Telemedicine and e-Health

Telemedicine and remote patient monitoring are rapidly growing fields. This scoping review provides an update on remote patient monitoring for neuropsychiatric disorders from recent publications and upcoming clinical trials.

Publications (PubMed and ICHUSHI; published January 2010 to February 2021) and trials (ClinicalTrials.gov and Japanese registries; active or recruiting by March 2021) that assessed wearable devices for remote management and/or monitoring of patients with neuropsychiatric disorders were searched. The review focuses on disorders with ≥3 publications.

We identified 44 publications and 51 active or recruiting trials, mostly from 2019 or 2020. Research on digital devices was most common for Parkinson's disease (11 publications and 19 trials), primarily for monitoring motor symptoms and/or preventing falls. Other disorders (3–5 publications each) included epilepsy (electroencephalogram [EEG] and seizure prediction), sleep disorder (sleep outcomes and behavioral therapies), multiple sclerosis (physical activity and symptoms), depression (physical activity, symptoms, and behavioral therapies), and amyotrophic lateral sclerosis (symptoms). Very few studies focused on newly emerging technologies (e.g., in-ear EEG and portable oximeters), and few studies integrated remote symptom monitoring with telemedicine.

Currently, development of digital devices for daily symptom monitoring is focused on Parkinson's disease. For the diseases reviewed, studies mostly focused on physical activity rather than psychiatric or nonmotor symptoms. Although the validity and usefulness of many devices are established, models for implementing remote patient monitoring in telehealth settings have not been established.

Verification of the clinical effectiveness of digital devices combined with telemedicine is needed to further advance remote patient care for neuropsychiatric disorders.

The COVID-19 pandemic accelerated the adoption of telehealth as an alternative to in-person hospital visits. To understand the factors impacting the quality of telehealth services, there is a need for validated survey instruments and conceptual frameworks. The objective of this study is to validate a telehealth patient satisfaction survey by structural equation modeling (SEM) and determine the relationship between the factors in the proposed telehealth patient satisfaction model (TPSM).

We conducted a cross-sectional survey of pediatric patients and families receiving care from a comprehensive pediatric hospital in the Midwest between September 2020 and January 2021. In total, 2,039 usable responses were collected. We used an SEM approach by performing confirmatory factor analysis with Diagonally Weighted Least Squares modeling and Partial Least Squares—Path Modeling to establish the structural validity and examined the relationships among the constructs of “Admission Process” (AP), “Perceived Quality of Service” (PQS), and “Telehealth Satisfaction” (TS).

Participants were predominantly White (75%) and English-speaking (95%) parents (85%) of patients (mean age of patients was 10.2 years old). The survey responses were collected from patients visiting 43 department specialties, whereas 50% were behavioral and occupational therapy patients. The structural model showed that the admission process (AP) had a strong positive impact on perceived quality of service (PQS) (p = 0.67, t = 36.1, p < 0.001). The PQS had a strong positive impact on telehealth satisfaction (TS) (p = 0.66, t = 31.8, p < 0.001). The AP had a low positive direct impact on TS (p = 0.16, t = 7.46, p < 0.05). Overall, AP and PQS explained 61% variances (R ²) of TS.

We validated a newly proposed TS assessment model by using SEM. The TPSM will inform researchers to better understand the influencing factors in TS and help health care systems to improve telehealth patient satisfaction through a validated model.

The COVID-19 pandemic has hastened the adoption of telehealth and the drastic shift to an unfamiliar process may impose significant impact to the quality-of-care delivery. Many providers are interested in understanding the quality of their telehealth services from the patients' experience.

A telehealth patient satisfaction survey (TPSS) was developed by using an iterative stakeholder-centered design approach, incorporating elements from validated telemedicine and customer service survey instruments, and meeting the operational needs and constraints. A cross-sectional study design was employed to collect survey responses from patients and families of a large pediatric hospital. Finally, we performed exploratory factor analysis (EFA) to extract latent constructs and factor loadings of the survey items to further explain relationships.

