Telemedicine and e-Health

Telemedicine is a rapidly expanding service in the digitization of health care systems. Recently emphasis has been placed on the decarbonization of health care systems with National and World Health Organization initiatives aimed at carbon neutrality toward the mid-21st century. This study investigates greenhouse gas emissions related to telemedicine, its potential role in achieving carbon neutrality and its role in determining policy. We further investigate patient benefits related to telemedicine.

A systematic review was conducted of the PubMed, Medline, EMBASE, EMCARE, CINAHL, and HMIC databases. Eligibility of studies was determined by predefined criteria.

A total of 31 studies were identified totaling over 57,000 patients. Carbon savings ranged from 0.69 kg CO₂e (carbon dioxide equivalent) to 893 kg CO₂e per encounter. Distances saved also ranged from 6.1 to 3,386 km. Further analysis of 18 included studies was conducted for cost savings that ranged from €1.73 in fuel costs to over U.S. $900 in travel related expenses. Similarly, 15 included studies were analyzed for time savings, which ranged from 38 min to 24 h.

There are substantial carbon savings to be made with telemedicine systems. Furthermore, there are substantial benefits to patients in terms of both time savings and cost savings. Rural and isolated communities or patients needing tertiary or quaternary care may be a particular cohort that might benefit disproportionally from telemedicine and is an area where the largest per capita emission savings can potentially be made.

The COVID-19 pandemic has prompted a shift in health care delivery and compelled a heavier reliance on telehealth. The objective of this study was to determine if differences in coverage policies by payer type resulted in differential telehealth use during the first 3 months of the COVID-19 pandemic. In this population-based cohort study of low-income Arkansans, Medicaid beneficiaries enrolled in the traditional Primary Care Case Management (PCCM) program were compared with Medicaid beneficiaries covered through premium assistance in private Qualified Health Plans (QHPs).

A retrospective review was conducted of insurance claims records from June 1, 2019, to June 30, 2020, for synchronous telehealth and mobile health (m-health) visits, as well as other forms of telehealth. To establish the baseline equivalence of enrollees in the two groups, propensity score matching design was used on demographic and geographic characteristics, Charlson Comorbidity Index, broadband availability, and prior service utilization.

Compared with enrollees in the PCCM program, Medicaid expansion enrollees in QHPs had higher odds of having had at least one telehealth visit (adjusted odds ratio [aOR] = 1.35, 95% confidence interval [CI]: 1.29–1.42) during the early phase of the COVID-19 pandemic. Categorizing utilizations by domain, QHP enrollees were more likely to use synchronous telehealth (aOR = 1.31; 95% CI: 1.25–1.37) and m-health (aOR = 5.91; 95% CI: 4.25–8.21). A higher proportion of QHP enrollees also had at least one mental or behavioral health telehealth session (aOR = 1.13; 95% CI: 1.07–1.19).

Our study demonstrated that within low-income populations, payer type was associated with inequitable access to telehealth during the early phase of the COVID-19 pandemic.

Back pain is among the most common presentations in primary care offices. National organizations have standardized the appropriate use of imaging for acute low-back pain (LBP). The objective of this study was to evaluate the use of imaging in LBP between telemedicine and in-person clinical encounters.

This retrospective cohort compared secondary data from 20,624 telemedicine and office encounters in a large nonprofit health system from July 1, 2019, to June 30, 2021. The proportion of patients aged 18–50 years who did not receive imaging for acute LBP (X-ray, computed tomography, or magnetic resonance imaging) within 28 days of the provider encounter was measured according to Healthcare Effectiveness Data and Information Set specifications. Performance was compared across race, ethnicity, age, body mass index, overall risk score, and insurance type. Chi-squared tests determined significant differences between cohorts (p < 0.05).

Patients seen via telemedicine had significantly lower rates of imaging within 28 days of their physician encounter (office: 16.32%, telemedicine: 11.20%; difference: 5.12%; p < 0.01). This was consistent across racial, ethnic, and risk score subgroups.

For practices and health systems, telemedicine might be a higher value approach for initial evaluation of acute LBP in primary care. For policy makers, telemedicine can save on health care costs without negatively impacting quality performance measures.

: Telemedicine is unlikely to compromise quality of acute LBP care, supporting this virtual space as an alternative care venue. The most beneficial use of telemedicine might be triaging initial encounters of acute LBP in primary care. Stronger evidence could support its long-term potential for driving value through cost savings.

