Abstract
Introduction
There are several ways in which a consultation with a physician can take place: traditional face-to-face meetings in a clinic (in-clinic visits), phone visits, or visits using video technology. Non face-to-face meetings (telemedicine) utilize a diverse range of technological possibilities, including various applications on the computer or cell phone. The use of telemedicine has grown rapidly in recent years and many in-clinic visits that were in the past face to face meetings are now performed remotely. 1 Telemedicine has been implemented in many healthcare organizations and has the potential to influence care availability and accessibility and quality of care. 2 Partially as the result of the COVID-19 pandemic, many visits in primary care have shifted from in-clinic visits to telemedicine visits that allows safe access to primary care. 3 There is a need to evaluate this change in the methods of interaction between patient and physician and identify changes in accessibility and quality of care.
Recently, video visits have been augmented with a new technology that has enabled the development of a mobile remote medical device which allows data to be displayed and transmitted from the patient to the physician. Meuhedet Health Maintenance Organization (HMO), provides universal, mandatory, tax-funded healthcare coverage from birth onward for 1.3 million Israeli residents. Patients have the option to receive, at no cost, health services from his/her primary care physician in-clinic or remotely by telemedicine. Telemedicine includes video consultation or an enhanced option, a video consultation with a medical home device Tytocare™. Tytocare™ is a medical device designed to display and transmit auditory canal, throat, and skin images; heart and lung auscultation, including heart rate detection, and temperature taken by infrared transdermal thermometer along with video visits on an Amwell™ platform. The device is used to facilitate medical examinations of the patient as part of the video visit and is remotely controlled by physicians. 4 It has a good comparative diagnostic score with a high reliability for otoscope diagnosis, and has shown to provide high quality sound and images that are comparable to traditional medical devices. 5
The patient population of interest for this study includes children seeking medical care for the diagnosis of upper respiratory tract infection (URTI), otitis media, and pharyngitis. These conditions have been selected as they account for a significant proportion of telemedicine visits within this age group. 1 The investigation is particularly relevant due to concerns raised in previous studies regarding the potential over-prescription of antibiotics during telemedicine visits for these conditions 6
The effect of this comparatively new style of interaction between patient and physician on the outcome of the interaction is not yet clear. Additionally, there is a need to characterize the accessibility and use of the new technologies that are constantly being developed, and understand their impact to the healthcare services. The American Telemedicine Association emphasizes the same standards of care must apply to telemedicine visits as they do to in-person care, including follow up treatment and diagnostic testing. 7 Also, the Israel Ministry of Health published criteria for operating telemedicine services (Circular 6/2019 https://www.health.gov.il/hozer/mk06_2019.pdf) and set out the principles relating to the provision of telemedicine services. The policy clarifies that telemedicine services are not intended to replace the corresponding face-to-face consultations, and it is thus recommended that both types of consultation services are available for patients to choose at their discretion.
A new Swiss study, 8 for minors and adults, demonstrated lower total health care expenditures and lower costs on the part of patients using the Tytocare medical device. However, the implementation of the telemedicine device did not lead to a significant reduction in service utilization. A study in Brazil of pediatric patients using Tytocare device indicated measurements from remote physical examination with a mobile medical device were comparable with those from in-person physical examination. 9
In a study performed in another large Health Maintenance Organization (HMO) in Israel during COVID-19, which is similar to our setting, it was reported that virtual visits resulted in more follow-up visits and the provision of fewer prescriptions for a sample of minor and adults. 10 In this study we focused on common childhood illnesses that consume the majority of a physician’s time. When considering the broader scope of global implementation, including countries like the United States, it was found that patients were more likely to undergo follow-up visits after a telemedicine visit for common infections than after in-clinic visits, 11 and they were more likely to receive antibiotics following telemedicine visits compared to in-clinic visits6,12–14. Regarding the risk of over-prescription of antibiotics in telemedicine visits settings, a study of children with pharyngitis in the United States, found gaps between observed practice and guideline recommendations for the treatment of pediatric pharyngitis. 15 Another study of telemedicine visits in children with URTI showed lower guideline-concordant antibiotic prescribing compared with other which ones settings. 6
The aim of this study is to compare three types of medical visits, namely video visits (VV), video visits with a medical device (VVMD) utilizing Tytocare, and in-clinic visits regarding the outcomes of the visit. The study aims to evaluate the utilization of medical services based on the outcomes of care, including the provision of prescriptions, follow-up visits, and referrals to other healthcare services. The specific objectives of the study are to: 1. Assess the impact of different types of medical visits on the provision of prescriptions. 2. To evaluate the frequency of follow-up visits following each type of medical visit. 3. To examine the rate of referrals to other healthcare services associated with different visit types.
