in terms of rigour, cost and impact.

Organizational responses to the COVID-19 pandemic in Victoria, Australia: A qualitative study across four healthcare settings

Objective

Organizational responses that support healthcare workers (HCWs) and mitigate health risks are necessary to offset the impact of the COVID-19 pandemic. We aimed to understand how HCWs and key personnel working in healthcare settings in Melbourne, Australia perceived their employing organizations' responses to the COVID-19 pandemic.

Method

In this qualitative study, conducted May-July 2021 as part of the longitudinal Coronavirus in Victorian Healthcare and Aged Care Workers (COVIC-HA) study, we purposively sampled and interviewed HCWs and key personnel from healthcare organizations across hospital, ambulance, aged care and primary care (general practice) settings. We also examined HCWs' free-text responses to a question about organizational resources and/or supports from the COVIC-HA Study's baseline survey. We thematically analyzed data using an iterative process.

Results

We analyzed data from interviews with 28 HCWs and 21 key personnel and free-text responses from 365 HCWs, yielding three major themes: navigating a changing and uncertain environment, maintaining service delivery during a pandemic, and meeting the safety and psychological needs of staff . HCWs valued organizational efforts to engage openly and honesty with staff, and proactive responses such as strategies to enhance workplace safety (e.g., personal protective equipment spotters). Suggestions for improvement identified in the themes included streamlined information processes, greater involvement of HCWs in decision-making, increased investment in staff wellbeing initiatives and sustainable approaches to strengthen the healthcare workforce.

Conclusions

This study provides in-depth insights into the challenges and successes of organizational responses across four healthcare settings in the uncertain environment of a pandemic. Future efforts to mitigate the impact of acute stressors on HCWs should include a strong focus on bidirectional communication, effective and realistic strategies to strengthen and sustain the healthcare workforce, and greater investment in flexible and meaningful psychological support and wellbeing initiatives for HCWs.

Strategies Facilitating Video Visit Implementation by a Medical Group Serving a Diverse Population

IntroductionVideo visits have created new opportunities to enhance access to care, but limited information exists on strategies medical groups can employ to facilitate video visit use by higher-risk patients. Our objective was to identify generalizable strategies to facilitate successful delivery of video visits by systems serving highly diverse patient populations. MethodsThe authors conducted a qualitative study of physicians and staff members in a large group practice with 4.5 million patients with diverse race and ethnicity and socioeconomic status. Semi-structured interviews were conducted between January 2021 and April 2021, with key informants identified via purposive and snowball sampling. Video-recorded interviews were transcribed and analyzed using thematic analysis to identify major themes and subthemes. ResultsThe 42 key informants included regional and medical center leaders, primary care physicians, service managers, and medical assistants. Participants described clinical leadership in technology and multidisciplinary collaboration as crucial to sustained video care adoption. Strategies to facilitate real-time learning included local innovation, rapid communication channels, and psychological safety. The organization offered broad access to frequently updated data reports to help managers and practitioners understand processes, measure performance, and share best practices. Medical assistants and physicians developed new approaches to empathize, tailor interactions with patients, and overcome psychological and technical barriers to connecting via video. ConclusionsKey strategies for sustained video care adoption included clinical leadership articulating its purpose, multidisciplinary collaboration, local innovation, effective data use, empathy, and personalized care. These findings provide a model for how health care systems can foster robust adoption of technologies to serve diverse populations.

Protocol for developing telephone-based brief psychosocial intervention for COVID-19 patients in India

Introduction

The ongoing Coronavirus disease 2019 (COVID-19) pandemic has had a huge mental health impact on people, especially the infected population. They are at greater risk of developing psychological symptoms due to the fear of death and developing severe disability, lack of proper treatment and social restrictions, stigma, and discrimination. The early psychological symptoms, if ignored, may have long-term consequences on the health and well-being of COVID patients. Due to the COVID-19 pandemic, the mental health services have been impacted negatively, and the need for technology-based psychological interventions has been identified as an alternative treatment method. Hence, the Telephone-Based Brief Psycho-Social interventions (TBPSI) will be developed for COVID-19 patients.

Materials and Method

A five-session tele psychosocial intervention including rapport establishment and assessment, supportive counselling, activity scheduling, relaxation technique, and post-assessment will be developed based on the extensive review of the literature. Face and content validation of the intervention package will be done by the mental health experts. Further, the feasibility of the intervention program will be tested on COVID-19 patients in the Dharwad district, and later, the same will be implemented across the COVID hospitals of Karnataka state.

Discussion and Conclusion

The study results may bring new insights into the culturally sensitive technology-oriented interventions during this pandemic in the country. The paradigm may be shifted from routine treatment to cost-effective and time-based intervention in the public health system in India. The telephonic brief psychosocial interventions can be utilised as a mainstream treatment during non-emergency situations as well.

Physicians' satisfaction with telehealth services among family physicians in Cluster 1 hospitals

Background

Physicians are increasingly applying telehealth services in the hospital. The use of telehealth services helps to ensure that doctors treat patients and write prescriptions remotely without the need to meet physically with the patient.

Methods

The study used a descriptive survey design, in which collection and sampling of data were standardized to represent the population of all physicians. The target population was all doctors in all private healthcare systems, King Saud Medical City (KSMC), and four hospitals in the southwest area of Saudi Arabia. Data were collected via a simple random sampling system and engaged questionnaires. Microsoft Office Excel was used for data entry and preparation of graphs and charts.

Results

We collected data from 151 physicians in Cluster 1 hospitals. Most were males (74.8%) with a mean age of 31.14 years. Of these, 57.6% thought that telemedicine saved physicians' traveling time, 27.8% were satisfied with telemedicine services, 28.5% were not satisfied, and 43.7% were neutral; 61.6% thought that telemedicine was important for them, and 53.6% liked using telemedicine because of the similarity of participants' values and society values underlying its uses; 59.6% reported that telemedicine improved their job effectiveness and performance, while 58.9% reported that telemedicine enabled them to accomplish tasks more quickly and made them more productive.

