Experiences of Older Adults with Heart Failure Using Telemedicine During the COVID-19 Pandemic: A Qualitative Study

Abstract

Background:

Telemedicine (TM) usage increased rapidly during the COVID-19 pandemic. This study is part of a larger mixed-methods study comparing TM and in-person visits of older adults with heart failure (HF) and describes patient’s TM experiences during the pandemic.

Methods:

This study employed qualitative design using survey responses and individual interviews. Study eligibility requirements included >55 years old, HF diagnosis, and TM visit between September 1, 2020 and May 31, 2021, at one of two participating health systems in the southern United States.

Results:

Twenty-two TM recipients completed qualitative interviews, and 91 of 125 online survey respondents answered open-ended questions. Data were gathered, sorted, and revealed five themes.

Discussion:

Interview respondents identified benefits, e.g., convenience, inclusion, decreased exposure, and problems, e.g., connectivity issues, inadequate equipment, and medical conditions impacting use. Recommendations included allocating sufficient appointment time, tailoring visits, and increasing written communication. This study was part of a larger clinical trial registered at ClinicalTrials.gov: NCT04304833.

Introduction

Heart failure (HF) affects more than 6.2 million adults in the United States,¹ and numbers continue to rise.^2,3 In 2018, HF was the second most common cause of hospitalization in people aged ≥65 years.⁴ In 2012, the estimated annual cost of HF care was approximately $30.7 billion and is expected to double by 2030.^3,5 Early diagnosis and treatment of HF can lead to improved quality and length of life and may delay hospitalization, thus reducing the associated health care costs.³

HF requires close monitoring and interdisciplinary care, as it necessitates the use of medication and lifestyle changes.^6
–8 Patients typically have routine quarterly in-person clinic appointments to detect early signs of worsening clinical status, modify management, and prevent hospitalization.⁶ During the first year of the COVID-19 pandemic, care delivery shifted to telemedicine (TM) to maintain social distance and protect vulnerable populations, including HF patients, at increased risk of adverse events from COVID-19 infection.^3,9,10

Before COVID-19, barriers to TM adoption among older adults included poor video quality, slow connection speeds, and lack of high-speed broadband access, particularly in rural communities.^11

–14 Additionally, the lack of technology support, frustration with new technology, and sensory impairments, such as hearing and vision deficiencies, among older adults remain problematic.^14
–16 Despite these barriers to adoption, TM has demonstrated benefits. A large study conducted to evaluate the effectiveness of TM use in patients with chronic diseases found that patients who used TM had reduced mortality rates (8.3–4.6%) and an 11% reduction in hospitalizations over a 12-month period.¹⁷ TM services can also help to reduce unnecessary hospitalizations and nursing home care, reduce out-of-pocket costs, and provide ongoing support to help older adults and their caregivers, thus reducing stress and increasing well-being.¹⁸ Moreover, TM helped providers offer preventive and treatment care and facilitate continuity of care during the COVID-19 pandemic.¹⁹

Despite the increase in TM use during the COVID-19 pandemic, older adults struggled to use TM during the early stages of the pandemic.^13
–15 Issues concerning TM compared to in-person visits for older adults must be addressed to improve TM visits.¹⁴ The purpose of this study was to describe the experiences of older community-dwelling adults living with HF during the pandemic.

Methods

This study is part of a larger study comparing TM and in-person visits of older adults with HF during the pandemic in two health systems in the southern United States. We used an interpretive phenomenology approach to understand the lived experiences of older adults with HF.²⁰

All study procedures were approved by the University of Arkansas for Medical Sciences Institutional Review Board (#261060) and the University of Tennessee Health Science Center Institutional Review Board (#20–07798-IAA). To be eligible for the study, participants had to be 55 years or older, have a health care visit between September 1, 2020, and May 31, 2021, and have a diagnosis of HF. Consent to participate in the qualitative study was obtained at the beginning of each interview. For more detail, see the Supplementary Data S1.

The qualitative interview guide and open-ended TM questions were based on the literature and previous qualitative TM studies.^21
–23 The interview guide and open-ended survey questions were reviewed and modified based on feedback from content experts (Table 1). Two open-ended questions from the survey were pertinent to the study and are included in the analysis.

Table 1.

