Telemedicine and e-Health

Telemedicine has emerged as a feasible adjunct to in-person care in multiple clinical contexts, and its role has expanded in the context of the COVID-19 pandemic. However, there exists a general paucity of information surrounding best practice recommendations for conducting specialty or disease-specific virtual care. The purpose of this study was to systematically review existing best practice guidelines for conducting telemedicine encounters.

A systematic review of MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) of existing guidelines for the provision of virtual care was performed. Data were synthesized using the Synthesis Without Meta-Analysis (SWiM) guideline, and the Appraisal of Guidelines for Research & Evaluation Instrument (AGREE II) tool was used to evaluate the quality of evidence.

A total of 60 guidelines for virtual care encounters were included; 52% of these were published in the context of the COVID-19 pandemic. The majority (95%) of provider guidelines specified a type of virtual encounter to which their guidelines applied. Of included guidelines, 65% provided guidance regarding confidentiality/security, 58% discussed technology/setup, and 56% commented on patient consent. Thirty-one guidelines also provided guidance to patients or caregivers. Overall guideline quality was poor.

General best practices for successful telemedicine encounters include ensuring confidentiality and consent, preparation before a visit, and clear patient communication. Future studies should aim to objectively assess the efficacy of existing clinician practices and guidelines on patient attitudes and outcomes to further optimize the provision of virtual care for specific patient populations.

Despite a good evidence base for telepsychiatry (TP), economic cost analyses are infrequent and vary in quality.

A scoping review was conducted based on the research question, “From the perspective of an economic cost analysis for telehealth and telepsychiatry, what are the most meaningful ways to ensure a study/intervention improved clinical care, provided value to participants, had population level impact, and is sustainable?” The search in seven databases focused on keywords in four concept areas: (1) economic cost analysis, (2) evaluation, (3) telehealth and telepsychiatry, and (4) quantifiable health status outcomes. The authors reviewed the full-text articles based on the inclusion (Medical Subject Headings [MeSH] of the keywords) and exclusion criteria.

Of a total of 2,585 potential references, a total of 99 articles met the inclusion criteria. The evaluation of telehealth and TP has focused on access, quality, patient outcomes, feasibility, effectiveness, outcomes, and cost. Cost-effectiveness, cost–benefit, and other analytic models are more common with telehealth than TP studies, and these studies show favorable clinical, quality of life, and economic impact. A standard framework for economic cost analysis should include: an economist for planning, implementation, and evaluation; a tool kit or guideline; comprehensive analysis (e.g., cost-effectiveness or cost–benefit) with an incremental cost-effectiveness ratio; measures for health, quality of life, and utility outcomes for populations; methods to convert outcomes into economic benefits (e.g., monetary, quality of adjusted life year); broad perspective (e.g., societal perspective); sensitivity analysis for uncertainty in modeling; and adjustments for differential timing (e.g., discounting and future costs).

Technology assessment and economic cost analysis—such as effectiveness and implementation science approaches—contribute to clinical, training, research, and other organizational missions. More research is needed with a framework that enables comparisons across studies and meta-analyses.

This systematic review aimed to evaluate the satisfaction of older adults with telemedicine during the COVID-19 pandemic, assess preferences to telemedicine or in-person visits, and identify factors of influence on the satisfaction with telemedicine.

The review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Statement. A search through key electronic databases identified 228 citations. After duplicate record removal, and title and abstract screening, 43 articles were eligible for full-text review. Of these, 10 studies meeting the inclusion criteria of the review were finally included.

Older adults were satisfied with telemedicine during the COVID-19 pandemic. Patients were in favor of telemedicine compared to in-person visits, but the evidence support for this preference was limited. Factors influencing satisfaction were identified and categorized under four main categories: system-related factors, patient-related factors, socioeconomic factors, and factors related to the nature of the medical intervention.

Older adults were satisfied with telemedicine during the COVID-19 pandemic. A positive trend of preference toward telemedicine was observed, but not well established due to the lack of an objective measure of assessment. Technical issues related to the telemedicine delivery system were the main challenges. The socioeconomic status and level of education of older adults can relatively influence the level of satisfaction with telemedicine. The experience of older adults with telemedicine is still evolving and advanced technologies specifically designed to address their needs must be explored to increase the telemedicine uptake among the older adult population during and beyond the COVID-19 pandemic.