Conclusion

Physicians expressed a high level of satisfaction and a positive attitude toward telemedicine. Future researches are essential to see how attitudes about telemedicine have altered since the pandemic.

The Impact of Digital Health Transformation Driven by COVID-19 on Nursing Practice: Systematic Literature Review

Background

The COVID-19 pandemic has accelerated the uptake of digital health innovations due to the availability of various technologies and the urgent health care need for treatment and prevention. Although numerous studies have investigated digital health adoption and the associated challenges and strategies during the pandemic, there is a lack of evidence on the impact on the nursing workforce.

Objective

This study aims to identify the impact of digital health transformation driven by COVID-19 on nurses.

Methods

The online software Covidence was used to follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. Relevant scientific health and computing databases were searched for papers published from January 2020 to November 2021. Using the 8D sociotechnical approach for digital health in health care systems, the papers were analyzed to identify gaps in applying digital health in nursing practice.

Results

In total, 21 papers were selected for content analysis. The analysis identified a paucity of research that quantifies the impact of the digital health transformation on nurses during the pandemic. Most of the initiatives were teleconsultation, followed by tele–intensive care unit (tele-ICU), and only 1 (5%) study explored electronic medical record (EMR) systems. Among the sociotechnical elements, the human-related factor was the most explored and the system measurement was the least studied item.

Conclusions

The review identified a significant gap in research on how implementing digital health solutions has impacted nurses during the COVID-19 pandemic. This gap needs to be addressed by further research to provide strategies for empowering the nursing workforce to be actively involved in digital health design, development, implementation, use, and evaluation.

Telehealth for the Longitudinal Management of Chronic Conditions: Systematic Review

BACKGROUND

Extensive literature support telehealth as a supplement or adjunct to in-person care for the management of chronic conditions such as congestive heart failure (CHF) and type 2 diabetes mellitus (T2DM). Evidence is needed to support the use of telehealth as an equivalent and equitable replacement for in-person care and to assess potential adverse effects.

OBJECTIVE

We conducted a systematic review to address the following question: among adults, what is the effect of synchronous telehealth (real-time response among individuals via phone or phone and video) compared with in-person care (or compared with phone, if synchronous video care) for chronic management of CHF, chronic obstructive pulmonary disease, and T2DM on key disease-specific clinical outcomes and health care use?

METHODS

We followed systematic review methodologies and searched two databases (MEDLINE and Embase). We included randomized or quasi-experimental studies that evaluated the effect of synchronously delivered telehealth for relevant chronic conditions that occurred over ≥2 encounters and in which some or all in-person care was supplanted by care delivered via phone or video. We assessed the bias using the Cochrane Effective Practice and Organization of Care risk of bias (ROB) tool and the certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation. We described the findings narratively and did not conduct meta-analysis owing to the small number of studies and the conceptual heterogeneity of the identified interventions.

RESULTS

We identified 8662 studies, and 129 (1.49%) were reviewed at the full-text stage. In total, 3.9% (5/129) of the articles were retained for data extraction, all of which (5/5, 100%) were randomized controlled trials. The CHF study (1/5, 20%) was found to have high ROB and randomized patients (n=210) to receive quarterly automated asynchronous web-based review and follow-up of telemetry data versus synchronous personal follow-up (in-person vs phone-based) for 1 year. A 3-way comparison across study arms found no significant differences in clinical outcomes. Overall, 80% (4/5) of the studies (n=466) evaluated synchronous care for patients with T2DM (ROB was judged to be low for 2, 50% of studies and high for 2, 50% of studies). In total, 20% (1/5) of the studies were adequately powered to assess the difference in glycosylated hemoglobin level between groups; however, no significant difference was found. Intervention design varied greatly from remote monitoring of blood glucose combined with video versus in-person visits to an endocrinology clinic to a brief, 3-week remote intervention to stabilize uncontrolled diabetes. No articles were identified for chronic obstructive pulmonary disease.

CONCLUSIONS

This review found few studies with a variety of designs and interventions that used telehealth as a replacement for in-person care. Future research should consider including observational studies and studies on additional highly prevalent chronic diseases.

Impact of the COVID-19 on the Health System and Healthcare Workers: A Systematic Review

Context: The coronavirus disease 2019 (COVID-19) pandemic has affected all sectors of life. The health system and healthcare workers also have been affected by the COVID-19 pandemic. Healthcare workers (HCWs) have faced major challenges in working in the hospitals due to COVID-19 pandemic. There is a need to provide evidence regarding challenges to working during the COVID-19 pandemic, specifically in developing countries. Objectives: The objective of this study was to evaluate the effect of the COVID-19 pandemic on health professionals and the health system. Methods: Ten studies conducted from January 1, 2020, to December 31, 2021were included in this review. Common search terms were impact, health, healthcare, providers, abuses, burden, and system. Different databases, such as Scopus, Web of Science, PubMed, and Google Scholar, were used. Data extraction was performed following the PRISMA recommendations. Results: The results of the systematic review showed that the hospitalization rate and numbers of out-patients have increased, leading to imposing a burden on the health system and healthcare workers (HCWs). A serious type of disease may need hospitalization and ventilatory support. The quality of healthcare institutions is unique and complex. HCWs, in their routine activities, face diverse challenges. The unexpected development of the COVID-19 pandemic was a great challenge faced by the health system and health professionals. Conclusions: The pandemic has altered the healthcare system and healthcare practice with innovative workplaces and social challenges confronted by the HCWs.

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.