Qualitative Interview Guide for Telemedicine Health Care Visits

QUESTIONS	PROBE QUESTIONS
1. Tell me how your Telemedicine visit went for you.	a. What did you like/not like about it? b. How did this visit impact your health condition that was the purpose for the visit? c. What was the result of the visit?
2. During your telemedicine visit, do you feel that your doctor listened to you?	a. Was your provider able to give enough information for you to understand your diagnosis and/or treatment? b. Did you feel like your provider understood your health concerns? c. Do you feel like you had a chance to make your wishes for the visit or your health known? d. How would you rate your visit?
3. Tell me how you got set up for the visit?	a. Was it easy to get set up/connected with your provider? b. Was it hard to get set up? c. Did anyone at the health system help you get set up? d. Did you have any problems with the equipment during the visit? e. What could we have done better before, during, or after this visit to make it better for you? f. Tell me about your comfort level in using technology? [email, FaceTime, streaming videos, text messaging, social media]
4. Did this visit change the way you think about Telemedicine?
5. From the survey, it says you prefer a [TM or in-person] visit in the future. Tell me more about why you say that.
6. [Only ask if needed] Is there someone, a caregiver, who normally goes with you to the doctor’s office or “helps” you remember the instructions or helps you with the care of your heart failure?	a. From your survey, you stated that [x person or no one] attended the TM visit with you.

All interviews were conducted via telephone between August 15 and October 8, 2021, and lasted 30–60 min. All interviews were recorded, transcribed, and uploaded into a text-based data management program, MAXQDA. Authors 1 and 2 led the analysis using a two-phase approach of content analysis with a constant comparison analytic procedure to identify themes. Please see Supplementary Data S2 for additional detail about qualitative data collection, analysis, rigor statements, and the Standards for Reporting Qualitative Research checklist.²⁴

Results

In total, 790 participants completed the parent study survey, and of this number, 125 had TM appointments and 66 agreed to be contacted for a qualitative interview. We contacted all 66, with 22 completing an interview. Of these, 45.5% were males and 54.5% were females. The mean age was 69.5, with 54.5% 55–71 years old and 45.5% over 71 years old. Most of the participants were White (77.3%), lived in urban areas (72.7%), and had an annual income of less than $50,000 (77.3%). Approximately half of the participants had a college degree (50.1%).

Of the open-ended survey respondents, 91 of the 125 answered the open-ended questions When asked how the staff could have improved the TM visit, 19 (20.9%) of the 91 participants gave advice on how to improve the visit, 49 (53.8%) had a positive comment about their TM visit or provider, and 23 (25.3%) typed none or N/A. When asked if there was anything else they would like to say about their visit, 88 participants provided responses. Nineteen (21.6%) provided negative comments, 24 (27.3%) typed positive comments, and 45 (51.1%) typed none or N/A. The open-ended survey responses were uploaded into MAXQDA along with the interview data and analyzed together.

Using content analysis, we identified code words, defined them, and used them to guide the coding of each interview. Next, we grouped segments of interview data with the same codes to form linked subthemes and, eventually, more global overarching themes. Five themes emerged: (1) Benefits of using TM; (2) Problems Using TM; (3) Preparation of TM Appointment; (4) Feeling Connected with Provider; and (5) Recommendations to Improve TM Appointments. Each theme and the corresponding subthemes are discussed below (See Table 2 for supporting quotes).

Table 2.