Telemedicine has emerged as a powerful tool in the delivery of health care to surgical patients and innovations are developing to address challenges in the technology, enhancing consumer–provider encounters while located remotely. Our study aims at collating and commenting on the published evidence for how current challenges in telemedicine for surgical clinics are met by innovations currently in development. We also comment on the implementation and monitoring strategies for telemedicine.

Databases searched included: PubMed, OVID Medline, Embase, Scopus, Web of Science, and review of reference lists. Key words used were “telemedicine”; “telehealth”; “videoconference”; “outpatient”; and “surgical clinic.” For inclusion, articles required to be in English, published between 2000 and 2021, were in an outpatient surgical setting, and if they had a focus during the COVID-19 pandemic.

Three hundred forty-five articles were identified and screened, so that 73 articles were included in the review. Almost all articles were from Western countries (n = 69), mostly in surgical journals (n = 39) and from a range of sub-specialties, but pre-dominantly orthopedics (n = 12) and general surgery (n = 9). The majority were original comparative studies, with 31 studies directly comparing telemedicine with in-person appointments and 22 articles focused on implementation during COVID-19.

Advanced telecommunication technology has enabled telemedicine to become an effective and safe form of health care delivery, with high consumer and provider satisfaction. Innovative protocol and technology developments have addressed the limitations of telemedicine. Sophisticated and familiar medical software integrates with electronic medical records to automate and streamline documentation, consent, and billing processes. Surgical clinics are investing in telehealth workflow co-ordination and information technology support to troubleshoot any technical difficulties as well as education for providers and consumers to address technology illiteracy. As health care services continue to transition their systems to an online network, further research is required to understand the ability and assess the feasibility of telemedicine to fully integrate.

We examine how and why Americans have experienced interrupted health care during the COVID-19 pandemic and measure awareness and usage of expanded benefits offered by health insurers and employers. We use an expanded concept of health literacy to include knowledge of access conditions and consider if patients' knowledge of the health system may relate to utilization of care.

We conducted an online survey of 451 U.S. adults in September 2020, asking respondents about their health care experiences since March 1, 2020. This survey measured usage of medical care and awareness of the efforts made by government, private insurers, and employers to increase access to benefits such as telehealth services, well-being and mental health programs, and new prescription options.

The most common reasons cited for postponing or skipping medical appointments included fears over COVID-19 exposure, following local restrictions, or wanting to preserve resources for those with COVID-19. Our survey also finds that many Americans are largely unaware of whether they have access to expanded benefits implemented during the pandemic. Critically, respondents who recalled telehealth and prescription medication benefits being promoted were more likely to report using such benefits.

This research suggests that greater attention to health literacy can help promote participation in the system by patients and has the potential to lead to improved health outcomes and greater adherence to treatment plans. Telehealth may offer patients increased opportunities to consult with their physicians for ailments that they might otherwise have delayed seeking care.

To improve patient access to skin care, the Department of Veterans Affairs (VA) developed a patient-facing asynchronous mobile teledermatology application (app), which allows patients to follow up remotely with dermatologists. To understand how the app would be received in VA, we examined Organizational Readiness for Change (ORC), an important prelude to effective implementation, which includes the shared resolve and collective ability of organizational members to implement a change.

We used a mixed-methods multiple case study approach to assess ORC at three VA facilities. Data derived from a site process call, surveys, and semistructured telephone interviews of VA staff, field notes, and administrative data.

Participants at all three facilities supported the intervention and recognized the value of using the app to increase patients' access to dermatologists, but expressed concerns largely related to disruption of the pre-existing clinical workflow. Participants at the facility most actively using the app had the highest overall ORC score and reported the most facilitators. Facility leadership support when guided by a clinical champion minimized barriers by recognizing the complexities of health care provision at specialty clinics.

