Telemedicine and e-Health

Lifestyle modification to promote regular physical activity and healthy eating is a key element of diabetes management. We aimed at evaluating randomized controlled trials that assess the impact of telemonitoring on diabetes outcomes with the inclusion of lifestyle change components.

A systematic review search in relevant databases was conducted for studies published from January 2000 to October 2018. The search was restricted to studies published in English and included adult patients with type 2 diabetes. Study selection criteria included telehealth programs with remote monitoring of physiological data and feedback features. We further performed meta-analyses to summarize the pooled effect size (presented by the mean difference [MD]) of hemoglobin A1c (HbA1c) and weight loss outcomes.

Seventeen studies were included in the data synthesis (15 of them were included in the meta-analysis), with the sample size ranging from 18 to 484 and the study period ranging from 3 to 12 months. Telemonitoring achieved a significant but modest reduction in HbA1c (MD = −0.30%; 95% confidence interval [CI]: −0.31% to −0.29%) and weight loss (kg) outcomes (MD = −0.62; 95% CI: −0.78 to −0.45) compared with usual care. In the subgroup analyses, it was suggested that telemonitoring with automatic mobile transmission or with real-time feedback modality led to a greater improvement in HbA1c outcomes (MD = −0.61% and −0.77%, respectively) when compared with telemonitoring without these features.

Telemonitoring has a great potential to further enhance diabetes management with the inclusion of a system approach for supporting patients' lifestyle changes. Features such as automatic mobile transmission and real-time feedback show promise to boost effectiveness of telemonitoring in diabetes management in the future.

Telehealth is a rapidly expanding health care delivery modality with increasing utility in the health care community. It is imperative that telehealth education is provided during the training of health care providers to ensure the proper usage and application of this health care delivery system. A comprehensive literature review of telehealth education integrated into the curricula of physician, physician assistant, and advanced practiced registered nurse training programs has not been reported to date.

An electronic literature search was performed using Scopus^®, PubMed, and 17 of the 35 databases on the EBSCOHost platform. We included studies where telehealth concepts and components were integrated in the curriculum for primary care students. We extracted information pertinent to understanding the scope and sustainability of the curriculum and tabulated the results.

After a full-text screening of 164 articles and critically analyzing 34, eight articles were included in this review. Comparison of these articles showed no consistency in how telehealth was integrated into the various health care curricula. Content delivered usually included basic telehealth information, however, the depth and breadth of content varied significantly based on the interventions.

For the articles included in this review, there were no formal study designs regarding basic telehealth educational integration or competencies. While authors recommended conducting evaluation and determining the effectiveness of the interventions, they did not provide a clear picture as to how these efforts should be conducted.

In addition to developing a standardized telehealth curriculum, national competencies need to be created, which will guide the development of standardized curriculum across health care training programs.

Many e-health services were launched after countries relaxed their telehealth regulations to combat the coronavirus disease 2019 (COVID-19) pandemic. e-Health technologies that support person-centered health care are crucial for the patient's needs. In this systematic review, we examined how e-health applications are used to support person-centered health care at the time of COVID-19.

Literature was systematically searched without language restriction and publication status between January 1 and May 25, 2020, to describe e-health's support on the person-centered health care to control the COVID-19 pandemic. PubMed, ScienceDirect, and CINAHL, MedRxiv, and Web of Science were used. Two researchers independently assessed the eligibility of each retrieved record. All included studies were subsequently rescreened by the researchers. The systematic review was conducted in accordance with preferred reporting items for systematic reviews and meta-analyses guidelines.

We identified 60 articles and selected 8 studies that met the inclusion criteria. Most of the studies used e-health technologies to facilitate clinical decision support and team care. Patient's engagement and access to health care from their homes were enhanced using telehealth and mobile health. Electronic health records were used to avail reliable data to health care providers and health authorities to make evidence-based decisions.

Although there are limited studies to evaluate the effectiveness of e-health technologies for person-centered health care, the reviewed studies indicated e-health's potentials to improve the quality of health care and personalized health systems during COVID-19 pandemic. Further research should be done to better understand applications of e-health to improve the quality of health care and patients' outcomes and evaluate its cost-effectiveness.

Telemedicine has been utilized to deliver pediatric weight management care in both rural and urban communities. This method of health care delivery may provide a solution to the many logistical obstacles to pediatric obesity management, including time, finances, and distance to programs.