A 22-item TPSS closely matched the existing in-person patient satisfaction survey and mapped to a revised SERVPERF conceptual model that was proposed by the interdisciplinary committee. Survey was implemented in the HIPAA-compliant online platform REDCap^® with survey link embedded in an automated Epic MyChart (Verona, WI) visit follow-up message. In total, 2,394 survey responses were collected between July 7, 2020, and September 2, 2020. EFA revealed three constructs (with factor loadings >0.30): admission process, perceived quality of services, and telehealth satisfaction.

We reported the development of TPSS that met the operational needs of compatibility with existing data and possible comparison to in-person survey. The survey is short and yet covers both the clinical experience and telehealth usability, with acceptable survey validity.

The clinical effectiveness of audio-only telemedicine has not been fully quantified. The pandemic afforded a unique situation to retrospectively observe clinical outcomes of care for three disease cohorts within three care models, including audio-only telemedicine.

Patients were classified into three care models: audio-only telemedicine, in-person, and hybrid. Each model was compared with an aggregate group before the onset of the pandemic and within each group during the pandemic. Each disease cohort was evaluated in cross-sectional and paired analyses.

Patients (n = 52,720) were grouped within one of three care models. A majority (n = 48,335) of patients qualified for the “pre” group comparison. The audio-only telemedicine care model showed similar control of renal disease, hypertension control, and diabetes management than in-person and hybrid care models.

Audio-only telemedicine appears to be noninferior to in-person or hybrid models for chronic disease management for the diseases studied. In all instances, it had similar control compared with the in-person care model. We acknowledge the limitations of this study, including convenience sampling and a limited observation timeframe. Audio-only telemedicine should be considered a viable care model modality that can be integrated into options for patient care. Further study and investment are warranted, as it provides efficacy and convenience to health systems (Clinical Registration Number # 32449).

Most patients with COVID-19 do not require hospitalization but may need close monitoring, which can strain primary care practices. Our objective was to describe the implementation of a mobile web application to monitor COVID-19 signs and symptoms among nonhospitalized primary care patients and to assess the feasibility and acceptability of the application.

Retrospective analysis of (1) mobile web application data from March through December 2020 and (2) cross-sectional surveys administered in June 2020.

We enrolled nonhospitalized patients and staff from nine New England primary care practices across 29 sites. Outcomes included feasibility and acceptability of the application as measured by the proportion of texts that resulted in a response, proportion of patients who agreed using the application was easy, and proportion of practice staff who agreed the application reduced outreach burden and that they would recommend use.

Five thousand five hundred thirty-two patients used the mobile web application, with 26,466 total responses. Overall, 78% of the daily texts resulted in a response from patients. Most patients agreed that responding to texts was easy (95%) and that they would be willing to participate in other texting programs (78%). Most staff agreed that the program reduced burden of outreach (94%) and that they would recommend use to other practices (100%).

Use of a COVID-19 symptom tracking application was feasible and acceptable to patients and primary care practice staff. Outpatient practices should consider use of mobile web applications to monitor nonhospitalized patients with other acute illnesses.

Many clinicians and patients tried telemedicine for the first time during the COVID-19 pandemic. In a prior survey, we found that clinicians who were adaptable and willing to incorporate technology into their clinical practice are more likely to utilize telemedicine. Seeking factors associated with current and future use of telemedicine, and identifying its relative advantages and drawbacks, may help determine the role of telemedicine after the pandemic.

We asked (1) which demographic factors and personal preferences are associated with current and planned future use of telemedicine, (2) what factors are associated with telemedicine utilization, and (3) what are clinician-reported advantages and disadvantages of telemedicine?

Approximately 750 clinicians within a national multispecialty hospital group were invited to complete an online survey assessing telemedicine use and preferences, self-reported technology proficiency, and personal characteristics. A total of 284 clinicians started the survey, and 259 complete responses were analyzed using bivariate analysis and multivariable regression.