These comparisons will assess the potential changes in health care utilization when a medical device, such as the remote health apparatus Tytocare, is added to video visits. While previous studies have primarily focused on comparing video visits with in-clinic visits , 8 this study advances our understanding regarding the impact of telemedicine with a remote device on healthcare utilization, specifically for common childhood illnesses.
Methods
This retrospective study examines community primary care medical visits of children, insured by Meuhedet healthcare services. All patient interactions are recorded in an electronic medical record (EMR). “Meuhedet”, Israel’s third largest of four state-mandated healthcare service organizations, has 1.3 million members, is charged with administering healthcare services nationally for its members and has implemented a scheduled video visit program via a technological platform Amwell™, which was first implemented in May 2019. When scheduling an appointment to a community primary care physician through the patient’s portal or service desk, patients are required to choose their visit type: video visit (VV), video visit with the remote medical examination device (VVMD), or a traditional in-clinic consultation. Remote devices allow physicians to conduct online remote examinations of patients during a VV. The physician controls the device remotely and instructs the patient or parent what to do with the device. If necessary, a follow-up can be conducted in the clinic or using a video visit. The physician has full access to the history and medical records of the patient and most often is familiar with the patient from previous interactions. The physician consistently records each medical visit in the patient’s electronic medical record (EMR) using a standardized approach. They have the ability to send referrals for laboratory tests, subspecialist consultations, or other necessary medical services, as well as prescribe medications as needed. Our study included all completed primary care visits of children aged <18 from the 1st of April 2021 to the 28th of February 2022. We included medical visits with diagnoses of acute respiratory infections and/or otitis and/or pharyngitis, which are commonly reported telemedicine complaints and diagnoses.1,16 Physicians' diagnoses are automatically coded using the ICD-9 classification. The final cohort included 470,825 patients (Figure 1) Number of visits in each step in Cohort.
The data extracted from the electronic medical records (EMR) included outcomes of each visit to the physician: 1. Follow-up medical visits within 5 days of the original visit. 2. Referrals (to subspecialists or additional medical services) and laboratory test referrals 3. Antibiotic prescriptions provided. In addition, patient socio-demographic characteristics previously shown to be associated with telemedicine visit choices 17 were extracted from the EMR. These include age, gender, geographic location, patients’ socioeconomic status, patients’ private insurance benefit cost-sharing and comorbidity. Socio-economic status (SES), was defined using the Israeli Central Bureau of Statistics classification which is based on place of residence. It uses a scale ranging from 1 to 20 with one representing the lowest and 20 the highest SES level. The scale is divided into three categories as follows: 1–7 for low status, 8–13 for intermediate status and 14–20 for high status. Patients’ private insurance was defined as supplementary health care services beyond existing medical services at an additional cost for members. Patients diagnosed with more than one condition in a single visit were categorized under “multiple diagnosis”, which may occur since these diseases often appeared simultaneously. An anonymized dataset containing no patient identifiers was provided for analysis. Frequencies were reported and χ2 tests were performed for all differences between the types of medical visits. Multivariable logistic regression models were run to examine the association between visit types and outcome. The models were adjusted for patient age, gender, and neighborhood socioeconomic status (SES). All analyses were conducted using 2-sided tests for significance and with p < .001 as the threshold for significance due to the large data set. Analyses were performed using IBM SPSS V27.
Results
Demographic and socioeconomic characteristics of pediatric patients by visit type [percent, (number), p value].
Outcomes of medical visits of pediatric patients, by type of visits and diagnosis [percent, (number), p value].
The association between type of pediatric visits and medical outcome, logistic regression models, Unadjusted. [Odds ratios, (OR), 95% confidence intervals (CI) and p values].
The association between type of pediatric visits and medical outcome, logistic regression models adjusting for age, gender and socio economic status [odd ratios, (OR), 95% confidence intervals (CI) and p values].