This review examines all studies in the past decade that employed telehealth communication directly between families and obesity specialists to treat pediatric obesity. To assess the practical use of such programs, studies that surveyed family satisfaction with this method of health care are also included.

A comprehensive electronic database search was conducted in PubMed/MEDLINE, Scopus, CINAHL, and Cochrane Library databases.

All studies demonstrated noninferiority in clinical efficacy as measured by weight status improvement in participants of either the telehealth cohort or the in-person cohort. Attrition rates were also not statistically significant between groups. Patient satisfaction with telemedicine delivery was high across studies. Lack of statistical significance in outcomes of these studies can be attributed to infrequent visits, limited duration of programs, and study size.

Future research is needed to evaluate the effect on health outcomes as well as compliance when direct to consumer telemedicine visits are integrated in pediatric weight management clinics with more frequency and for longer duration. This method of telemedicine would allow for increased contact with patients and families in between face-to-face encounters. Telehealth provides the potential to create more robust, accessible, and effective pediatric weight management programs.

Previous studies have shown that primary stroke centers (PSCs) have shorter door to needle (DTN) time than non-PSCs hospitals. We aimed to validate these findings in a high-volume telestroke network.

The prospectively maintained data on all consecutive stroke patients who received intravenous alteplase (tissue plasminogen activator [tPA]) between July 2016 and November 2019 through a large telestroke program in Southeast United States was reviewed. Wilcoxon Rank-sum (Mann–Whitney) test was used to compare median times between different groups. Multivariate logistic regression model was used to assess the association between presenting to PSC and having DTN ≤45 and ≤60 min.

During the study period, 1,517 patients received tPA, 874 (57.6%) at PSC sites. There were more white patients in the PSC group (64.3%) compared to non-PSC group (58%) (p < 0.001). Other characteristics were similar in patients in both groups. Time metrics were as follows, Door to telestroke page: 16 min versus 13 min (p < 0.001), telestroke page to tPA recommendation: 23 min versus 22 min (p = 0.975), tPA recommendation to tPA bolus administration: 13 min versus 10 min (p < 0.001), and DTN 58 min versus 49 min (p < 0.001) at non-PSC and PSC sites, respectively. On multivariate analysis, there were significantly higher odds for achieving a DTN ≤45 min (OR 2.8, 95% CI 1.8–4.4, p < 0.001) and DTN ≤60 min (OR 3, 95% CI 2.1–4.3, p < 0.001) in the PSC group.

In our study, PSCs had better performance in the procedural metrics for tPA administration than non-PSCs in a large contemporary telestroke cohort.

The Cabo Verde Telemedicine program (CVTP) was established by the International Virtual e-Hospital Foundation using the Initiate-Build-Operate-Transfer strategy to improve access to specialty care for the population in the archipelago of Cabo Verde in 2012. Since its inception, the CVTP has proven a great success story of telemedicine in Africa. Our first report on the initial results of a nationwide CVTP was published in 2014. The aim of this article is to analyze the follow-up data and analyze the activity of CVTP.

All telemedicine consultations of the CVTP from 2014 to 2018 were analyzed. Patient demographics, clinical discipline, and transfer status were analyzed. Categorical variables were compared with a chi-squared test.

There were 2,442 telemedicine consultations in 24 clinical programs performed during the study period. The most common clinical disciplines with >100 consultations were neurology, cardiology, orthopedic surgery, general surgery, endocrinology, otolaryngology, urology, and dermatology. Overall, the transfer rate was 34.3%.

The nationwide CVTP continues to increase access to specialized care, prevent unnecessary and costly transfers, and has become a great success story of telemedicine in Africa. Moreover, this program should serve as a model for establishing island-nations telemedicine programs worldwide.

Evaluation of direct-to-consumer (DTC) telemedicine programs has focused on care delivery via personal electronic devices. Telemedicine kiosks for the delivery of virtual urgent care services have not been systematically described.

Our institution has placed kiosks for DTC urgent care in pharmacies. These kiosks can be used without a personal electronic device.

Retrospective review of adult patients using pharmacy-based kiosks (kiosk) or personal electronic devices (app) for DTC evaluation. Data for patient characteristics, wait time, technical quality, visit duration diagnosis codes, follow-up recommendations, and whether the patient was traveling were compared. Results were interpreted using the National Quality Forum framework for telemedicine service evaluation, focused on access, experience, and effectiveness. Comparisons were made using chi-square test, Student's t-test, and Wilcoxon rank-sum tests.

