A qualitative investigation of uninsured patient and primary care provider perspectives on specialty care eConsults.

BACKGROUND: Uninsured and underinsured patients face specialty care access disparities that prevent them from obtaining the care they need and negatively impact their health and well-being. We aimed to understand how making specialty care electronic consultations (eConsults) available at a multi-site Federally Qualified Health Center (FQHC) in central Texas affected uninsured patients' care-seeking experiences and impacted their ability to receive the needed care. METHODS: We used concepts from Ecological Systems Theory to examine individual, interpersonal, organization-level, social, and health policy environment factors that impacted patients' access to specialty care and the use of eConsults. We conducted thematic analysis of semi-structured, qualitative interviews with patients about seeking specialty care while uninsured and with uninsured patients and FQHC PCPs about their experience using eConsults to obtain specialists' recommendations. RESULTS: Patients and PCPs identified out-of-pocket cost, stigma, a paucity of local specialists willing to see uninsured patients, time and difficulty associated with travel and transportation to specialty visits, and health policy limitations as barriers to obtaining specialty care. Benefits of using eConsults for uninsured patients included minimizing/avoiding financial stress, expanding access to care, expanding scope of primary care, and expediting access to specialists. Concerns about the model included patients' limited understanding of eConsults, concern about cost, and worry whether eConsults could appropriately meet their specialty needs. CONCLUSIONS: Findings suggest that eConsults delivered in a primary care FQHC addressed uninsured patients' specialty care access concerns. They helped to address financial and geographic barriers, provided time and cost savings to patients, expanded FQHC PCPs' knowledge and care provision options, and allowed patients to receive more care in primary care.

Impact of eConsults on Clinical Care in Primary Care: A Cross-Sectional Analysis of Primary Care Provider Behavior.

INTRODUCTION/OBJECTIVES: Asynchronous electronic consultations (eConsults) support primary care providers (PCPs) by providing rapid specialist feedback and improve medically underserved patients' access to care. METHODS: This cross-sectional study assessed all eConsults requested over a one-year period at a multi-site federally qualified health center in Texas. We analyzed eConsult content and quality and conducted chart reviews for a randomly selected subsample (n = 100) to determine whether PCPs implemented specialists' recommendations within 90 days. Semi-structured interviews with PCPs assessed their ability and willingness to follow recommendations. RESULTS: There were 367 eConsults submitted by 25 PCPs across 15 adult medical and surgical specialties. Of the 100 charts reviewed n = 77 (77.0%) contained documentation indicating that the PCP had followed at least 1 of the specialist's recommendations within 90 days. In two-thirds of the cases (n = 66, 66%) the reviewing specialist indicated that a face-to-face referral was not needed. PCPs were most likely to follow recommendations for new medications and least likely to document that they had obtained additional patient history. PCPs noted that they were sometimes unable to follow recommendations when patients could not afford or access treatment or did not return for follow up care, or when they felt that the specialist did not address their specific question. CONCLUSIONS: eConsults delivered to medically underserved patients in primary care help PCPs provide timely care for their patients. PCPs utilized a broad range of eConsult specialties and generally implemented eConsult specialists' recommendations within 90 days.

Increased Revenue From Averted Missed Appointments Following Telemedicine Adoption at a Large Federally Qualified Health Center.

This study examined savings from averted missed appointments following telemedicine adoption. Data were obtained from a large Federally Qualified Health Center in Texas during the early pandemic months. Patient encounters fell into one of three categories: (1) in-person visit, (2) telemedicine alone with no support team engagement, and (3) telemedicine with previsit support team engagement for device and connectivity testing. Our findings revealed that in-person visits had a 21% missed appointment rate compared to 19% for telemedicine alone and 15% for telemedicine with previsit support. Translating the reductions following both telemedicine encounters into net reimbursement, telemedicine alone saved the Federally Qualified Health Center $16 444 per month, while telemedicine + support team reduced missed appointments and saved the clinic an additional $29 134. The revenue from averted missed appointments totaled $45 578 per month. In conclusion, telemedicine reduced missed appointments, and these averted missed appointments translated into cost-savings. Savings were more pronounced with the implementation of a support team that conducted previsit device and connectivity testing.

The Impact of eConsults on Access to Specialty Care for the Uninsured in Rural Texas.

OBJECTIVE: This study evaluated the impact of eConsults on access to specialty care for uninsured patients in Central Texas. METHODS: eConsults for four specialties, cardiology, gastroenterology, rheumatology, and endocrinology, were implemented in a large, multi-site federally qualified health center. Data were collected on specialty care access and utilization for a one-year period before and after implementation of the new process. RESULTS: Prior to implementation, 23% of uninsured patients referred to the included specialties completed a visit with a specialist. After implementation, 62% received a specialty consultation either through an eConsult or with a face-to-face visit. Wait times for referrals improved from a median of 54 days to seven days. CONCLUSION: This project demonstrated that eConsults improve access and reduce wait times for specialty care for uninsured patients. Interventions such as this have the potential to reduce health inequalities by providing timely access to care for common specialty concerns.

Associations between Patient- and Provider Level Factors, and Telemedicine Use in Family Medicine Clinics.