Telemedicine services for living kidney donation: A US survey of multidisciplinary providers

Individuals considering living kidney donation face geographic, financial, and logistical challenges. Telemedicine can facilitate healthcare access/care coordination. Yet difficulties exist in telemedicine implementation and sustainability. We sought to examine centers' practices and providers' attitudes toward telemedicine to improve services for donors. We surveyed multidisciplinary providers from 194 active adult US living donor kidney transplant centers; 293 providers from 128 unique centers responded to the survey (center representation rate = 66.0%), reflecting 83.9% of practice by donor volume and 91.5% of US states/territories. Most centers (70.3%) plan to continue using telemedicine beyond the pandemic for donor evaluation/follow-up. Video was mostly used by nephrologists, surgeons, and psychiatrists/psychologists. Telephone and video were mostly used by social workers, while video or telephone was equally used by coordinators. Half of respondent nephrologists and surgeons were willing to accept a remote completion of physical exam; 68.3% of respondent psychiatrists/psychologists and social workers were willing to accept a remote completion of mental status exam. Providers strongly agreed that telemedicine was convenient for donors and would improve the likelihood of completing donor evaluation. However, providers (65.5%) perceived out-of-state licensing as a key policy/regulatory barrier. These findings help inform practice and underscore the instigation of policies to remove barriers using telemedicine to increase living kidney donation.

COVID-19 - an opportunity to improve access to primary care through organizational innovations? A qualitative multiple case study in Quebec and Nova Scotia (Canada)

BACKGROUND

COVID-19 catalyzed a rapid and substantial reorganization of primary care, accelerating the spread of existing strategies and fostering a proliferation of innovations. Access to primary care is an essential component of a healthcare system, particularly during a pandemic. We describe organizational innovations aiming to improve access to primary care and related contextual changes during the first 18 months of the COVID-19 pandemic in two Canadian provinces, Quebec and Nova Scotia.

METHODS

We conducted a multiple case study based on 63 semi-structured interviews (n = 33 in Quebec, n = 30 in Nova Scotia) conducted between October 2020 and May 2021 and 71 documents from both jurisdictions. We recruited a diverse range of provincial and regional stakeholders (e.g., policy-makers, decision-makers, family physicians, nurses) involved in reorganizing primary care during the COVID-19 pandemic using purposeful sampling (e.g., based on role, region). Interviews were transcribed verbatim and thematic analysis was conducted in NVivo12. Emerging results were discussed by team members to identify salient themes and organized into logic models.

RESULTS

We identified and analyzed six organizational innovations. Four of these - centralized public online booking systems, centralized access centers for unattached patients, interim primary care clinics for unattached patients, and a community connector to health and social services for older adults - pre-dated COVID-19 but were accelerated by the pandemic context. The remaining two innovations were created to specifically address pandemic-related needs: COVID-19 hotlines and COVID-dedicated primary healthcare clinics. Innovation spread and proliferation was influenced by several factors, such as a strengthened sense of community amongst providers, decreased patient demand at the beginning of the first wave, renewed policy and provider interest in population-wide access (versus attachment of patients only), suspended performance targets (e.g., continuity ≥80%) in Quebec, modality of care delivery, modified fee codes, and greater regional flexibility to implement tailored innovations.

CONCLUSION

COVID-19 accelerated the uptake and creation of organizational innovations to potentially improve access to primary healthcare, removing, at least temporarily, certain longstanding barriers. Many stakeholders believed this reorganization would have positive impacts on access to primary care after the pandemic. Further studies should analyze the effectiveness and sustainability of innovations adapted, developed, and implemented during the COVID-19 pandemic.

Doctoring from home: Physicians' perspectives on the advantages of remote care delivery during the COVID-19 pandemic

BACKGROUND

During the COVID-19 pandemic, stay-at-home orders as well as shortages of personal protective equipment forced primary care physicians (PCPs) to transition rapidly from in-person visits to telehealth. While telehealth expanded extensively in a short period of time, research about the consequences of the shift to remote care is lacking. The objective of this qualitative study was to examine how telehealth benefited PCPs and their patients during the COVID-19 pandemic.

METHODS

From July to August 2020, semi-structured interviews were conducted with 20 PCPs associated with a single academic medical center to examine their perspectives about delivering care remotely during the COVID-19 pandemic. All interviews were recorded, transcribed verbatim, coded, and analyzed using deductive thematic analysis.

RESULTS

PCPs identified several benefits of remote care delivery for both physicians and patients. They indicated that (1) patients were reassured that they could receive safe and timely care, (2) remote visits were convenient for patients, (3) patients were comfortable receiving care at home, and (4) video visits enhanced patient- and family-centered care during the COVID-19 pandemic. Participants also noted that (1) telehealth accommodated working from home, (2) physicians were equitably reimbursed for telehealth visits, and that (3) telehealth promoted physician work-life balance.

CONCLUSIONS

Our data provides preliminary evidence that PCPs and their patients had positive experiences with remote care during the early months of the COVID-19 pandemic. Physicians identified opportunities by which telehealth could enhance the delivery of patient-centered care by allowing them to see patients' home environments and to engage family members and caregivers during telehealth visits. More research is needed to understand how to sustain these benefits beyond the global COVID-19 pandemic and ensure patients' needs are met.

The Impact of COVID-19 on Primary Care Teamwork: a Qualitative Study in Two States

BACKGROUND

The emergence of coronavirus disease 2019 (COVID-19) disrupted how primary care physicians (PCPs) and their staff delivered team-based care.

OBJECTIVE

To explore PCPs' perspectives about the impact of stay-at-home orders and the increased use of telemedicine on interactions and working relationships with their practice staff during the first 9 months of the pandemic.

DESIGN

Qualitative research.

PARTICIPANTS

Participants included PCPs from family and community medicine, general internal medicine, and pediatrics.