Qualitative Themes and Sub-Themes^a

THEMES	SUBTHEMES	QUOTES
Benefits of Using Telemedicine	Convenient	Enjoyed not having to leave home (SR).Yes, I liked it because we did not have to go (to the) office during the COVID (SR).I live in (name of small rural town) which is about 6 h round trip drive (from cardiac clinic at the urban health system) and my niece has to drive me (SR).I like it because it’s more comfortable and much easier than getting out and traveling (SR).I live 3 h away from (cardiac clinic at the urban health system) that’s the main reason but a I had a great experience with telemedicine appointment (QI).
	Include others-family, caregivers	Because it was more convenient for me and for my daughter to sit in on the visit with my doctor, I liked it very much thank you (SR).
	Protect health with less exposure	Out of concern for my health the doctor said we would do the visit via telemedicine (SR).It was more convenient and safer to have a telephone consult (SR).So stressed that if I contract the (corona) virus, I will die (SR).Yes, COVID-19 was very strong, I was afraid to leave my home (SR).Right now, I just won’t hardly go to the doctor because of the pandemic. I did go in, I believe Friday of last week and had a flu shot, but. I was really uncomfortable being in there. I didn’t feel safe (QI).
	Timeliness	Everything worked, I spent what time I needed, got info shared and had no questions. End of story (SR).It’s available for those that need it in a hurry. If I had an emergency, then I would do that. I would go with telemedicine (QI).
Problems Using Telemedicine	Lack of experience using technology	I balked at video at first. They let me come in for the previous appointment. The time before that, I cancelled because of video (SR).I would video again now that I have crossed that “privacy” line (SR).I don’t have a problem with it (telemedicine) unless I have to troubleshoot. Troubleshooting is not good, but if all the equipment works well, I had no problem with that (QI).I get nervous trying to set it up because sometimes it’s hard to understand how to... You follow directions, but they’re not always very clear. Typically, my kids have done these things before (QI).
	Limited available equipment	I’m 80 and I’m not a techno savvy. But I’m just not good with technology. I don’t even own a computer. I own a tablet and my phone. So no, I’m not very good at it (QI).I think I will be better next appointment. (A telemedicine appointment) is hard with cellphone. (SR).
	Broadband connectivity	I live in the middle of (nowhere), never never land, and we do not have internet real well here. So, we can’t do a visit here (QI).
	Chronic illness/medical limitations (hearing, arthritis, vision)	I usually tried to (connect) on Wednesday when (my daughter) was going to be here and then she would connect me up....because my vision is impaired. I’m legally blind. It’s not because I don’t know how but can’t see (QI).It probably was easier if I had somehow had the instructions printed before me, like I said, having Parkinson’s when you get nervous, the shaking becomes a lot more intense, therefore it’s harder to concentrate. And if, and when I did it again, I would prefer to have written instructions in front of me that I could follow (QI).
Preparation for Telemedicine Appointment	Making arrangements with others to enable TM visit	And out of concern for me needing transportation (for an in-person visit). (My doctor) said he think (TM) would be better… . (SR).And to make arrangement for us to get to where we can... I live in the middle of (nowhere), never never land, and we do not have internet real well here. So, we can’t do a visit here. So, we had to make arrangements with his daughter in town so that she had no appointments in her office. And we had to make the arrangements with the doctor so that we could be there on time (QI).
Preparation for Telemedicine Appointment	HC system assistance for set up (or lack thereof)	I think everything is good, who can improve great (SR).Better upfront training on what to do, how to do the call (SR).I’m grateful that they set it up. I’m appreciative of being able to use the telephone and I hope it continues (SR).Well, his nurses would always call and give me the time and number, but you had to put it in or whatever. I got real good with remembering numbers and stuff like that. I just put them in my head and give them to whoever was going to do it for you (QI).(better if the HC system) Advising me ahead of time that that would be how I would be seeing my doctor (SR).It would help if (we) had a specific phone number to be able to reach my PCP’s office (SR).
Feeling Connected with Provider	Previous interaction with provider (known vs. unknown)	There is no way to improve, in my opinion. I am extremely satisfied with my care by my provider (SR).I enjoyed the telecommunication appointment I had with my PCP and the staff it was interesting and new-wave (SR).She confused the situation even more! After I saw my regular doctor, the problem has occurred again, and they are not treating it serious. (SR).I would like to meet my Dr. & nurse (SR).I am extremely satisfied with my care by my provider (SR).
Feeling Connected with Provider	Provider communication style	The provider gave good information so that I could understand it (SR).She was very clear and concise, and listened to and answered any questions I had. There were no problems (SR).(My usual doctor) has always taken time by telemedicine or in person to listen and care for me. The nurse on call has always been informative and respectful (SR).I really only want to talk to (usual provider). He listens and has so much patience and empathy (QI).
Recommendations to Improve Telemedicine	Printed patient educational materials or training for using TM	Better upfront training on what to do, how to do the call (SR). I used to could remember instructions on how to do things but now I find that I need to print them out and refer to them on how to do certain things. And when you talk about new technology and at 71 it’s hard to remember how to get on the portal and do all that stuff you supposed to do for a virtual visit (QI).
Recommendations to Improve Telemedicine	Better provider communication style	Seem more interested in your care (SR).Talking a little slower, breaking down the language that is used, showing lab results, MRI results to me as the patient would be helpful and not just talking about them… Even if I’m on a telemedicine visit, you have me sign in and I wait for 10 or 15 min before he signs on. But then I feel rushed for him to get through the visit, and I just don’t feel like that’s good patient care. I just don’t (SR).
Recommendations to Improve Telemedicine	Better communication before and after the TM visit	The doctor didn’t help with my situation and I’m still in need of help and I keep message them in MyChart (patient portal)!! (SR).Would like written information about the visit and what was talked about with provider (QI).Better communication with me and my family (SR).
Recommendations to Improve Telemedicine	More time for the TM visit	Taking more time with me in explaining my procedure (SR).Had talked a bit longer (during the TM visit) (SR).Spend more time with patient (SR).Making (more) frequent appointments (SR).