Over 1 year there were 1,996 DTC visits; 238 (12%) initiated from kiosks. Kiosk patients were slightly older (mean age 38 ± 13 vs. 35 ± 11; p < 0.001), more likely to be male (52% vs. 39%; p < 0.001), more likely to be remote from home (25% vs. 3%; p < 0.001), and had less technical difficulty (10% vs. 19%; p = 0.003). Referral for urgent in-person evaluation was low in both groups (10% kiosk vs. 16%; app p = 0.017).

Kiosks may increase access to care and improve technical experience. Low urgent referral rates suggest effective care for both types of visit.

Despite their potential advantages, kiosk visits accounted for a minority of overall visits for our DTC telemedicine service line, and daily use of each kiosk location was low.

Self-management and healthy habits (long-term health-related behaviors) are life-long requirements for the prevention of chronic back pain. Adherence to health interventions is often low because of the target groups' lack of interest. Electronic health (e-Health) information offers an opportunity to solve this issue, but many e-Health interventions are of poor quality. This study explores factors in the effectiveness of e-Health interventions and health-related behavioral changes and, thus, is among the first to develop a theoretical basis for e-Health programs.

An online survey was conducted among the target groups of primary and secondary health programs promoting the management of possibly chronic back pain in Germany and Austria (N = 224). Measurements of e-Health literacy (eHL), self-efficacy, organized physical exercise, and the patients' social and mental balance were applied in all cases. Participants were categorized into dichotomous subgroups regarding the severity of their back pain. In addition to several significance tests, a correlation analysis and mediation analysis were both performed using PROCESS version 2.0 for SPSS.

It was observed in the nonrisk group that self-efficacy has a mediation effect on the connection between eHL and healthy habits. Significant correlations between eHL and self-efficacy in both groups revealed associations between the major driving forces of healthy habits.

In keeping with previous research, the findings suggest that a high level of self-efficacy plays a significant role in correctly performing e-Health interventions. Nevertheless, further research should identify the effects of online social surroundings on eHL and self-efficacy in detail.

The University of Virginia's (UVA's) adult cystic fibrosis (CF) program implemented a rapid and successful transition to telemedicine care mid-March of 2020 in response to the coronavirus disease 2019 (COVID-19) pandemic. In May 2020, the adult UVA CF program redesigned the care model to adjust to the reopening of ambulatory operations and introduced hybrid clinics. The goal remained to minimize person-to-person contacts for patients and care team members (CTMs) while ensuring patient access to quarterly, coproduced, synchronous, multidisciplinary CF care, similar to pre-COVID-19 era regular CF care.

Using quality improvement tools, the UVA adult CF program created a standardized hybrid model of care for in-clinic visits, which included combined components of in-person and synchronous virtual interactions with members of the multidisciplinary team.

A total of 16 hybrid visits occurred between May 14 and June 11, 2020. All hybrid visits were multidisciplinary and fulfilled patient requests to see CTMs. All patients seen by hybrid encounter participated in coproduced agenda setting, underwent spirometry, and obtained blood work; 75% provided sputum for surveillance culture. Each hybrid visit type was attended by an average of four CTMs and amounted to 63 separate interactions. Of these interactions, 28 were completed virtually, reducing in-person contacts and personal protection equipment utilization by 44% compared with a fully in-person model of care.

Combining in-person and telehealth components in a multidisciplinary CF care model reduces patient and staff interactions and personal protective equipment utilization. The hybrid model of in-person/remote combined care enables reliable access to biological data to support medical decision making while mitigating the risks of person-to-person contact for patients and staff.

Telemedicine systems increase access to care, particularly in remote and developing countries. Nationwide telemedicine programs in Cabo Verde and Albania have been built by the International Virtual e-Hospital Foundation (IVeH) and based on the effective Initiate-Build-Operate-Transfer (IBOT) strategy. The aim of this study was to compare the clinical results between the two programs and examine the relationship between the clinical teleconsultations as an indicator of health care system needs and the contribution of local telemedicine champions.

Data were prospectively collected between 2014 and 2018 from Albania and Cabo Verde. Telemedicine champions were defined as programs, physicians, or hospitals who have contributed at least 100 telemedicine consultations during the study periods. Chi-squared test was utilized to analyze the data.