This article describes the experience of the Singapore Armed Forces (SAF) implementing telemedicine consultations for COVID-19–positive patients recovering within community recovery facilities (CRFs) in a semi-inpatient setting.

The SAF adopted a systematic approach to telemedicine implementation and scaling up, with Phase 1 being the deployment of medical teams operating on-site clinics daily at six CRFs and telemedicine only provided for after-hours medical consultations on an ad hoc basis. Subsequently in Phase 2, most clinical consultations in the CRFs were conducted virtually.

Phases 1 and 2 recorded 1,902 and 449 clinical consultations, respectively. The mean number of clinical encounters was 33 per 1,000 occupants per day in Phase 1, and 12 per 1,000 occupants per day in Phase 2 (p < 0.001). Acute respiratory illness (52.3% in Phase 1 and 46.7% in Phase 2) was the most common reason for consultations. With full telemedicine in Phase 2, there was reduction in the mean number of clinical encounters per 1,000 occupants per day (p = 0.001), lower man-hours in personal protective equipment (PPE) (p < 0.001), and rise in escalation of care (p < 0.001) but without adverse events reported.

Telemedicine for patients was safe, improved medical manpower efficiency, and reduced man-hours in PPE. The increased escalation of care in Phase 2 due to the lack of physical examination capabilities was to be expected to ensure patients' safety. Overall, it is recommended that for stable and mild medical conditions, telemedicine is a viable, safe, and efficient health care delivery tool in crisis situations similar to COVID-19.

Owing to the coronavirus disease 19 pandemic, the demand for telemedicine has increased. However, the awareness of and experience with telemedicine among the Korean population have not been investigated. Therefore, we examined Korean outpatients' experience with and awareness of telemedicine.

From December 2020 to March 2021, we conducted a survey exploring the awareness of and experience with telemedicine of outpatients who were consecutively enrolled by family physicians from four hospitals. The participants completed questionnaires on sociodemographic characteristics and knowledge, experience, satisfaction, preference, and future considerations concerning telemedicine. We evaluated factors associated with satisfaction with telemedicine experiences using multivariate logistic regression analysis.

Among the 563 study participants, 364 participants had experience with telemedicine. More than 95% of the telemedicine visits were performed by telephone consultation, and the most common disease type for telemedicine visits was chronic diseases (67.5%). Overall, 82.4% of the participants were satisfied with telemedicine. More than 90% of the participants were satisfied with telemedicine in terms of saving time and money relative to hospital visits, no risk of infection, and convenience. According to the multivariate logistic regression analysis, adults aged ≥65 years (odds ratio [OR] 3.53, 95% confidence interval [CI] 1.44–8.68), residents of a metropolitan city (OR 6.8, 95% CI 1.41–32.55), and those with knowledge of telemedicine (OR 2.96, 95% CI 1.21–7.26) were more likely to be satisfied with their telemedicine experience, compared with their counterparts. For chronic diseases, participants with telemedicine experience were significantly more likely to prefer telemedicine for revisits, compared with those with no telemedicine experience. Nonetheless, most respondents recognized that telemedicine requires improvement.

Most Korean outpatients showed high satisfaction with telemedicine. Telemedicine may be considered in various medical situations in the future. Therefore, building a practical system for telemedicine and changes in the medical environment are required.

The COVID-19 pandemic has led to considerable changes in the health care system. Experts suggested that individuals protect themselves through social isolation during the pandemic, and consequently, the importance of telemedicine came to be understood for patients with chronic diseases. Telemedicine started to be used in developing countries where the appropriate infrastructure was lacking earlier. The present study investigates the level of satisfaction of patients with inherited metabolic disorders (IMDs) with telemedicine.

This prospective study was conducted by making use of a new video appointment program that ensures the privacy of the patients in video-based consultations. The sociodemographic characteristics of the patients, their clinical status, their views on the telemedicine system, and their levels of satisfaction were questioned.

Overall, 174 patients were included in the study. The most common diagnoses were aminoacidopathies, lipid metabolism disorders, biotinidase deficiency, and lysosomal/peroxisomal diseases. More than half of the parents (67.6%) who lived in another city reported accommodation issues when coming to the hospital, and most believed telemedicine would save them time (93.1%) and money for travel (81.6%). The lack of laboratory and radiological tests (83.9%) was stated as the main disadvantage by most parents. Almost all the parents (96.6%) stated that they would opt for telemedicine if it became available in daily practice. The overall satisfaction rate was 94.6 (±10.1)/100.