More frequent current telemedicine use was associated with being a nonsurgeon clinician, not primarily practicing in an inpatient setting, preferring either telemedicine or having no preference for discussing sensitive topics, and greater self-reported technological proficiency. Planned future telemedicine use was associated with greater self-reported troubleshoot ability and less desire for a hands-on physical examination. Clinicians reported that the top benefits of telemedicine are decreased barriers for patients and convenience for clinicians, and disadvantages are technical difficulties for both patients and clinicians.

Telemedicine continues to be widely utilized by clinicians, particularly those who are confident in their ability to examine patients over video, and who can troubleshoot issues that arise on the platform. With continued reimbursement, telemedicine is likely to remain a convenient and effective method of caring for patients.

The use of telehealth screening (TS) for diabetic retinopathy (DR) consists of fundus photography in a primary care setting with remote interpretation of images. TS for DR is known to increase screening utilization and reduce vision loss compared with standard in-person conventional diabetic retinal exam (CDRE). Anti-vascular endothelial growth factor intravitreal injections have become standard of care for the treatment of DR, but they are expensive. We investigated whether TS for DR is cost-effective when DR management includes intravitreal injections using national data.

We compared cost and effectiveness of TS and CDRE using decision-tree analysis and probabilistic sensitivity analysis with Monte Carlo simulation. We considered the disability weight (DW) of vision impairment and 1-year direct medical costs of managing patients based on Medicare allowable rates and clinical trial data. Primary outcomes include incremental costs and incremental effectiveness.

The average annual direct cost of eye care was $196 per person for TS and $275 for CDRE. On average, TS saves $78 (28%) compared with CDRE and was cost saving in 88.9% of simulations. The average DW outcome was equivalent in both groups.

Although this study was limited by a 1-year time horizon, it provides support that TS for DR can reduce costs of DR management despite expensive treatment with anti-VEGF agents. TS for DR is equally effective as CDRE at preserving vision.

Annual TS for DR is cost saving and equally effective compared with CDRE given a 1-year time horizon.

Telemedicine is the practice of caring for patients remotely when the patient and provider are not physically present at the same location. Within orthopedic surgery, telemedicine offers care without the typical obstacles of an in-person appointment such as difficulty ambulating following surgery and patient wait times. In this study, we evaluated patient interest and satisfaction in postoperative telemedicine visits following hip or knee arthroplasty surgery.

Patients were offered either a traditional in-person or a remote telemedicine postoperative visit following surgery. Patients were asked to complete a satisfaction survey following their postoperative visit regarding their experience. Patient-survey responses as well as patient-reported outcome metrics were captured using a mobile and web-based electronic patient rehabilitation application.

A total of 766 patients were included in this study with 360 offered postoperative telemedicine visits and 402 offered traditional in-person visits. Two hundred fifty-nine patients reported satisfaction levels with their telemedicine visit, with 58.3% of patients characterizing their feelings with the visit as “extremely satisfied,” 32.0% as “satisfied,” 8.9% as “neutral,” 0.3% as “dissatisfied,” and 0.3% as “extremely dissatisfied.” A total of 713 patients reported how the COVID-19 pandemic effected their feelings toward telemedicine with 12.9% of patients characterizing the affect as “extremely positively,” 33.1% of patients as “positively,” 48.9% of patients as “neutral,” 3.6% of patients as “negatively,” and 1.4% of patients as “extremely negatively.” There were no significant differences in the change between preoperative Hip disability and Osteoarthritis Outcome Scores/Knee Injury and Osteoarthritis Outcome Score Joint Replacement, or Veterans RAND 12 Physical and Mental components and these values at 12 weeks follow-up and 1-year follow-up, respectively, in patients who had telemedicine visits versus those who had traditional in-person visits.

The results of this study demonstrate that the patients who decided to have a telemedicine visit during their postoperative visit were satisfied with their experience. Overall, COVID-19 had a positive influence on patient's feelings toward telemedicine visits.

Telemedicine retains potential for increasing access to specialty providers in underserved and rural communities. COVID-19 accelerated adoption of telehealth beyond rural populations, serving as a primary modality of patient–provider encounters for many nonemergent diagnoses.