Discussion
The main findings in this study suggests that care received through telemedicine consultation via video visits with a remote medical device (VVMD) in pediatric patients reduced healthcare service utilization compared to video visits (VV) without a medical device. There seemed to be a lower rate of follow-up visits, referrals to subspecialists or additional medical services and fewer referrals to laboratory testing in the telemedicine consultations with a medical device. The prevalence of antibiotic prescriptions was not higher in telemedicine consultations compared to in clinic consultations. Even the incorporation of medical devices did not lead to a higher frequency of antibiotic prescriptions in comparison to in-clinic visits. As the implications of the introduction of new technologies is unpredictable, the incorporation of such technology did not result in increase in usage. Similarly to previous research, higher socio-economic status patients or used video consultation more often compared to in-clinic consultations,as they have better technological resources, awareness and knowledge. 17 Overall, telemedicine visits reduced healthcare services utilization compared to in-clinic visits, with the exception of follow-up visits.
One of the significant changes during the COVID-19 pandemic was the increase in telemedicine use, especially video consultations. 18 The global acceptance of telemedicine in healthcare systems underwent a significant transformation with the onset of the COVID-19 pandemic in the first quarter of 2020. The compelling necessity for social distancing, along with the rapid spread of the virus, heightened the demand for various telemedicine applications. By April 2020, nearly 43.5% of primary care visits covered by US Medicare were already being conducted via telehealth, marking a substantial increase from the minimal 0.1% recorded in February before the pandemic’s emergence. 19 Israeli primary care physicians reported ambivalent feelings regarding the increased use of telemedicine. 20 The physician’s challenge was the difficulty in making a diagnosis from a distance due to their inability to perform physical examinations in the telemedicine setting. 21 In another Israeli study, the probability of video-consultation usage by primary-care physicians for follow-up purposes was significantly higher than the probability that they would use it for diagnosis and treatment, also due to the inability to conduct a physical examination. 22 Increasingly, remote medical devices can be used to overcome this barrier. It offers the potential to enhance healthcare management through improved efficiency, cost reduction, and an emphasis on patient-centered care. 23 Two recent studies conducted in Israel have demonstrated that there was no significant difference in patient compliance when using the TytoCare device for examinations. 24 Additionally, in certain situations, telemedicine facilitated by the TytoCare device could be considered a practical alternative to traditional in-person clinical assessments. 9 Using a remote medical device during a video visit reduced medical services utilization compared to a regular video visit and can reduce physicians' concern about whether telemedicine visits can accurately diagnose patients without a physical examination and face-to-face contact. 25 Another recent research paper indicates that the adoption of these devices, while leading to a 12% higher utilization rate of primary care and increased use of antibiotics, is partially balanced by reduced reliance on other primary care methods 26 Most physicians were trained to rely on history taking and physical examinations to make a diagnosis. They may worry that relying on a remote medical devices during virtual consultation could compromise the quality of care. Our results suggest that the medical services utilization of telemedicine consultations can be improved by adding a medical examination device. This is important as The American College of Physicians’ policy states that telemedicine should offer the same quality of care as in-person care. 27 Yet Tytocare™ is still a new device with a limited number of recorded visits, so patients and physicians are only gradually learning to use and trust it. We postulate that the limited number of visits with this remote medical device may have been due to its cost and its recent introduction.
Another key finding in our study is the difference in medical services utilization between telemedicine video visits (with or without medical device) and in-clinic visits. Some Recent studies have indicated that telemedicine visits exhibit similar or lower subsequent healthcare utilization patterns when compared to office visits.28,29 Telemedicine visits when compared to in-clinic visits suggest lower referrals to subspecialists or additional medical services and lower laboratory test referrals, but more follow-up visits. As in previous studies, we found that referrals and laboratory test referrals were lower in telemedicine visit consultations6,10 and had increased follow-up visits.13,30 The higher number of follow-ups visits we found in telemedicine visits could be an indication of misdiagnosis or inadequate treatment during the initial visit, resulting in additional unplanned care. Based on the visit data, it is impossible to determine whether these follow-up visits were planned, or unplanned, or what was the severity of the medical conditions presented during the visits.