APPROACH

One-on-one, semi-structured video interviews with 42 PCPs were conducted between July and December 2020. Physicians were recruited from 30 primary care practices in Massachusetts and Ohio using a combination of purposeful, convenience, and snowball sampling. Interview questions focused on work changes and work relationships with other staff members during the pandemic as well as their experiences delivering telemedicine. All interviews were audio-recorded, transcribed verbatim, and coded using deductive and inductive approaches.

KEY RESULTS

Across respondents and states, the context of the pandemic was reported to have four major impacts on primary care teamwork: (1) staff members' roles were repurposed to support telemedicine; (2) PCPs felt disconnected from staff; (3) PCPs had difficulty communicating with staff; and (4) many PCPs were demoralized during the pandemic.

CONCLUSIONS

The lack of in-person contact, and less synchronous communication, negatively impacted PCP-staff teamwork and morale during the pandemic. These challenges further highlight the importance for practice leaders to recognize and attend to clinicians' relational and work-related needs as the pandemic continues.

Has Virtual Care Arrived? A Survey of Rural Canadian Providers During the Early Stages of the COVID-19 Pandemic

We investigated the uptake and perceptions of virtual care solutions by rural Canadian primary and specialist providers during the early phase (May-June 2020) of the COVID-19 pandemic. A web-based, cross-sectional survey of rural primary and specialty care providers examined types of virtual care platforms used (eg, phone, video), appointment length, experience and satisfaction with the solution used, plans for future use of virtual care, and patients' use of virtual care services. Targeted participants were actively-practicing providers in rural Western Canada who were emailed an invitation for the study and its survey link. Fifty-nine providers (26% response rate) completed the survey. During the pandemic, 78% of providers reported using virtual care for more than 60% of their appointments, while only 3% did so frequently pre-pandemic. Most providers used phone consultations, despite believing that video provided a better virtual visit. Key barriers included workflow interruptions, unique concerns about quality of care, remuneration and sustainability, or poor internet access and bandwidth for both providers and patients. The key opportunity noted was improved access to care. While most virtual care visits were not conducted using video technologies, overall virtual care resulted in high provider satisfaction, while not increasing workload. Virtual care will continue to play an important role in future rural care practice; however, sustainability will require both provider-level and system-level changes.

Implementing a virtual emergency department: a qualitative study using the NPT theory (Preprint)

Background

COVID-19 necessitated the rapid implementation and uptake of virtual health care; however, virtual care’s potential role remains unclear in the urgent care setting. In December 2020, the first virtual emergency department (ED) in the Greater Toronto Area was piloted at Sunnybrook Health Sciences Centre by connecting patients to emergency physicians through an online portal.

Objective

This study aims to understand whether and how ED physicians were able to integrate a virtual ED alongside in-person operations.

Methods

We conducted semistructured interviews with ED physicians guided by the Normalization Process Theory (NPT). The NPT provides a framework to understand how individuals and teams navigate the process of embedding new models of care as part of normal practice. All physicians who had worked within the virtual ED model were invited to participate. Data were analyzed using a combination of inductive and deductive techniques informed by the NPT.

Results

A total of 14 physicians were interviewed. Participant experiences were categorized into 1 of 2 groups: 1 group moved to normalize the virtual ED in practice, while the other described barriers to routine adoption. These groups differed in their perception of the patient benefits as well as the perceived role in the virtual ED. The group that normalized the virtual ED model saw value for patients (coherence) and was motivated by patient satisfaction witnessed (reflexive monitoring) at the end of the virtual appointment. By contrast, the other group did not find virtual ED work reflective of the perceived role of urgent care (cognitive participation) and felt their skills as ED physicians were underutilized. The limited ability to examine patients and a sense that patient issues were not fully resolved at the end of the virtual appointment caused frustration among the second group.

Conclusions

As further digital integration within the health care system occurs, it will be essential to support the evolution of staff skill sets to ensure physicians are satisfied with the care they are providing to their patients, while also ensuring the technology and process are efficient.

A Specialized Acute COVID-19 Outpatient Clinic at an Academic Medical Center

Health systems are challenged to provide equitable access to coronavirus disease 2019 (COVID-19) outpatient care during the pandemic. Infected patients may have difficulties accessing regular care and rely on emergency rooms. With the goal to improve system efficiencies and access to care, Stanford launched a designated outpatient COVID-19 "Care and Respiratory Observation of Patients With Novel Coronavirus" clinic in April 2020 in which all adult Stanford patients with newly diagnosed severe acute respiratory syndrome coronavirus 2 were offered follow-up for 2-3 weeks through video, telephone, and in-person encounters. Patients were triaged into risk categories and received home pulse oximeters based on a standardized protocol. Between April 15, 2020, and March 26, 2021, the Care and Respiratory Observation of Patients With Novel Coronavirus clinic enrolled 1317 patients. The clinic provided evaluation of Patients under Investigation, management of acute COVID-19 symptoms, care for COVID-19 patients after hospital discharge, clinical advice, and opportunities for research. The authors share crucial implementation lessons related to team agility, care personalization, and resource optimization.

Physicians’ Perceptions of Telemedicine Use During the COVID-19 Pandemic in Riyadh, Saudi Arabia: Cross-sectional Study (Preprint)

Background

Objective

Methods

Results

Conclusions

Physicians’ perception toward using telephone consultations during the COVID-19 pandemic in Korea

Background: As the world faced a pandemic caused by the coronavirus disease (COVID-19) outbreak in 2019, telemedicine quickly spread and was widely adopted. This was the first instance where telephone consultations were temporarily allowed in Korea. We used data from the 2020 Korean Physician Survey and analyzed the physicians’ perceptions of telephone consultations, the reasons for providing these consultations, and the level of physician satisfaction after providing it.Current Concepts: A total of 6,342 respondents were selected for the final analysis of the research results. Regardless of the COVID-19 pandemic, the data showed that most physicians had a negative perception (77.1%) toward the introduction of the telemedicine system. A third (31.1%) of physicians surveyed had provided medical treatment via telephone consultation. According to the position the physicians held, professors, fellows, self-employed physicians, and public health physicians had the most experience in this method of consultation. The use of telephone consultation was highest in the field of internal medicine (44.5%) treatment. Data also showed that most physicians (83.5%) who provided such consultations experienced difficulties in making a medical judgment that could ensure their patients’ safety.Discussion and Conclusion: The results of this study verified that physicians’ opinions about the telemedicine system differed according to service, area of specialization, region, and type of medical institution. A closer review and establishment of policy alternatives are required to explore the possible expansion of teleconsultations and related medical treatments in the future.