The present research is the most extensive cohort study to date assessing telemedicine in patients with IMDs and it highlights the importance of telemedicine, especially in developing countries during the COVID-19 pandemic.

Remote telemonitoring (RTM) for patients with chronic heart failure (HF) holds promise to improve prognosis and well-being beyond the standard of care (SoC). The CardioBBEAT trial assessed the health economic and clinical impact of an interactive bidirectional RTM system (Motiva^®) versus SoC for patients with HF and a reduced ejection fraction (HFrEF), in Germany.

This multicenter, randomized controlled trial enrolled 621 patients with HFrEF (mean age 63.0 ± 11.5 years, 88% men). The primary endpoint was the integrated effect of the intervention on total costs and nonhospitalized days alive after 12 months, reported as incremental cost-effectiveness ratio (ICER). Costs (in k€) were based on actual charges of patients' statutory health insurance. Among secondary outcome measures were mortality and disease-specific quality of life.

We found a neutral effect on nonhospitalized days alive (RTM mean 341 ± 59 days, SoC 346 ± 45 days; p = 0.298) associated with increased total costs (RTM 18.5 ± 39.5 k€, SoC 12.8 ± 22.0 k€; p = 0.046). This yielded an ICER of −1.15 k€/day. RTM did not impact mortality risk. All quality of life scales were consistently and meaningfully improved in the RTM group at 12 months compared to SoC (all p < 0.01).

The first 12 months of RTM were not cost-effective compared to SoC in patients with HFrEF, but associated with a relevant improvement in disease-specific quality of life. The balanced assessment of the potential benefit of RTM requires integration of both the societal and patient perspective.

ClinTrials.gov (NCT02293252).

The lockdown imposed by the COVID-19 pandemic rendered teledentistry (TD) necessary to maintain the continuity of oral health services and avoid missing emergency dental conditions, while minimizing face-to-face visits. Our objective was to evaluate the ability of a newly introduced triage-based TD service to deliver its goals, by evaluating its processes and outcomes and assessing the demand for TD.

This cross-sectional report assessed the triage processes and outcomes (triage category, referral to emergency/dental facility undertaken, remote medications prescribed, and procedures performed at the point of referral); and evaluated the demand for the newly introduced TD service during 5 months of the first wave of the pandemic.

Of 850 calls, about 70.6% of the samples were managed remotely; 29.4% were categorized as emergency/urgent and referred to the emergency/dental facility. Compared with other complaints, orofacial dental pain was the most common reason for the calls (41.6%, p < 0.0001). About 14.71% of callers received prescription for medications remotely. The most demanded disciplines were general dentistry, orthodontics, and oral surgery, respectively (p < 0.0001). Of those referred to a dental facility, 31.84% required no clinical intervention, 28.7% received orthodontic appliance repair, and 14.3% and 11.2% had urgent dental extractions or root canal treatments. Demand on the service fluctuated through various distinct stages of the lockdown.

There has been continuous demand for the newly introduced TD service throughout the period of the current report despite the fluctuations, with most complaints managed remotely. TD was effective and suitable for triage, service delivery, and care during the pandemic.

The Veteran Integrated Service Network (VISN) 20 Veterans Affairs-Extension for Community Healthcare Outcomes (VA-ECHO) program connects specialty and primary care providers (PCPs) across large geographic areas, utilizing video-teleconferencing with the intention of increasing access to care among underserved and isolated populations. No previously published work describes participation patterns of a multispecialty ECHO program. We describe the development of VISN 20 VA-ECHO program to inform the design and evaluation of ECHO programs.

The participant cohort included VA-affiliated licensed health care professionals, including trainees, who attended at least one VISN 20 VA-ECHO session between April 2012 and December 2018. Participant characteristics reported include gender, clinical location, clinical specialty, discipline, and rurality.

Over the 6-year time frame, VISN 20 VA-ECHO offered 945 sessions in 14 clinical specialties and recorded 17,893 hours of attendance. The cohort included 1,346 participants, 74.3% of whom were female, 85.2% employed in medical centers, and 40.7% affiliated with primary care. Most participants (62.3%) attended one specialty exclusively; among all participants, 40% attended five or more sessions.

Although VA-ECHO was implemented to develop single specialty expertise among PCPs, our participant cohort represented a more diverse audience from a range of disciplines and specialties. Our experience may be valuable to other teams implementing ECHO programs.