From 2020 to 2021, telemedicine was incorporated in management of stereotactic radiosurgery patients. Retrospective data on diagnoses, demographics, distance to primary clinic, and encounter type were captured and statistically analyzed using descriptive measures and Cox proportional regression modeling. Graphical representation of service areas was created using geo-mapping software.

Patients (n = 208) completed 331 telemedicine encounters over 12 months. Metastases and meningiomas comprised 60% of diagnoses. Median age was 62 years with median household income and residential population of $44,752 and 7,634 people. The one-way mean and median travel distances were 74.6 and 66.3 miles. The total potential road mileage for all patients was 44,596 miles. A total of 118 (57%) patients completed video visits during the first encounter, whereas 90 (43%) opted for telephone encounters. At 12 months, 138 patients (66%) utilized video visits and 70 (34%) used telephone visits. Predictors of video visit use were video-enabled visit during the first encounter (hazard ratio [HR] 2.806, p < 0.001), total potential distance traveled (HR 1.681, p < 0.05), and the need for more than one visit per year (HR 2.903, p < 0.001).

Telemedicine can be effective in radiosurgery practice with predictors of video-enabled use being pre-existing patient comfort levels with videoconferencing, total annual travel distance, and number of visits per year. Age, rural population status, and household income did not impact telemedicine use in our patient cohort.

Avoidable hospital admissions put increased pressure on already strained health care resources, causing emotional and financial distress for patients and their families while taxing the health system. Pharmacist involvement in patient care has been shown to improve health care outcomes. Telepharmacy allows for personalized interaction and access to pharmacy services in a flexible format. The primary aim of this report is to explore the impact that access to a personalized telepharmacy service has on the hospital admission rate in an outpatient population before and during the COVID-19 pandemic.

A retrospective, double-arm cohort study was performed. Hospital admission rates were analyzed in two similarly aged groups; one group (n = 2,242) had access to telepharmacy services through their primary care provider and another group did not (n = 1,540), from 2019 to 2020. Statistical analysis was performed to explore hospitalization rates in both groups.

An increase in hospitalization rates was observed in both groups of patients from 2019 to 2020. The patient group that had access to the telepharmacy service demonstrated a reduced rise in hospitalization rates versus the group without access to the telepharmacy service (access group +12.9% vs. nonaccess group +40.2%, p < 0.05, Student's t-test).

The patient group with access to telepharmacy services demonstrated a reduced increase in hospitalizations versus the group without access in 2020. While this represents a preliminary investigation into the potential impacts of telepharmacy on hospitalization rates, telepharmacy services may have a role in improving patient outcomes and cost savings.

To examine the variety of patient satisfaction instruments (i.e., measures, methods, and scales) used within telemedicine remote patient monitoring (RPM) services; and to assess the quality of RPM patient satisfaction instruments.

Three databases were searched for articles that used survey instrumentation to assess patient satisfaction of RPM services: (1) Healthcare Administration Database (PROQUEST), (2) Cumulative Index to Nursing and Allied Health Literature (CINAHL), and (3) PubMed (MEDLINE). The quality of survey instrumentation methods was assessed based on validity and reliability using the Terwee et al. framework.

Nine studies were included in the final review. For internal consistency, seven out of nine studies received an “indeterminant” quality rating; six out of nine of the studies received a “positive” quality rating for measurement error. For content validity, seven out of nine studies received a “positive” quality rating.

There are several RPM surveys that are used to assess patient satisfaction. This review suggests wide variation among the quality, reliability, and validity of the surveys currently used in practice. Assessing patient satisfaction of RPM services by organizations, researchers, and practitioners should be done through use of reliable instrumentation.

Children with autism achieve improved behavioral outcomes with applied behavior analytic (ABA) interventions. Typically, ABA is delivered in a participant's home or in a clinic setting. At the onset of COVID-19, treatment in these environments was not available due to health exposure concerns. A large social service organization in California rapidly pivoted to the delivery of ABA intervention through telehealth. Access disparity for telehealth has been a historical concern in health care delivery, particularly for disenfranchised populations within the autistic participant population.