Implementing COVID-19 Surveillance Through Inter-Organizational Coordination: A Qualitative Study of Three Cities in Colombia

Introducing comprehensive surveillance is recommended as an urgent public health measure to control and mitigate the spread of coronavirus disease 2019 (COVID-19) worldwide. However, its implementation has proven challenging as it requires inter-organizational coordination among multiple healthcare stakeholders. The purpose of this study was to examine the role of soft and hard mechanisms in the implementation of inter-organizational coordination strategies for COVID-19 surveillance within Colombia, drawing on evidence from the cities of Bogotá, Cali and Cartagena. The study used a case study approach to understand the perspectives of local and national authorities, insurance companies and health providers in the implementation of inter-organizational coordination strategies for COVID-19 surveillance. Eighty-one semi-structured interviews were conducted between June and November 2020. The data were analysed by codes and categorized using New NVivo software. The study identified inter-organizational coordination strategies that were implemented to provide COVID-19 surveillance in the three cities. Both soft (e.g. trust and shared purpose) and hard mechanisms (e.g. formal agreements and regulations) acted as mediators for collaboration and helped to address existing structural barriers in the provision of health services. The findings suggest that soft and hard mechanisms contributed to promoting change among healthcare system stakeholders and improved inter-organizational coordination for disease surveillance. The findings contribute to evidence regarding practices to improve coordinated surveillance of disease, including the roles of new forms of financing and contracting between insurers and public and private health service providers, logistics regarding early diagnosis in infectious disease and the provision of health services at the community level regardless of insurance affiliation. Our research provides evidence to improve disease surveillance frameworks in fragmented health systems contributing to public health planning and health system improvement.

Improvise, Adapt, Overcome: How COVID-19 Transformed Inpatient Pediatric Gastroenterology

The coronavirus disease-2019 (COVID-19) pandemic has disrupted inpatient pediatric services across the United States, creating opportunities for innovation. A recent Webinar organized by the Telehealth for Pediatric GI Care Now working group and sponsored by the North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition provided insights into how inpatient pediatric gastroenterology services were affected and how physicians adapted during the crisis. These findings suggest the use of telehealth technologies may augment family communication and facilitate multidisciplinary care in the future. We anticipate that these innovative applications of telehealth will comprise a part of a toolkit for gastroenterologists to be used during this public health emergency and beyond.

Hands Off Yet All In: A Virtual Clerkship Pilot in the Ambulatory Setting During the COVID-19 Pandemic

PROBLEM

There is a paucity of guidance regarding implementation of telemedicine curricula at the clerkship level, particularly with students actively engaged in video and telephone encounters. The COVID-19 pandemic caused rapid shifts in the delivery of medical education to clerkship-level students. This article describes the successful pilot of a direct patient care, virtual health curriculum at the clerkship level and discusses lessons learned.

APPROACH

All 18 preceptors and 5 students at Stanford University School of Medicine, California, enrolled in the required 4-week family medicine clerkship in April 2020 were connected as virtual partners via a commercial video platform. The combined use of both this video program and Epic electronic health record (EHR) software as modes for teaching and patient care led to technical challenges and logistical hurdles. As part of an iterative process, clerkship leadership identified problems via preceptor and student interviews and integrated that feedback to create a model for delivering high-quality, clerkship-level clinical instruction during the COVID-19 shelter in place order.

OUTCOMES

Of those who completed an evaluation, the majority of preceptors (n = 16; 89%) and students (n = 4; 100%, 1 student did not respond) expressed satisfaction with the virtual, remote teaching model conducted over 37 clinic visits. A detailed 14-step process list resulted from identifying and addressing both audio and video technical challenges and is provided for use by other institutions that wish to implement this workflow.

NEXT STEPS

Future directions include assessing patient perspectives on the involvement of students in virtual visits, soliciting patient input for a more robust patient-physician-student virtual experience, and integrating a multiparty platform, when available, via the EHR to afford greater student autonomy.

Virtual Primary Care Implementation During COVID-19 in High-Income Countries: A Scoping Review

Background: The purpose of this scoping review was to map the challenges, strategies, and lessons learned from high-income countries that can be mobilized to inform decision-makers on how to best implement virtual primary care services during and after the COVID-19 pandemic. Findings of our scoping review identified the barriers and strategies within the Quadruple Aim components, which may prove to be an effective implementation strategy for virtual care adoption in primary care settings. Materials and Methods: The two concepts of virtual care and COVID-19 were searched in MEDLINE, EMBASE, and CINAHL on August 10, 2020, and Scopus was searched on August 15, 2020. The database searches returned 10,549 citations and an additional 766 citations were retrieved from searching the citations from the reference lists of articles that met all inclusion criteria. A total of 1,260 full-text articles were reviewed of which 38 articles met the eligibility criteria for inclusion in the review. Results: Seven key barriers and strategies were identified for the implementation of virtual primary care. Of the 38 articles included, the key barriers identified were equitable access to care (n = 20; 53%), lack of funding for virtual care (n = 14; 37%), negative patient and clinician perception (n = 11, 29%), lack of regulatory policies (n = 10, 26%), inadequate clinical workflows (n = 9, 21), lack of virtual care infrastructure (n = 8, 21%), and insufficient virtual care training and education (n = 5, 13%). Strategies included the following: increased funding (n = 15, 39%), improving clinical workflows (n = 13, 34%), appropriate education and training (n = 11, 29%), improving virtual care infrastructure and patient equity (n = 7, 18%), establishing regulatory policies (n = 5, 13%), and improving patient and clinician perceptions (n = 3, 7%). Conclusions: As many countries enter potential subsequent waves of the COVID-19 pandemic, applying early lessons learned to mitigate implementation barriers can help with the transition to equitable and appropriate virtual primary care services.