Through adaptability and strategies that actively promoted inclusion of a diverse audience, VISN 20 VA-ECHO expanded to include multiple clinical specialties and successfully engaged an audience across a large geographic area and beyond PCPs.

Providing care over telehealth grew slowly until the COVID-19 pandemic. Since the onset of the COVID-19 pandemic, providing mental health care was readily adapted to virtual means; however, clinical trial research is nascent in adapting methods and procedures to the virtual world.

We present protocol modifications to pivot a multisite randomized controlled trial study, conducted at Southeastern and Pacific Northwestern Veterans Affairs Health Care Systems, from being conducted in-person to virtually, following the onset of the COVID-19 pandemic. We measured outcomes of posttraumatic stress disorder (PTSD) symptoms and psychophysiological markers of stress among female Veterans with PTSD secondary to military sexual trauma. We collected qualitative data about provider and participant experiences with telehealth.

Across sites, 200 participants were consented (48 virtually), 132 were randomized (28 to virtual groups), and 117 completed data collection and treatment (69 completed all or some data collection or treatment virtually).

The pivots made for this study were in response to the COVID-19 pandemic and offer innovative procedures leveraging technology and contributing to the broader landscape of conducting research virtually. Clinical Trials Number: NCT02640690.

To assess the overall satisfaction level of movement disorder specialists using a virtual platform during the COVID-19 pandemic.

This was a multicenter cross-sectional survey for a 6-month period during the beginning of the COVID-19 pandemic. Movement disorder specialists, who utilized telehealth visits from March 2020 to August 2020, were included. The study surveys, including provider's satisfaction with the care that they were able to provide and visit quality, were completed by the provider after each visit.

A total of 206 visits, provided by movement disorder specialists, were analyzed. Zoom was the most popular platform used for remote visits (70, 34%). A backup platform was not needed in the majority of movement disorder visits (171, 83%). The majority of physicians were very satisfied or satisfied with the care provided (72.9%) and visit quality (61%).

The satisfaction level of specialists using telemedicine during COVID-19 was high despite having encounters with elderly patients with cognitive impairment or lacking advanced skills with technology.

Telemedicine is a relatively new adjunct in orthopedic care but it has emerged from the periphery, driven in part by the COVID-19 pandemic. Although it has drastically increased in use, little is known of the factors that drive satisfaction with telemedicine. The purpose of the current study was to evaluate the patient's satisfaction with postoperative telemedicine visits in those undergoing knee or shoulder arthroscopy, and to analyze the factors associated with satisfaction with telemedicine.

A prospective study was performed to evaluate satisfaction comparing postoperative telemedicine and in-office visits, in those undergoing shoulder and knee arthroscopy. Multiple factors were analyzed for correlation with satisfaction via multi-linear regression, including demographics such as gender, education, age, and race. Patients were also evaluated for preference for future visits with reference to the group in which they were placed.

Overall, 215 patients were included with a subgroup analysis of 93 patients receiving telemedicine visits. Patients reported overall similar satisfaction with telemedicine visits after shoulder and knee arthroscopy, with a high level of satisfaction seen in both. Female sex was found to be associated with decreasing satisfaction with telemedicine visits (p = 0.036). In addition, as a whole, the cohort was found to prefer future visits to be the same as the group they were placed in, but females statistically did not have this preference for their familiar group and were skewed toward the preference of in-person visits (p = 0.377).

Our study found that female patients were less likely to be satisfied with postoperative telemedicine visits after knee or shoulder arthroscopy. Further, females were also less likely to indicate preference for future telemedicine visits. In contrast, education, history of prior surgery, age, and race were not associated with postoperative satisfaction.

Second medical opinions (SOs) can strengthen patients' certainty in decision making. In Germany, both personally delivered and telemedical SOs (often based on documents only) are provided. Our aim was to analyze the experiences of people who obtained telemedical SOs. We also investigated different routes of SO delivery (personally/by phone/documents only).

German residents who obtained a telemedical SO via an online portal between January 2016 and February 2019 (n = 1,247) were contacted by post between August and November 2019 up to three times. The results were analyzed descriptively.