This study evaluated the demographic and behavioral variables associated with the acceptance or declination of telehealth by the pediatric participants' caregivers at the onset of the pandemic.

A non-experimental design was used, and archival data were compared for a random sample of 100 participants with autism who accepted telehealth interventions with 100 participants who declined it.

Socioeconomic data, gender, age, ethnicity, language, and household size were compared. Clinical data were compared for treatment dosage, standardized Vineland Adaptive Behavior Scales scores, and Verbal Behavior Milestones Assessment and Placement Program scores.

None of the demographic variables were statistically significant in a participant's acceptance or declination of telehealth, but there were moderate differences in treatment dosage across the groups.

It is concerning that a large portion of participants initially declined intervention via telehealth, resulting in these participants experiencing a gap in intervention during the pandemic. As intervention is imperative for pediatric autism participants, it is untenable that ∼40% of the population initially declined telehealth at the start of the pandemic.

Satisfaction with telemedicine is generally high; however, it can lead to communication problems for people with hearing loss (HL), especially when encounters are conducted by telephone, because of the inability to see the face and lips on which many people with HL rely. Despite acknowledgement that HL might affect telemedicine outcomes, no studies have directly examined this. The primary aims of this study were to determine whether and how HL impacts patient satisfaction and willingness to use telemedicine.

Opinions about telemedicine were assessed in a survey of 383 members of the general public. Data regarding reported hearing ability, use of hearing assistive technology, and preferred form of communication (oral/aural vs. sign language) were also collected; people with HL were intentionally oversampled. Survey items included closed set and open-ended responses.

People with HL declined the offer of telemedicine appointments, rated telemedicine outcomes significantly less positively, and had stronger preferences for in person care than did people without HL. Explanations provided for this were directly associated with hearing-related difficulties or the indirect consequences of those difficulties. HL resulted in concerns about communication during the appointment, a lack of privacy when an intermediary helped with communication during the appointment, worries that critical information has been misheard/missed, and anxiety/stress.

The needs of people with HL during telemedicine encounters must be addressed to ensure equitable access. Health care providers should take responsibility to communicate clearly with people with HL and individuals with HL should be willing to advocate for their needs and use special access tools during telemedicine appointments.

Eye movement desensitization and reprocessing (EMDR) is an evidence-based psychotherapy method designed to treat distress associated with traumatic memories. The COVID-19 pandemic has challenged providers to shift EMDR to telehealth platforms.

This research had to aims. (1) To compare EMDR in conjunction with cognitive behavioral therapy (CBT) with CBT alone for treatment of a patient population with prevalent anxiety and (2) to compare the efficacy of virtual EMDR with that of in-person EMDR in the primary care setting.

Retrospective chart review of all adult patients seen by a single therapist at a primary care center was conducted from January 2018 to December 2020. Charts were reviewed for demographics, psychiatric diagnoses, number of visits, number and type of EMDR treatments, and patient health questionnaire (PHQ)-9 and general anxiety disorder (GAD-7) scores pre- and post-treatment.

Patients who underwent EMDR with CBT demonstrated greater decreases in PHQ-9 and GAD-7 scores than patients who had only CBT (2.4, 2.5 vs. 0.9, 1.1). However, after adjusting for total number of sessions, post-traumatic stress disorder, grief, and pain, the adjusted mean differences of change in PHQ-9 and GAD-7 scores between those who underwent EMDR with CBT and CBT-exclusive patients were not statistically significant. Similarly, the adjusted mean differences of change in PHQ-9 and GAD-7 scores between those who underwent virtual EMDR and those who had in-person EMDR were not statistically significant.

To our knowledge, this is the first study describing the use of virtual EMDR in a primary care setting. Although our data did not provide evidence for the superiority of EMDR with CBT over CBT alone, we demonstrate that both in-person and virtual EMDR led to significantly improved GAD-7 scores.

Although many studies have explored the perceived ease-of-use of telemedicine, the perceived usefulness of telemedicine for pediatric subspecialty care is less clear.