There were 2,442 teleconsultations in Cabo Verde and 2,724 teleconsultations in Albania during the study periods. Using the 100-consultation benchmark as the indicator of telemedicine champion, we identified radiology (n = 1,061), neurotrauma (n = 742), and general neurology or stroke (n = 489) as champion clinical disciplines in Albania. With the same method of 100 consultations, we identified eight champion clinical disciplines in Cabo Verde, including neurology (n = 720), cardiology (n = 313), orthopedics (n = 190), surgery (143), endocrinology (141), otolaryngology (n = 139), urology (n = 139), and dermatology (126). The patient transfer/nontransfer ratio was 0.5 in Cabo Verde and 0.3 in Albania (p < 0.001). Three hospitals in Albania and eight community hospitals/health care centers in Cabo Verde requested the majority of teleconsultations. Two main hospitals in Cabo Verde and Albania responded to the consultations.

The successful implementation of a telemedicine program depends on many factors. However, physician champions, who eventually create clinical discipline champions, and represent the hospital champions, are the backbone of the sustainability and progress of any telemedicine program. The number of consultations reflects the lack of local specialty expertise to provide health care service and thus can be used for future planning and investment.

The objective of this study was to investigate the impact of applying static telecytology for teleconsultation purposes during preoperative evaluation of challenging thyroid fine-needle aspiration specimens.

The study was performed on 141 cytologically challenging specimens of 125 patients referred to Alpha Prolipsis Cytopathology Department. All cases were finally confirmed histologically. During the study, 10 characteristic images from each case were transferred through file transfer protocol to password-protected accounts for remote review by three independent cytopathologists, with documented experience in the field of thyroid cytology. In addition to diagnosis, reviewers also commented on overall digital image quality. Contributor's and reviewer's diagnoses were collected, recorded, and statistically evaluated. No significant difference in diagnostic accuracy could be detected between the diagnoses proffered based on digitized images and conventional slides. Telecytology is a prompt and valid method for acquisition of a second opinion diagnosis in challenging cases and can be integrated into daily workflow. The use of telecytology for teleconsultation purposes in the laboratory's daily workflow will further ensure the accuracy of preoperative cytological diagnoses and will contribute to cytopathologists continuous education and better understanding of the criteria applied in thyroid gland lesions cytomorphological diagnosis.

Statistical evaluation of cytological diagnoses detected no significant difference in diagnostic accuracy between the diagnoses proffered based on digitized images among contributing cytopathologists. The overall interobserver agreement was very good with κ values of 0.73–0.88.

The widespread availability of imaging technology and telecommunication enables instant access to global expert cytopathologists. Static telecytology can be used as an efficient method for acquisition of second opinion in challenging thyroid fine-needle aspiration specimens. It can be used for rapid and accurate diagnosis, by diminishing turnaround times and improving small cytology departments' quality indices.

Telemedicine allows health care professionals to diagnose and treat patients remotely. Enuresis is one of the most common chronic problems in childhood and specialized care can be limited. Utilization of telemedicine in this setting has not been previously analyzed.

This study's aim is to evaluate the feasibility and effectiveness of telemedicine follow-up treatment of enuresis compared with traditional follow-up at our institution. A retrospective review of patients treated for nocturnal enuresis with either telemedicine (Group 1) or traditional (Group2) follow-up care was conducted. Patients, aged 5–18 years, treated for enuresis between July 2016 and December 2017 were included. Patients with confounding disease were excluded. Resolution of enuresis was the primary outcome as categorized by the International Children's Continence Society standards.

Seventy-seven (n = 77) patients met inclusion criteria with 23 patients in Group 1 and 54 patients in Group 2. Two patients in each group were lost to follow-up and 61.9% in Group 1 and 48.1% in Group 2 responded to treatment. The average age for both groups was 9.2 years. Patients in Group 1 averaged four appointments per patient and patients in Group 2 averaged 3.04 appointments per patient. Telemedicine follow-up patients missed fewer appointments (0.14) than patients with traditional follow-up (0.5) (p-value = 0.016). Thirteen of 21 patients (61.9%) responded to treatment in Group 1 (7 partial and 6 complete responders) as compared with 25 of 52 patients (48.1%) responding to treatment in Group 2 (8 partial and 17 complete responders) (p = 0.22). Of patients in Group 1, 87% reported they would use telemedicine again.

Telemedicine follow-up of patients with enuresis demonstrated comparable effectiveness. Most patient families demonstrate a favorable opinion of using telemedicine again for this problem. Further research to understand the efficacy and benefits of telemedicine in this setting is needed.