The 368 participants (response rate 30%) were 54% male, 95% statutory health insured, and 61 years old (median; interquartile range 51–72). Approximately 75% were (rather) satisfied with obtaining the SO via the online portal. The most preferred route of SO delivery was a personally delivered SO, which 80% would (rather) consider, followed by 70% (rather) considering SOs based on documents only and 48% (rather) considering SOs by phone. The most often mentioned advantage of telemedical SOs was independence of time and place, while the most important disadvantage was the standardized process resulting in a lack of direct and personal contact between the patient and the physician.

Although our results show that SOs (based on documents only) support patients and that patient satisfaction was high, personally delivered SOs were still preferred. Future research on the use of SOs based on documents only (in which patient population and in what situations) is needed.

The aim of this evaluation was to assess the rapid implementation of obstetric telemedicine during the COVID-19 pandemic using the Consolidated Framework in Implementation Research (CFIR) evaluation framework.

Following 1 month of telemedicine implementation, obstetric providers at the University of South Florida clinic completed qualitative surveys and in-depth interviews about the implementation of obstetric telemedicine in the clinic guided by the CFIR evaluation framework.

Overall, providers considered obstetric telemedicine comparable to traditional in-person clinic visits and acknowledged that they were adequately prepared for the telemedicine implementation. They perceived that obstetric telemedicine mostly met the needs of patients in terms of convenience and comfort of visits, decreased exposure to COVID-19 infection, and the ability of the patient to listen to fetal heart sounds if at-home doppler monitoring was available.

The implementation of the obstetric telemedicine care model was deemed a favorable alternative option for patients during the COVID-19 pandemic.

This study asked: (1) How does digital literacy influence one's decision to consent to a social media intervention study? (2) What is a brief way to assess individual digital literacy before an individual's decision to participate in a trial? and (3) How can a consent process be tailored around an individual's digital literacy level?

We used an assessment tool to investigate digital literacy of those who chose to consent to a clinical trial and those who did not consent to the clinical trial but agreed to participate in a digital literacy study.

A total of 161 hospice caregivers completed the digital literacy assessment. Older individuals and those who rated themselves as more proficient in the use of technology and social media were more likely to consent to the social media clinical trial.

We found that asking participants to rate their technology skills and social media skills allows researchers to tailor a consent process. For those who are comfortable with technology and social media the traditional process is appropriate. For individuals that rate themselves with weaker technology and social media skills it is important that the consent process includes assurance they will receive adequate support in the use of the technology and the media. The next step is to test the assessment and tailoring of consent processes for a social media clinical trial. Clinical Trial # NCT02929108.

During the COVID-19 pandemic, keratoconus patient care moved from in-person clinics to virtual care. We surveyed patient satisfaction with the new virtual clinic model.

We assessed the views of keratoconus patients enrolled in the novel virtual service between June 1 and July 31, 2020, in individual structured telephone interviews using Likert questions.

Of the 88 patients enrolled, the opinions of 69 patients could be evaluated (78.4%). Compared with previous in-person visits, mean waiting times for diagnostic examinations dropped from 43 (±32) min to 4 (±3) min (p < 0.001). The majority of patients (68; 99%) were satisfied or very satisfied with the overall service irrespective of the communication channel (telephone or video). A majority also indicated a desire to continue attending the virtual keratoconus clinic after the pandemic and supported the idea of decentralized sites for future diagnostic measurements.

A novel virtual service to monitor keratoconus progression was well received and was associated with shorter waiting times. There was a strong interest on the part of patients to further develop the virtual keratoconus clinic.

This study demonstrates that keratoconus patients managed very well the conversion from in-person to virtual care. A solid majority of keratoconus patients also supported further expansion of the virtual consultations to a completely decentralized telemedicine model.

We examine trends in telemedicine use by race, geography, and age among Louisiana Medicaid beneficiaries in the months preceding the COVID-19 pandemic.

Using Louisiana Medicaid claims data from January 2018 through February 2020, we calculated a relative ratio of telemedicine use as the share of telemedicine claims by race, age, and geography and conducted two-sample t-tests.

In 2018, White beneficiaries used telemedicine at a relative ratio of 1.92 compared with Black beneficiaries (p < 0.001) and 2.02 compared with Hispanic beneficiaries (p < 0.001). Rural beneficiaries used telemedicine at a relative ratio of 1.27 (p < 0.001) compared with urban beneficiaries. Children and adolescents used telemedicine at a higher rate than other age groups. Racial and geographic disparities narrowed in the first months of 2020.

Telemedicine use in Louisiana Medicaid was low but growing before the pandemic with narrowing disparities by race and geography and emerging disparities by age.