INTRODUCTION: Increased telemedicine implementation may promote primary care access. However, gaps in telemedicine uptake may perpetuate existing disparities in primary care access. This study assessed provider- and patient-level factors associated with telemedicine use in community-based family practice clinics. METHODS: This retrospective study used electronic medical records data from a large Federally Qualified Health Center. A 3-level mixed-effects logistic regression model explored predictors of telemedicine use, with provider and patient as random effects. RESULTS: The analytic sample included 37,428 unique patients with 106,567 primary care encounters with 42 family medicine providers. Fifty-seven percent of the sample identified as Hispanic, 28% non-Hispanic White, and 11% non-Hispanic Black. Compared to Hispanics, non-Hispanic White patients had 61% higher odds of a telemedicine visit, and non-Hispanic Black patients had 32% higher odds of a telemedicine visit. The odds of telemedicine use were lower for those who were uninsured. Those residing in metropolitan areas or medically underserved areas had greater odds of a telemedicine appointment. Commute time exhibited a dose-response relationship with telemedicine use. Provider characteristics were not significantly associated with telemedicine use. DISCUSSION: While provider characteristics were not associated with telemedicine use, greater focus on patient characteristics specific to the population served is necessary.

Utilization Gaps During the COVID-19 Pandemic: Racial and Ethnic Disparities in Telemedicine Uptake in Federally Qualified Health Center Clinics.

BACKGROUND: The Coronavirus Aid, Relief, and Economic Security (CARES) Act led to the rapid implementation of telemedicine across healthcare office settings. This innovation has the potential to improve healthcare use and ensure continuity of care. However, this delivery model could have an unintended consequence of worsening racial/ethnic disparities in healthcare utilization if adoption varies across sub-populations. OBJECTIVE: To examine associations between telemedicine use and race/ethnicity between 3/1/2020 and 11/30/2020, and the influence of other individual- and geographical-level factors on this relationship. DESIGN: Cohort study PARTICIPANTS: EMR data from 55 clinics in a FQHC network MAIN MEASURES: The dependent variable was visit type (in-person vs. telemedicine). Predictors of interest were patient race and ethnicity. To account for repeated visits within each patient nested within clinic, a three-level, mixed-effects, multivariable, logistic regression model was used. Subgroup analyses examined correlates of telemedicine use in African American and Hispanic cohorts, separately. KEY RESULTS: The analytic sample included 233,302 visits for 67,733 unique patients. African Americans (OR = 0.65, 95% CI: 0.61, 0.69), Asians (OR = 0.58, 95% CI: 0.52, 0.65), and American Indians / Alaska Natives and other Pacific Islanders (OR = 0.82, 95% CI: 0.70, 0.98) were significantly less likely to use telemedicine compared to Whites. Hispanics were also less likely to have a telemedicine visit (OR = 0.49, 95% CI: 0.47, 0.51) compared to non-Hispanics. Nonacute visits were more likely to be conducted via telemedicine. Distance to clinic exhibited a dose-response relationship such that patients who lived farthest from the clinics were most likely to have telemedicine visits. In the subgroup analyses to examine predictors of telemedicine use, the dose-response relationship between distance from clinic and telemedicine use persisted, with increasing distance associated with increasing likelihood of telemedicine use, in both African American and Hispanic cohorts. Nonacute visits were associated with telemedicine use in the Hispanic cohort, but not in the Black / African American cohort. CONCLUSION: Racial/ethnic disparities in telemedicine use persisted among this cohort. However, telemedicine improved utilization for African Americans and Hispanics living farther away from the clinic.

Transition to telemedicine and its impact on missed appointments in community-based clinics.

BACKGROUND AND OBJECTIVE: The Coronavirus Aid, Relief, and Economic Security Act led to the rapid implementation of telemedicine across health care office settings. Whether this transition to telemedicine has any impact on missed appointments is yet to be determined. This study examined the relationship between telemedicine usage and missed appointments during the COVID-19 pandemic. METHOD: This retrospective study used appointment-level data from 55 Federally Qualified Health Centre clinics in Texas between March and November 2020. To account for the nested data structure of repeated appointments within each patient, a mixed-effects multivariable logistic regression model was used to examine associations between telemedicine use and missed appointments, adjusting for patient sociodemographic characteristics, geographic classification, past medical history, and clinic characteristics. The independent variable was having a telemedicine appointment, defined as an audiovisual consultation started and finalized via a telemedicine platform. The outcome of interest was having a missed appointment (yes/no) after a scheduled and confirmed medical appointment. Results from this initial model were stratified by appointment type (in-person vs. telemedicine). RESULTS: The analytic sample included 278,171 appointments for 85,413 unique patients. The overall missed appointment rate was 18%, and 25% of all appointments were telemedicine appointments. Compared to in-person visits, telemedicine visits were less likely to result in a missed appointment (OR = 0.87, p < .001). Compared to Whites, Asians were less likely to have a missed appointment (OR = 0.82, p < .001) while African Americans, Hispanics, and American Indians were all significantly more likely to have missed appointments (OR = 1.61, p < .001; OR = 1.19, p = .01; OR = 1.22, p < .01, respectively). Those accessing mental health services (OR = 1.57 for in-person and 0.78 for telemedicine) and living in metropolitan areas (OR = 1.15 for in-person and 0.82 for telemedicine) were more likely to miss in-person appointments but less likely to miss telemedicine appointments. Patients with frequent medical visits or those living with chronic diseases were more likely to miss in-person appointments but less likely to miss telemedicine appointments. CONCLUSIONS: Telemedicine is strongly associated with fewer missed appointments. Although our findings suggest a residual lag in minority populations, specific patient populations, including those with frequent prior visits or chronic conditions, those seeking mental health services, and those living in metropolitan areas were less likely to miss telemedicine appointments than in-person visits. These findings highlight how telemedicine can enable effective and accessible care by reducing missed healthcare appointments.KEY MESSAGESTelemedicine was associated with 13% lower odds of missed appointments.Patients with frequent medical visits or those living with chronic diseases were less likely to miss telemedicine appointments but more likely to miss in-person appointments.Patients seeking mental health services were less likely to miss telemedicine appointments but more likely to miss in-person appointments.Similarly, those living in metropolitan areas were less likely to miss telemedicine appointments but more likely to miss in-person appointments.