Few systematic evaluations of implementing teledermatology programs in large health care systems exist. We conducted a longitudinal evaluation of a U.S. Department of Veterans Affairs (VA) initiative to expand asynchronous consultative teledermatology services for rural veterans.

The reach, effectiveness, adoption, implementation, and maintenance framework guided the evaluation, which included analysis of quantitative VA administrative data as well as an online survey completed by participating facilities. The first 2 years of the program were compared with the year before the start of funding.

Sixteen hub facilities expanded teledermatology's reach over the 2-year period, increasing the number of referral spoke sites, unique patients served, and teledermatology encounters. Effectiveness was reflected as teledermatology constituted an increasing fraction of dermatology activity and served more remotely located patients. Adoption through defined stages of implementation progressed as facilities engaged in a variety of strategies to enhance teledermatology implementation, and facilitators and barriers were identified. Program maintenance was assessed by Program Sustainability Index scores, which reflected the importance of executive support, and ongoing concerns about staffing and longitudinal funding.

: Enabling hubs to create solutions that best fit their needs and culture likely increased reach and effectiveness. Important facilitators included organizational leadership and encouraging communication between stakeholders before and during the intervention.

A systematic analysis of teledermatology implementation to serve rural sites in VA documented a high degree of implementation and sustainability as well as areas for improvement.

As coronavirus disease 2019 (COVID-19) continues to be a global pandemic, there is a growing body of evidence suggesting that incidence of diseases that require emergent care, particularly myocardial infarction and ischemic stroke, has declined rapidly. The objective of this study is to quantify our experience of telestroke (TS) consults at a large tertiary comprehensive stroke center during the COVID-19 pandemic.

We retrospectively reviewed TS consults of patients presenting to our neuroscience network. Those with a confirmed diagnosis of acute ischemic stroke or transient ischemia attack were included. Data were compared from April 1, 2019, to June 30, 2020, which include consults prepandemic and during the crisis.

A total of 1,982 TS consults were provided in 1 year. Prepandemic, the mean monthly consults were 148. In April 2020, only 59 patients were seen (49% decline). Mobile stroke unit consults decreased by 72% in the same month. The 30-day moving average of patients seen per day was between five and six prepandemic declined to between two and three in April, and then began to uptrend during May. The mean percentage of patients receiving intravenous tissue plasminogen activator was 16% from April 2019 to March 2020 and increased to 31% in April 2020. The mean percentage of patients receiving endovascular therapy was 10% from April 2019 to March 2020 and increased to 19% in April 2020.

At our large tertiary comprehensive stroke center, we observed a significant and rapid decline in TS consults during the COVID-19 pandemic. We cannot be certain of the reasons for the decline, but a fear of contracting coronavirus, social distancing, and isolation likely played a major role. Further research must be done to elucidate the etiology of this decline.

Ophthalmic clinicians report low confidence in telemedicine-based eye care delivery, but it may have changed given its rapid expansion during the coronavirus 2019 (COVID-19) pandemic.

The purpose of this study was to determine clinician confidence in telemedicine-based eye care services during COVID-19.

An electronic survey was sent to clinicians at University of Michigan Kellogg Eye Center (April 17, 2020–May 6, 2020) when nonemergent in-person visits and procedures were restricted. The primary outcome was clinician confidence in using telemedicine-based eye care during COVID-19. Secondary outcomes included telemedicine utilization and its association with clinician confidence using Fisher's exact test.

Of the 88 respondents (90.7% response rate; n = 97 total), 83.0% (n = 73) were ophthalmologists and 17.0% (n = 15) were optometrists. Telemedicine utilization increased from 30.7% (n = 27) before the pandemic to 86.2% (n = 75) after the pandemic. Clinicians' confidence in their ability to use telemedicine varied with 28.6% (24/84) feeling confident/extremely confident, 38.1% (32/84) somewhat confident, and 33.3% (28/84) not-at-all confident. Most felt that telemedicine was underutilized (62.1%; 54/87) and planned continued use over the next year (59.8%; 52/87). Confident respondents were more likely to have performed three or more telemedicine visits (p = 0.003), to believe telemedicine was underutilized (p < 0.001), and to anticipate continued use of telemedicine (p = 0.009).

The majority of clinicians were at least somewhat confident about using telemedicine during the pandemic. Clinician confidence was associated with telemedicine visit volume and intention to continue using telemedicine.

Policies that foster clinician confidence will be important to sustain telemedicine-based eye care delivery.