While provider buy-in remained a barrier, leadership, guided by the clinical champion, played a critical role instituting implementation strategies. The strong association between the ORC survey score and the presence of facilitators and barriers suggests that the ORC survey may be a rapid, convenient, and effective tool for health care systems to identify favorable sites for wider implementation of mobile telehealth care. Clinical Trials Identifier: NCT03241589

Lower insurance reimbursements have limited the financial sustainability of remote eye screening programs. Greater utilization and insurance coverage for teleophthalmology screening during the coronavirus disease 2019 (COVID-19) pandemic in 2020 may enhance awareness and expand remote retinal imaging services. This retrospective cross-sectional study evaluates utilization and insurance coverage for remote retinal imaging in the United States in 2020.

We analyzed teleretinal imaging utilization and insurance payments from January 1 to December 31, 2020, using the Optum Labs Data Warehouse, a comprehensive national database of deidentified administrative claims for commercial and Medicare Advantage enrollees in the United States. We evaluated frequency of claims and insurance payment for services using the Current Procedural Terminology codes 92227 and 92228 for remote eye imaging by any provider, and 92250 for fundus photography by non-eye care providers.

The use of remote retinal imaging in the United States declined rapidly during the initial COVID-19 lockdown from 3,627 claims in February 2020 to 1,414 claims in April 2020, but returned to 3,133 claims by December 2020, similar to mean prepandemic levels in 2019 (2,841 ± 174.8 claims). The proportion of insurance payments for remote imaging increased temporarily from 47.4% in February to 56.7% in April, and then returned to 45.9% in December of 2020.

Utilization of remote retinal imaging declined steeply, while the insurance coverage increased during the initial COVID-19 lockdown in 2020, but returned to prepandemic levels by end of the year. Changes in utilization and relaxed restrictions on insurance reimbursements for teleophthalmology during the COVID-19 pandemic were not sustained.

In the United States, colorectal cancer (CRC) is the second leading cause of cancer death in men and women combined. The United States Preventive Services Task Force recommends that average risk adults have regular CRC screening to detect and prevent CRC. Despite published CRC screening guidelines, national CRC screening rates remain suboptimal. With the exponential increase in technology use and device ownership, many mobile health applications (apps) have been developed to improve health outcomes. There is great potential for smartphone or tablet apps to help improve CRC screening uptake, with the ultimate goal of reducing CRC morbidity and mortality. To date, there are no systematic reviews that have examined the publicly available, free apps that are related to CRC screening, and therefore, the quality and the content of these apps remain unknown.

The purpose of this study was to systematically review smartphone and tablet apps that could be used to improve CRC screening uptake.

Apps available on the Google Play and Apple App stores that were compatible with smartphones and tablets were reviewed. Of the 2,790 apps reviewed, 20 met inclusion criteria.

Of the 20 apps that met inclusion criteria, most were informational in nature. Approximately half of the apps focused on colonoscopies and did not discuss other CRC screening options. Furthermore, more than half of the apps did not include video/audio content and the majority of the apps did not provide navigation support (e.g., reminders, instructions, maps).

There are multiple free, publicly available apps that may encourage CRC screening uptake. Despite their promise, there is a paucity of empirical evidence evaluating the efficacy and usability of these apps. Future research efforts can evaluate the content, usability, accessibility, and potential impact of these apps.

The use of digital technology within health care service delivery, monitoring, and research is becoming progressively popular, particularly given the ongoing COVID-19 pandemic. Mobile health (m-health) apps, one form of digital technology, are increasingly being used to promote positive health related behavior change. Therefore, it is important to conduct research to understand the efficacy of m-health apps. The process of participant recruitment is an essential component in producing strong research evidence, along with ensuring an adequately powered sample to conduct meaningful analyses and draw robust conclusions.

In this work we outline and reflect on the strategies used to recruit help-seeking military veterans into an intervention study, which aimed to evaluate the efficacy of an app (Drinks:Ration) to modify behavior in alcohol misusers. Recruitment strategies included through (1) partner organizations and (2) social media and Facebook advertising (ads).

Facebook ads were live for a period of 88 days and were viewed by a total audience of 29,416 people. In total 168 military veterans were recruited across all recruitment strategies, meaning that Drinks:Ration exceeded its recruitment targets. Half of the sample (n = 84) were recruited through social media, including Facebook ads.