Contrary to other surveys,6,12 in our present study, antibiotics were prescribed less often in VV and VVMD than in-clinic visits, similar to the findings in studies for adults.31,32 A reason for the reduction in antibiotic prescriptions in telemedicine visits can be related to the fact that antibiotic prescriptions can be influenced by the inability to physically examine the patient, especially with pharyngitis, which is one of the most common reasons for physician visits. 33 Indeed, the prescribing of antibiotics during telemedicine visits appears to vary between different diagnoses, with more prescriptions given during VVMD visits than in VV. Our findings of low antibiotic prescription in VV may be explained by the observation of other researchers, who have consistently found that physicians generally prescribe antibiotics based on patient demand. 34 We postulate that the video consultation setting, when the patient is not present in the examining room, may reduce pressure on the physician to prescribe medication and reduce expectation among parents for antibiotics. Pediatricians may prefer in-clinic visits in order to avoid reduce diagnostic uncertainty and inappropriate antibiotic treatment.35,36 It is possible that this reflects the strive to maintain a high standard of care and please parents at the same time as reported by pediatricians in an Israeli study on pediatric telemedicine. 21 All in all, the finding of this study indicate antibiotic prescription rate was the highest in pharyngitis in all type of medical visits and may support the concern of overprescribing and inappropriate antibiotic selection for children with pharyngitis.15,37
Another finding of this study is that telemedicine visits, VV and VVMD, were positively associated with patients’ with high sociodemographic characteristics. Previous studies indicate that choosing telemedicine by patients or parents is statistically significantly associated with patient sociodemographic characteristics and age.17,38 Our study has also found parents opted for the video visits with or without a device, had supplementary private insurance and higher socio-economic status than those who opted in-clinic visits. As the visits are scheduled by the parents for their children, it is most likely they are under age 50, therefore have a higher rate of telemedicine usage. Furthermore, patients who chose telemedicine video visits may have perceived their condition as less urgent, felt more comfortable using the platform or had a higher level of health literacy than those who chose in-clinic visits. It is not possible within this study design to ascertain the reasons for choosing telemedicine visits rather than in-clinic.
This study has several limitations. Firstly, the groups may not be directly comparable since this is a real-world study. Telemedicine video visits may have been chosen by patients because they perceived them as the most convenient option, even for minor ailments. The parents may bring what they perceive to be sicker children for in-clinic consultation. Secondly, though a unique strength of this study was the large database, the use of video visits with medical devices was still at an early stage. The number of such visits was low and may be a new experience for both patients and physicians. This should be further evaluated after more visits are conducted. Thirdly, it was not possible to determine conclusively whether the original complaint was resolved after the original visit, or if the follow-up visit was part of the care or based on a new complaint as the electronic health record summarizing the visit does not provide sufficient information to determine this. While randomized trials are generally regarded as the gold standard for assessing intervention effectiveness, their implementation in primary care may pose ethical challenges and practical limitations. Lastly, despite being subsidized, the medical device required a co-payment; thus, it is not accessible to all patients equally. Therefore, we assumed that certain patient groups, such as those of lower socio-economic status, might be less able to use remote care. 39
Conclusions
We found that the use of a remote medical device during video visits for upper respiratory infection in pediatric patients is associated with a decreased number of follow-up visits, referrals, laboratory tests, and antibiotics prescriptions compared to video visits without the use of such a device. The significance of this finding, if replicated in other healthcare systems, should lead to the rapid introduction of such devices in order to improve patient care. As primary healthcare is changing and developing with increased use of telemedicine, it is crucial to understand how these changes effect healthcare services. This study presents data suggesting that the use of a remote medical device during video visits for upper respiratory infection in pediatric patients is associated with a decreased number of follow-up visits, referrals, laboratory tests compared to video visits without the use of such a device. These results suggest that increased use of medical devices during a video visit can overcome some of the problems of video visits and maybe lower costs for medical care. In the realm of healthcare innovation, the integration of medical devices has emerged as a promising avenue for enhancing patient care and clinical practice. While initial studies have provided valuable insights into the potential benefits of medical device adoption, there exists a compelling need for further research.
Data Availability Statement
The datasets during and/or analyzed during the current study available from the corresponding author on reasonable request.
Footnotes
Acknowledgements
We thank the Meuhedet health organization for their contribution to this work.
Author contributions
I.M. contributed to the study conception and design, acquisition, analysis and interpretation of the data, and drafting and revising the article. O.B.A. contributed to analyzing and interpreting the data, and drafting and critically revising the article. A.H. contributed to the interpretation of the data and critical revision of the article. All authors provided critical feedback and editing of each version of the manuscript. All authors read and approved the final manuscript and agreed to be accountable for all aspects of the work.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