This table includes quotes from the survey responses and interviews.

HC, health care; QI, qualitative interview; SR, survey response; TM, telemedicine.

THEME 1: BENEFITS OF USING TM

This theme was defined as participants’ positive perceptions of using TM and included four subthemes. All participants discussed the convenience of using TM (Subtheme 1). One said, “I like it because it’s more comfortable and much easier than getting out and traveling,” whereas another stated, “We live 250 miles away, so it is more convenient.” Others discussed the benefit of having a family member and/or caregiver present during TM appointments (Subtheme 2). In the early phase of the COVID-19 pandemic no one other than the actual patient was allowed during in-person appointments.²⁵ For an older adult with HF who may have difficulty managing a variety of prescribed medications, this was an important benefit of a TM appointment. Although the third subtheme, Timeliness, was not frequently mentioned, it was notable to those who discussed it. Participants mentioned that access to prompt appointments for unexpected health problems was an advantage of TM and contrasted with the significantly longer delays for in-person appointments.

Most participants discussed Protect Health with Less Exposure (Subtheme 4), which was perceived as a weighty benefit. One participant stated, “It was safer to have the visit via phone than to have to be at clinic with COVID epidemic.” Another stated, “Well, right now, I just won’t hardly go to the doctor because of the pandemic. I did go in … last week, but I was uncomfortable being in there. I didn’t feel safe.” Another stated, “I was so stressed that if I contract the virus, I might die.” The participants were very aware that they were considered “high-risk” due to their age and comorbidity of HF and believed TM was a much safer option for appointments.

THEME 2: PROBLEMS USING TM

This global theme encapsulated data related to perceived problems using TM and has four subthemes: Lack of Experience Using Technology, Limited Available Equipment, Broadband Connectivity, and Chronic Illness/Medical Limitations. Most participants had never had a previous TM appointment, and many had limited experience using technology. Lack of experience using anything except FaceTime was a common trend. One woman stated, “I cannot do video unless it is FaceTime, so the visit was phone conversation only.” Another participant stated, “When you talk about new technology and at 71 (years old) it’s hard to remember how to get on the [patient] portal and do all that stuff you’re supposed to do for a virtual visit.” Still, others had limited equipment—often lacking a computer or tablet—but most owned the smartphone they used for the TM visit. All rural-dwelling participants discussed issues related to broadband connectivity. Some rural participants had to drive to other locations, such as a family member’s home or office to connect to the TM visit.

A key group of data emerged that focused on medical issues impacting their technology use. The study participants had a variety of comorbidities that affected their physical ability to use TM. For instance, one was legally blind, and one recently had a stroke. One participant with severe arthritis experienced trouble holding her smartphone for the TM visit due to joint pain (she had no tablet or computer and held the phone for the entire visit). Some participants encountered issues remembering how to access the TM appointment. Moreover, they identified that the lack of step-by-step printed directions on how to access the site for TM visits was problematic, especially for those with memory issues and/or limited technology experience.

THEME 3: PREPARATION FOR TM APPOINTMENT

We aggregated data into patient or health care system preparations. Most participants discussed the necessity of making prearrangements for the TM appointment (Subtheme 1). Due to the lack of digital health competency, access to a device, and/or access to broadband connectivity, many patients had to coordinate their TM visit with others. For instance, one participant said, “We had to make arrangements with [husband’s daughter] in town….[to connect] in her office.” Others typically arranged with family members to come to their homes to connect to the TM appointment. Often, they had to arrange their TM appointment around their family members’ work or personal schedules.

Patients who had a device often stated that they took steps to ensure they were ready for the TM appointment. For instance, one person said, “I made sure my phone was charged and I had prepared a list of all medications that I’m currently using… Because I knew they would ask about medication.”