The current article highlighted that targeted Facebook ads were an efficient strategy to recruit military veterans into a digital intervention trial aiming to reduce alcohol consumption because they reduced the amount of time and resources required to contact a large number of potentially eligible individuals for our study. This article acts as a starting point for other researchers to evaluate their recruitment pathways for recruiting military veterans into alcohol misuse research.

The COVID-19 pandemic has renewed the interest in telepsychiatry as a way to help psychiatrists care for their patients, but mental health providers' unfamiliarity and concerns may impede implementation of such services. This study aimed to determine the effect of an online educational intervention on awareness, knowledge, attitude, and skills (AKAS) of telepsychiatry among psychiatrists.

The study used a pre-post-test design to compare AKAS of telepsychiatry among psychiatrists participating in an online course of practical telepsychiatry. The telemedicine AKAS questionnaire adapted to telepsychiatry was applied before and after the educational intervention, during the months of October to December 2020.

Responses from 213 participants were analyzed before the educational intervention and from 152 after it. The knowledge showed by Spanish psychiatrists before the educational intervention was good in 61% of participants, fair in 37%, and inadequate in 2%. With respect to attitudes toward telepsychiatry, 62% self-reported a high attitude, 33% moderate, and 5% low. With regard self-reported skills, 57% of the participating psychiatrists were highly skilled or experts, 22% moderately skilled, and 9% unskilled in handling telepsychiatry equipment. Despite the high baseline values, the educational intervention significantly improved psychiatrists' awareness, knowledge and attitudes toward telepsychiatry although not their skills.

Online course of practical telepsychiatry was effective although future editions need to improve its focus on skills. This educational intervention represents an effort to promote the implementation of telepsychiatry as a health care alternative.

Telehealth is a potential solution to persistent disparities in health and health care access by eliminating structural barriers to care. However, its adoption in urban underserved settings has been limited and remains poorly characterized.

This is a prospective cohort study of patients receiving telemedicine (TM) consultation for specialty care of diabetes, hypertension, and/or kidney disease with a Federally Qualified Health Center (FQHC) as the originating site and an academic medical center (AMC) multispecialty group practice as the distant site in an urban setting. Primary data were collected onsite at a local FQHC and an urban AMC between March 2017 and March 2020, before the COVID-19 pandemic. Clinical outcomes of study participants were compared with matched controls (CON) from a sister FQHC site who were referred for traditional in-person specialty visits at the AMC. No-show rates for study participants were calculated and compared to their no-show rates for standard (STD) in-person specialty visits at the AMC during the study period. A patient satisfaction questionnaire was administered at the end of each TM visit.

Visit attendance data were analyzed for 104 patients (834 visits). The no-show rate was 15%. The adjusted odds ratio for no-show for TM versus STD visits was 1.03 [0.66–1.63], p = 0.87. There were no significant differences between TM and CON groups in the change from pre- to intervention periods for mean arterial pressure (p = 0.26), serum creatinine (p = 0.90), or estimated glomerular filtration rate (p = 0.56). The reduction in hemoglobin A1c was significant at a trend level (p = 0.053). Patients indicated high overall satisfaction with TM.

The study demonstrated improved glycemic control and equivalent outcomes in TM management of hypertension and kidney disease with excellent patient satisfaction. This supports ongoing efforts to increase the availability of TM to improve access to care for urban underserved populations.

Rural injured workers requiring multidisciplinary assessments for musculoskeletal disorders face health access disparities, which include travel to urban centers. Virtual care can enhance access to multidisciplinary team care for musculoskeletal conditions in rural areas.

A retrospective chart audit of 136 multidisciplinary assessment reports of injured workers was conducted. Comprehensive management recommendations from the health care assessment team were extracted for analysis. The health care team used virtual technologies to join with patients and at least one local rural health practitioner in one of three locations. Remote presence robotics (RPR; Xpress Technology™) or laptop-based telehealth was used to complete the assessments.