A qualitative study of high-performing primary care practices during the COVID-19 pandemic

BACKGROUND

Primary care practices have remained on the frontline of health care service delivery throughout the COVID-19 pandemic. The purpose of our study was to understand the early pandemic experience of primary care practices, how they adapted care processes for chronic disease management and preventive care, and the future potential of these practices' service delivery adaptations.

METHODS

We interviewed 44 providers and staff at 22 high-performing primary care practices located throughout the United States between March and May 2020. Interviews were transcribed and coded using a modified rapid assessment process due to the time-sensitive nature of the study.

RESULTS

Practices reported employing a variety of adaptations to care during the COVID-19 pandemic including maintaining safe and socially distanced access through increased use of telehealth visits, using disease registries to identify and proactively outreach to patients, providing remote patient education, and incorporating more home-based monitoring into care. Routine screening and testing slowed considerably, resulting in concerns about delayed detection. Patients with fewer resources, lower health literacy, and older adults were the most difficult to reach and manage during this time.

CONCLUSION

Our findings indicate that primary care structures and processes developed for remote chronic disease management and preventive care are evolving rapidly. Emerging adapted care processes, most notably remote provision of care, are promising and may endure beyond the pandemic, but issues of equity must be addressed (e.g., through payment reform) to ensure vulnerable populations receive the same benefit.

Telehealth challenges during COVID-19 as reported by primary healthcare physicians in Quebec and Massachusetts

BACKGROUND

The COVID-19 pandemic has driven primary healthcare (PHC) providers to use telehealth as an alternative to traditional face-to-face consultations. Providing telehealth that meets the needs of patients in a pandemic has presented many challenges for PHC providers. The aim of this study was to describe the positive and negative implications of using telehealth in one Canadian (Quebec) and one American (Massachusetts) PHC setting during the COVID-19 pandemic as reported by physicians.

METHODS

We conducted 42 individual semi-structured video interviews with physicians in Quebec (N = 20) and Massachusetts (N = 22) in 2020. Topics covered included their practice history, changes brought by the COVID-19 pandemic, and the advantages and challenges of telehealth. An inductive and deductive thematic analysis was carried out to identify implications of delivering care via telehealth.

RESULTS

Four key themes were identified, each with positive and negative implications: 1) access for patients; 2) efficiency of care delivery; 3) professional impacts; and 4) relational dimensions of care. For patients' access, positive implications referred to increased availability of services; negative implications involved barriers due to difficulties with access to and use of technologies. Positive implications for efficiency were related to improved follow-up care; negative implications involved difficulties in diagnosing in the absence of direct physical examination and non-verbal cues. For professional impacts, positive implications were related to flexibility (teleworking, more availability for patients) and reimbursement, while negative implications were related to technological limitations experienced by both patients and practitioners. For relational dimensions, positive implications included improved communication, as patients were more at ease at home, and the possibility of gathering information from what could be seen of the patient's environment; negative implications were related to concerns around maintaining the therapeutic relationship and changes in patients' engagement and expectations.

CONCLUSION

Ensuring that health services provision meets patients' needs at all times calls for flexibility in care delivery modalities, role shifting to adapt to virtual care, sustained relationships with patients, and interprofessional collaboration. To succeed, these efforts require guidelines and training, as well as careful attention to technological barriers and interpersonal relationship needs.

Financial Incentives for Medical Assistants: A Mixed-Methods Exploration of Bonus Structures, Motivation, and Population Health Quality Measures

PURPOSE

Medical assistants (MAs) have seen their roles expand as a result of team-based primary care models. Unlike their physician counterparts, MAs rarely receive financial incentives as a part of their compensation. This exploratory study aims to understand MA acceptability of financial incentives and perceived MA control over common population health measures.

METHODS

We conducted semistructured focus groups between August and December of 2019 across 10 clinics affiliated with 3 institutions in California and Utah. MAs' perceptions of experienced and hypothetical financial incentives, their potential influence on workflow processes, and perceived levels of control over population health measures were discussed, recorded, and qualitatively analyzed for emerging themes. Perceived levels of control were further quantified using a Likert survey; measures were grouped into factors representing vaccinations, and workflow completed in the same day or multiple days (multiday). Mean scores for each factor were compared using repeated 1-way ANOVA with Tukey-Kramer adjustment.

RESULTS

MAs reported little direct experience with financial incentives. They indicated that a hypothetical bonus representing 2% to 3% of their average annual base pay would be acceptable and influential in improving consistent performance during patient rooming workflow. MAs reported having greater perceived control over vaccinations (P <.001) and same-day measures (P <.001) as compared with multiday measures.

CONCLUSIONS

MAs perceived that relatively small financial incentives would increase their motivation and quality of care. Our findings suggests target measures should focus on MA work processes that are completed in the same day as the patient encounter, particularly vaccinations. Future investigation is needed to understand the effectiveness of MA financial incentives in practice.

Increased Utilization of Virtual Visits and Electronic Approaches in Clinical Research During the COVID-19 Pandemic and Thereafter

OBJECTIVES

To assess the impact of the COVID-19 pandemic on clinical research and the use of electronic approaches to mitigate this impact.

METHODS

We compared the utilization of electronic consenting, remote visits, and remote monitoring by study monitors in all research studies conducted at Mayo Clinic sites (Arizona, Florida, and Minnesota) before and during the COVID-19 pandemic (ie, between May 1, 2019 and December 31, 2020). Participants are consented through a participant-tracking system linked to the electronic health record.