We invited a national sample of 840 general pediatricians and 840 pediatric subspecialists to participate in a survey fielded in May–June 2020. Respondents ranked perceptions of usefulness of telemedicine for pediatric subspecialty care on a 5-point Likert scale and prioritization of potential strategies to support telemedicine use on a 4-point scale.

Of 285 respondents (18% response rate), physicians perceived that increased telemedicine use by pediatric subspecialists would modestly improve child health (mean = 3.5, standard deviation [SD] = 0.7), and access to care (mean = 3.9, SD = 0.6), but would slightly worsen the clinician experience (mean = 2.8, SD = 0.8). Most respondents highly prioritized payment-related strategies to support use of telemedicine.

Pediatric clinicians anticipated that increased telemedicine use by pediatric subspecialists would improve child health and health care access but would worsen clinician experience.

Telemedicine could increase timely access to primary care—a key dimension of care quality.

Among patient-scheduled appointments with their own primary care providers using the online portal in a large integrated health care delivery system, we measured the association between visit type (telemedicine or in-person) and appointment timeliness. We calculated the calendar days between the scheduling date and the actual appointment time.

Overall, 2,178,440 primary care visits were scheduled and 14% were done through telemedicine. The mean calendar days between the scheduling and the appointment time were 1.80 for telephone visits, 2.29 for video visits, and 3.52 for in-person visits. After multivariate adjustment, 66.61% (confidence interval [95% CI]: 66.44–66.79) of telephone visits, 56.58% (95% CI: 55.90–57.27) of video visits, and 46.49% (95% CI: 46.42–46.57) of in-person visits were scheduled to occur within 1 day of making the appointment.

In a setting with comparable in-person and telemedicine scheduling availability, choosing telemedicine was associated with more timely access to primary care.

Since the onset of the COVID-19 pandemic, there has been rapid expansion in the use of telehealth. As a result, many providers who had no prior experience using telehealth are now using it to provide patient care. The goal of this study was to survey health care providers on a wide range of telehealth topics including their experiences examining and connecting with patients digitally, identifying which types of patients may be best suited to telehealth, and identifying technical and logistical areas for improvement when using telehealth.

Physicians and advanced practice providers (n = 944) at a large midwestern academic system were invited to complete an anonymous online survey during a 2-week period in October 2020.

Surveys, completed and analyzed (n = 178), indicated 86.6% of respondents felt confident in their clinical assessment, and 86.1% felt they formed an adequate personal connection with the patient in the majority of telehealth visits. A majority (58.5%) of providers felt telehealth was not effective for new patients, but 83% of providers felt it was effective for providing care to established patients. Respondents identified several areas for technological improvement including issues with video (27.5%) and audio (16.8%) quality. In 24.4% of visits, these technology issues were severe enough providers needed to convert an audiovisual appointment to telephone.

Provider experience with telehealth has largely been positive at our institution. Although telehealth may not be appropriate for new patients, providers did feel it was an effective means of providing care for established patients. To continue improving the quality of telehealth, a multiteam approach should be considered, including members of technology and clinical operations teams working closely with those providers experienced in telehealth.

To evaluate physician's opinion and availability to participate in mHealth-related clinical studies with patient recruitment and assessment via telemedicine and to identify characteristics associated with the willingness to participate.

Cross-sectional, observational study, based on an anonymous web survey conducted in May–Jun of 2020 to 237 physicians, from Portugal and Spain that collaborated with an asthma mHealth project (INSPIRERS).

Response rate was 51% (n = 120). Most (74%, n = 89) physicians were available to participate in such studies, but 62% anticipated lower recruiting capacity and 40% increased difficulty in obtaining quality data. Physicians aged ≤40 years, from secondary care (vs. general practitioners) and that used apps in personal life or clinical practice were more likely to be available.

Three-quarters of the physicians were available to participate in mHealth-related clinical studies with patient recruitment and assessment through telemedicine. Age group, medical specialty, and app use were associated with the willingness to participate.