RPR were used in 46% of assessments over two sites, with 54% using laptop-based telehealth at a third site. Frequencies of team members' assessment using technologies were as follows: physical therapist (100%), psychologist (78%), plastic surgeon (8%), and physician (43%). Spine (42%) and shoulder (32%) disorders were the most common problems. Most workers (79%) were 3 or more months postinjury. The most common management recommendation was the need for daily comprehensive rehabilitation care (76%). Travel time was saved by 89% of participants.

Virtual care was used to unite multidisciplinary assessment teams for the evaluation of injured rural workers with complex musculoskeletal injuries. Future research recommendations include comparing between virtual and fully in-person multidisciplinary assessment and recommendation findings, and evaluation of patient and practitioner experiences with comprehensive virtual team assessments.

Pediatric acute respiratory tract infections (ARTIs) were a common reason for commercial direct-to-consumer (DTC) telemedicine use before the COVID-19 pandemic, but the factors associated with this use are unknown.

To identify child and family factors associated with use of commercial DTC telemedicine for ARTIs in 2018–2019.

We performed a retrospective cohort analysis of claims data from the Optum Clinformatics^® Data Mart Database. Among children with ARTI visits, we fitted logit models to examine child and family characteristics associated with DTC telemedicine use.

Of 660,725 children with ARTI visits, 12,944 (2.0%) had ≥1 commercial DTC telemedicine encounter. The odds of DTC telemedicine use were higher for children with age ≥12 years, lower parent educational attainment, higher household income, white non-Hispanic race/ethnicity, and residency in the West South Central census division.

In 2018–2019, commercial DTC telemedicine use varied with child age, child race/ethnicity parent educational attainment, household income, and geography.

As telemedicine becomes standard in pediatrics, further research is required to ensure optimal adoption. This study seeks to characterize visits best suited for telemedicine by analyzing usage trends and encounter attributes associated with immediate in-person follow-up.

Analysis of ambulatory pediatric encounters from the first quarter of 2021 in a nationwide insurance claims database.

Telemedicine comprised 9.5% (138,346) of ambulatory encounters. Among telemedicine visits, 7.5% (10,304) yielded in-person follow-up within 3 days. Encounters involving infants and diagnoses of the perinatal period were most frequently followed by in-person visits (11% and 20%, respectively). Mental health visits were least likely to have in-person follow-up.

In 2021, telemedicine remained a common modality of care in pediatrics. Varying medical needs still require in-person evaluation, whereas other diagnoses may be conducive to even greater expansion. Insights from this study inform further research into optimization of pediatric telemedicine utilization and development of guidelines.

To identify clinical and informational services that telemental health (TMH) providers need to be more successful in their practice.

In February–March 2021, 472 TMH providers completed a cross-sectional survey. Providers indicated the degree to which they need clinical (e.g., build therapeutic alliances) and informational (e.g., learn about regulatory changes) services. Independent samples t-tests were conducted to examine differences in needs according to when telemedicine was adopted.

TMH providers neutrally-to-somewhat agreed they could benefit from clinical (M = 3.24; standard deviation [SD] = 0.78) and informational (M = 3.66; SD = 0.82) services. Prepandemic TMH providers reported a greater need for services that help them cultivate relationships with patients, monitor health conditions, and to remain updated about reimbursement processes.

All TMH providers could benefit from information about the latest trends and best practices in telemedicine. Prepandemic providers could benefit most from policy-related updates and patient-engagement services.

Young children with congenital heart disease (CHD) are at heightened risk of developmental delay. The outbreak of COVID-19 and the ensuing lockdowns presented an opportunity to test the feasibility of using a short neurodevelopmental assessment tool—the Brief Developmental Assessment (BDA)—remotely via new technologies.

We tested the feasibility and acceptability of remote testing of the tool's 6 domains of development with 30 children younger than 5 years with CHD and 10 healthy controls.

Despite some technical issues, parents largely responded positively to the use of the remote assessment as opposed to traditional face-to-face appointments, citing the beneficial saving of time, money, and childcare.

The acceptability of the remote use of the BDA for the developmental screening of children with CHD will allow for the possibility of increased screening for more children and earlier identification of developmental problems, both during and after COVID-19 restrictions.