RESULTS

Between May 2019, and December 2020, there were 130,800 new consents across every modality (electronic and paper) to participate in a non-trial (107,176 [82%]) or a clinical trial (23,624 [18%]). New consents declined from 5741 in February 2020 to 913 in April 2020 but increased to 11,864 in November 2020. The mean (standard deviation [SD]) proportion of electronic consent increased from 22 (2%) before to 45 (20%) during the pandemic (P=.001). Mean (SD) remote electronic consenting increased from 0.3 (0.5%) to 29 (21%) (P<.001). The mean (SD) number of patients with virtual visits increased from 3.5 (2.4%) to 172 (135%) (P=.003) per month between pre-COVID (July 2019 to February 2020) and post-COVID (March to December 2020) periods. Virtual visits used telemedicine (68%) or video (32%). Requests for remote monitor access to complete visits increased from 44 (17%) per month between May 2019 and February 2020 to 111 (74%) per month between March and December 2020 (P=.10).

CONCLUSION

After a sharp early decline, the enrollment of new participants and ongoing study visits recovered during the COVID-19 pandemic. This recovery was accompanied by the increased use of electronic tools.

Physician Satisfaction With Telemedicine During the COVID-19 Pandemic: The Mayo Clinic Florida Experience

OBJECTIVE

To evaluate physician perceptions and attitudes toward telemedicine use at a tertiary care academic institution in northeast Florida during the coronavirus disease 2019 pandemic.

PATIENTS AND METHODS

An anonymous 38-question cross-sectional survey was developed using Qualtrics survey software (Qualtrics) and e-mailed to all staff physicians from all specialty disciplines at Mayo Clinic in Florida. The survey was open from August 17, 2020, through September 1, 2020. Collected data included general demographic characteristics and employment information, attitude and experience with telemedicine use before and during the coronavirus disease 2019 pandemic, perception of patients' experience, and the effect of telemedicine on burnout.

RESULTS

The survey was distributed to 529 eligible physicians at our institution, with 103 physicians responding (20%). The distribution of specialties was 22% primary care specialties, 41% other internal medicine subspecialties, and 18% surgical specialties. Collectively, 63% found comparable quality of care when provided virtually (vs in-person) whereas 80% perceived telemedicine as cost-effective. A total of 76% of physicians felt that telemedicine increased flexibility and control over patient care activities, with 36% reporting improved work-life balance and 30% reporting improved burnout symptoms. Overall, 42% preferred using telemedicine over in-person visits when possible.

CONCLUSION

Physicians generally had positive attitudes regarding the adoption of telemedicine and perceived that the quality of health care delivery as generally comparable to in-person care. Future studies are needed to explore attitudes regarding telemedicine after the pandemic and how this virtual technology may be further used to improve physicians' professional and personal well-being.

Primary Care Informatics Response to Covid-19 Pandemic: Adaptation, Progress, and Lessons from Four Countries with High ICT Development

OBJECTIVE

Internationally, primary care practice had to transform in response to the COVID pandemic. Informatics issues included access, privacy, and security, as well as patient concerns of equity, safety, quality, and trust. This paper describes progress and lessons learned.

METHODS

IMIA Primary Care Informatics Working Group members from Australia, Canada, United Kingdom and United States developed a standardised template for collection of information. The template guided a rapid literature review. We also included experiential learning from primary care and public health perspectives.

RESULTS

All countries responded rapidly. Common themes included rapid reductions then transformation to virtual visits, pausing of non-COVID related informatics projects, all against a background of non-standardized digital development and disparate territory or state regulations and guidance. Common barriers in these four and in less-resourced countries included disparities in internet access and availability including bandwidth limitations when internet access was available, initial lack of coding standards, and fears of primary care clinicians that patients were delaying care despite the availability of televisits.

CONCLUSIONS

Primary care clinicians were able to respond to the COVID crisis through telehealth and electronic record enabled change. However, the lack of coordinated national strategies and regulation, assurance of financial viability, and working in silos remained limitations. The potential for primary care informatics to transform current practice was highlighted. More research is needed to confirm preliminary observations and trends noted.

Telehealth in Primary Healthcare: A Portrait of its Rapid Implementation during the COVID-19 Pandemic

OBJECTIVE

This study documents the adoption of telehealth by various types of primary healthcare (PHC) providers working in teaching PHC clinics in Quebec during the COVID-19 pandemic. It also identifies the perceived advantages and disadvantages of telehealth.

METHOD

A cross-sectional study was conducted between May and August 2020. The e-survey was completed by 48/50 teaching primary care clinics representing 603/1,357 (44%) PHC providers.

RESULTS

Telephone use increased the most, becoming the principal virtual modality of consultation, during the pandemic. Video consultations increased, with variations by type of PHC provider: between 2% and 16% reported using it "sometimes." The main perceived advantages of telehealth were minimizing the patient's need to travel, improved efficiency and reduction in infection transmission risk. The main disadvantages were the lack of physical exam and difficulties connecting with some patients.

CONCLUSION

The variation in telehealth adoption by type of PHC provider may inform strategies to maximize the potential of telehealth and help create guidelines for its use in more normal times.

COVID-19's impact on primary care and related mitigation strategies: A scoping review

Background

The COVID-19 pandemic has had a substantial impact on primary care throughout Europe and globally.

Objectives

This review aims to ascertain how the pandemic has impacted primary care service provision/patients and to examine strategies to mitigate these impacts.

Methods

The scoping review framework comprised a six-stage process developed by Arksey and O'Malley. The search process was guided by the Joanna Briggs Institute three-step search strategy and involved searching the PubMed, Embase, Scopus, CINAHL Plus, and Cochrane Library databases. The review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. A thematic analysis approach by Braun and Clarke was used to interpret the findings.