On the health care system side (Subtheme 2), some clinics prioritized ease of access for patients to connect to the TM visit site. For example, one patient said, “So, when he called, all I had to do was just answer, punch FaceTime, and we were connected. I could see him, and he could see me.” Some voiced that the office staff did not provide adequate instructions or assistance with the initial TM visit. These few people were the ones who expressed dissatisfaction with TM visits.

THEME 4: FEELING CONNECTED WITH PROVIDER

Most patients wanted a TM visit with their usual provider (Subtheme 1). TM visits with an unknown provider made it more difficult for them to feel connected with their provider. For instance, one participant expressed, “She (new provider) didn’t have any patience when I tried to explain my concerns about the medicine that she wanted me to take at a higher dose. I really only want to talk to Dr. D (my usual doctor). He listens and has so much patience and empathy.” Another stated that a new provider wore a mask during the TM visit, which made the patient feel disconcerted. In contrast, when the provider was known, participants readily felt connected and understood. As one participant noted, “They were thorough. They stayed on the line as long as they felt I needed to be there with them to answer my questions. So again, it’s because Dr. M (usual provider) knew who I was from having seen me in-person before for many years.”

The above quote also emphasizes the importance of positive provider communication (Subtheme 2), such as listening carefully, being attentive, and taking time to explain using understandable language. One participant provided this example: “The Doctor has always taken time by telemedicine or in person to listen and care for me. The nurse on call has always been informative and respectful.” Another important aspect of care was follow-up after the visit. One patient explained, “I appreciate that the Doctor did a follow-up after the telemed visit via phone to check to see how things were going after she made a few changes with…my medication. She was very through [sic] and caring.” However, not everyone received any follow-up. Those who did not discuss how useful it would have been to receive a summary of the visit, they had a record of medication changes or other issues discussed.

THEME 5: RECOMMENDATIONS TO IMPROVE TM APPOINTMENTS

Although most participants had a positive experience despite having limited to no experience using technology, most were pleased with the overall experience. One participant summarized, “I really liked it, and I understand it because of the COVID situation.” Even those reluctant to have a TM visit perceived its need and thought it was beneficial. After completing an initial TM visit, one participant stated, “I don’t like telephone appointments, but I can learn to like it.”

Participants expressed the need for educational materials or training before TM visits (Subtheme 1). They wanted printed instructions on how to connect to the visit and prior notification of the type of TM visit. One participant said, “I’m 71 years old, and with Parkinson’s, you forget. In other words, I used to could remember instructions on how to do things, but now I find that I need to print them out and refer to them on how to do certain things.” Similarly, another respondent asked for “better upfront training on what to do, how to do the call.”

Many participants discussed provider communication style and how it could be improved (Subtheme 2). They want providers who are interested in them and their health, such as one participant remarking that their TM visit could have been improved by their provider “being more virtuous and listening and caring [about] what I have to say.” Another participant discussed that their provider had a mask on during the TM visit and, as a result, they could not determine if it was their usual provider or a resident. Another was frustrated by the amount of time spent waiting in the virtual waiting room for the visit; once their provider joined the virtual call, the provider rushed through the visit.

A similar subtheme (3) emerged, with participants requesting more time for TM visits or more frequent TM visits. Participants discussed how they wanted their providers to take more time explaining procedures or medications, as well as listening to their concerns and responding to their questions. One participant expressed that the TM visit could have been improved by the provider “spending more time with the patient.”

Another factor of concern for patients was communication with the provider and health care system before and after the TM visit (Subtheme 4). One participant reported using the patient portal, but communication, such as follow-up information after the visit, was lacking. Additional information about their care team, such as timely notification and communication concerning changes in providers or case managers, was also important to some participants.

Discussion

Before the pandemic, federal regulations greatly limited where TM could be performed. A fee-for-service virtual clinic visit in a patient’s home was eligible only when the patient was in a designated rural area. Otherwise, patients needed to travel to a regional TM clinic to connect with their provider and receive care.

During the COVID-19 pandemic, regulatory suspension (waiver under Section 1135 of the Social Security Act²⁶) permitted the originating site of service to be the patient’s home. Additionally, payment for telephone visits and evaluation and management crosswalks for coding TM visits expanded care while decreasing the administrative complexity.^26,27 Both health systems in this study implemented and/or expanded TM to provide care. Some clinics and service lines in these health systems were able to seamlessly integrate virtual care, whereas others struggled to implement TM. Hence, the implementation of TM varied from provider-to-provider and clinic-to-clinic in both health systems.