Results

Thirty-two studies from 18 countries and six continents were included, 13 reported original research, three were reviews, and 16 were case reports reporting healthcare systems’ experiences of dealing with the pandemic. Emerging themes concerned the COVID-19 pandemic’s impact on primary care service provision and patients, the impact of the rapid transition to telemedicine due to COVID-19 on primary care, and strategies to mitigate the impact of COVID-19 on primary care (i.e. infection prevention and control measures, alternatives/modifications to traditional service delivery or workflow, government policy responses, and education).

Conclusion

The COVID-19 pandemic has considerably impacted on primary care at both service and patient levels, and various strategies to mitigate these impacts have been described. Future research examining the pandemic’s ongoing impacts on primary care, as well as strategies to mitigate these impacts, is a priority.

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.

Strategies to Improve Bedside Clinical Skills Teaching

The bedside encounter between a patient and physician remains the cornerstone of the practice of medicine. However, physicians and trainees spend less time in direct contact with patients and families in the modern healthcare system. The current pandemic has further threatened time spent with patients. This lack of time has led to a decline in clinical skills, and a decrease in the number of faculty who are confident in teaching at the bedside. In this review we offer several strategies to get physicians and trainees back to the bedside to engage in clinical skills teaching and assessment. We recommend that providers pause before bedside encounters to be present with patients and learners and develop clear goals for a bedside teaching session. We suggest that clinical teachers practice an evidence-based approach, including a hypothesis-driven physical examination. We encourage the use of point-of-care technology to assist in diagnosis and allow learners to calibrate traditional physical exam skills with real-time visualization of pathology. Tools like point-of-care ultrasound can be powerful levers to get learners excited about bedside teaching, and to engage patients in their clinical care. We value telemedicine visits as unique opportunities to engage with patients in their home environment and to participate in patient-directed physical exam maneuvers. Finally, we recommend that educators provide feedback to learners on specific clinical exam skills, whether in the clinic, the wards, or during dedicated clinical skills assessments.

Provider Perceptions of Virtual Care During the Coronavirus Disease 2019 Pandemic: A Multispecialty Survey Study

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has led to a dramatic increase in virtual care (VC) across outpatient specialties, but little is known regarding provider acceptance of VC.

OBJECTIVE

The objective of this study was to assess provider perceptions of the quality, efficiency, and challenges of VC versus in-person care with masks.

DESIGN

This was a voluntary survey.

PARTICIPANTS

Mental health (MH), primary care, medical specialty, and surgical specialty providers across the 8 VA New England Healthcare System medical centers.

MEASURES

Provider ratings of: (1) quality and efficiency of VC (phone and video telehealth) compared with in-person care with masks; (2) challenges of VC; and (3) percentage of patients that providers are comfortable seeing via VC in the future.

RESULTS

The sample included 998 respondents (49.8% MH, 20.6% primary care, 20.4% medical specialty, 9.1% surgical specialty; 61% response rate). Most providers rated VC as equivalent to or higher in quality and efficiency compared with in-person care with masks. Quality ratings were significantly higher for video versus phone (χ2=61.4, P<0.0001), but efficiency ratings did not differ significantly. Ratings varied across specialties (highest in MH, lowest in SS; all χ2s>24.1, Ps<0.001). Inability to conduct a physical examination and patient technical difficulties were significant challenges. MH providers were comfortable seeing a larger proportion of patients virtually compared with the other specialties (all χ2s>12.2, Ps<0.01).

CONCLUSIONS

Broad provider support for VC was stratified across specialties, with the highest ratings in MH and lowest ratings in SS. Findings will inform the improvement of VC processes and the planning of health care delivery during the COVID-19 pandemic and beyond.

Inpatient Telemedicine Implementation as an Infection Control Response to COVID-19: Qualitative Process Evaluation Study

Background

The COVID-19 pandemic created new challenges to delivering safe and effective health care while minimizing virus exposure among staff and patients without COVID-19. Health systems worldwide have moved quickly to implement telemedicine in diverse settings to reduce infection, but little is understood about how best to connect patients who are acutely ill with nearby clinical team members, even in the next room.

Objective

To inform these efforts, this paper aims to provide an early example of inpatient telemedicine implementation and its perceived acceptability and effectiveness.

Methods

Using purposive sampling, this study conducted 15 semistructured interviews with nurses (5/15, 33%), attending physicians (5/15, 33%), and resident physicians (5/15, 33%) on a single COVID-19 unit within Stanford Health Care to evaluate implementation outcomes and perceived effectiveness of inpatient telemedicine. Semistructured interview protocols and qualitative analysis were framed around the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework, and key themes were identified using a rapid analytic process and consensus approach.

Results

All clinical team members reported wide reach of inpatient telemedicine, with some use for almost all patients with COVID-19. Inpatient telemedicine was perceived to be effective in reducing COVID-19 exposure and use of personal protective equipment (PPE) without significantly compromising quality of care. Physician workflows remained relatively stable, as most standard clinical activities were conducted via telemedicine following the initial intake examination, though resident physicians reported reduced educational opportunities given limited opportunities to conduct physical exams. Nurse workflows required significant adaptations to cover nonnursing duties, such as food delivery and facilitating technology connections for patients and physicians alike. Perceived patient impact included consistent care quality, with some considerations around privacy. Reported challenges included patient–clinical team communication and personal connection with the patient, perceptions of patient isolation, ongoing technical challenges, and certain aspects of the physical exam.

Conclusions

Clinical team members reported inpatient telemedicine encounters to be acceptable and effective in reducing COVID-19 exposure and PPE use. Nurses adapted their workflows more than physicians in order to implement the new technology and bore a higher burden of in-person care and technical support. Recommendations for improved inpatient telemedicine use include information technology support and training, increased technical functionality, and remote access for the clinical team.