Experiences of participants in our study also varied. The majority appreciated the convenience of TM and stated after their first visit that they would use it again. Of survey respondents, 53.8% reported a variety of positive comments. For example, those who had TM visits enjoyed the convenience, the ability of family members or caregivers to attend, limited exposure to COVID-19, and the ability to receive timely care. Although most participants reported a positive experience, as stated above, 20.9% gave advice on how to improve the visit, and 21.6% reported a negative TM experience. Participants experienced TM limitations due to issues such as lack of experience using technology, limited devices available for use, insufficient broadband connectivity, rushed provider visits, and/or poor health. Some of these issues have been reported in other studies and support our findings.¹³ Many older adults with HF also have other chronic health conditions or limitations, so it is essential that providers and clinics be cognizant of these when scheduling a TM visit. It is also vital to determine whether a family member/caregiver should join in the visit or assist the adult in connecting with the TM visit before scheduling.

Participants’ overall recommendations on ways to improve TM visits included the ability to see their typical provider, increased time for the visit especially if it is a new provider, written instructions before the visit on how to connect, and an easily accessible after-visit summary. Recommendations to improve TM visits are summarized (Table 3). We acknowledge that these recommendations are based on a limited number of participants who were patients in two southern health care systems. Older persons living with HF in other regions may express different views and experiences. This study was also conducted early in the COVID-19 pandemic; therefore, health systems and providers might have implemented improvements in their TM care since the study was conducted.

Table 3.

Key Takeaways for Providers and Health Systems to Improve TM Visits for Older Adults

Additional TM Training and/or Printed Instructions o

Ask the older adult if they need additional training before the visit

Ask the older adult if they would like printed instructional materials

Don’t Rush or Hurry Though a TM Visit o

Allot the same amount of time as they would with an in-person visit

Spend time with the patient to build rapport

Additional time needed for new providers to build rapport

Tailor the Visit to the Patient o

Consider conditions or limitations

Tailor assistance provided because some patients may need extra time and assistance

Schedule additional time for a new provider visit vs. an established provider

Determine if a caregiver or family member needs to be present to assist

Determine the type of device the older adult is using to connect for the visit

Try to schedule the visit with the older adult’s established providers or have an in-person visit with a new provider before a TM visit

Communicate After the Visit o

Provide a verbal and written summary of the treatment plan, medications, and need for follow-up

Ask the older adult if they would like a mailed visit summary

TM, telemedicine.

Conclusions

In summary, many health systems quickly implemented TM visits during the early stages of the pandemic. The findings from our study describe older adults’ experiences with TM use during the pandemic and their opinions related to using TM for their care in the future. They also offer excellent guidance to improve the TM experience for the older adult population.

Footnotes

Acknowledgments

We thank our Community Advisory Board members for their valuable input and contributions to our research project and reports. We were unable to make this possible without their expertise along the way. We would also like to thank the UAMS Cardiology Clinic, UAMS Institute for Digital Health & Innovation nurse call center, and the West Tennessee Healthcare informatics team for their assistance with this project.

Data Access Statement

Following the Transparency and Openness Promotion (TOP) guidelines, deidentified data from this study are available upon a reasonable request to the corresponding author. This study was not preregistered.

Authors’ Contributions

S.R.: Methodology, Investigation, Formal analysis, Writing—Original draft, Review & Editing. J.M.: Methodology, Investigation, Formal analysis, Writing—Original draft, Review & Editing. H.S.: Writing—Original draft, Review & Editing. J.J.: Data curation, Formal analysis, Writing—Original draft, Review & Editing. C.P.: Resources, Writing—Reviewing and Editing. J.S.: Resources, Writing—Reviewing and Editing.

Disclosure Statement

Sarah Rhoads receives royalties for the development of the Angel Eye Webcamera System. Joseph Sanford has potential corporate conflict of interests with Microsoft, Datafy, Kuria, and Qventus. No other authors have a conflict of interest.

Funding Information

This work was supported by a Patient Centered Outcomes Research Institute (PCORI) Award [PCS 1409 24099, 2020]. The statements in this article are solely the responsibility of the authors and do not necessarily represent the views of the Patient Centered Outcomes Research Institute (PCORI), its Board of Governors, or Methodology Committee. The research reported in this publication was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under award number UL1 TR003107. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Supplementary Material

Supplementary Data S1

Supplementary Data S2

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