Healthcare System Sustainability Challenges in Nepal and Opportunities Offered by Alternative Healthcare Delivery Arrangements.

ABSTRACT: The burden of chronic diseases in Nepal is increasing due to demographic and epidemiological transitions; alongside the persistent impact of communicable, maternal, newborn, and child health diseases, this critical situation acts as the precursor to rising healthcare costs. Nepal struggles to sustain its healthcare system amidst political instability, pandemics, natural disasters, and slow economic growth, particularly when healthcare funding is mainly dependent on out-of-pocket payments. Nepal requires lower-cost alternative healthcare delivery arrangements to provide high-value care while relieving economic sustainability pressures. Alternative healthcare delivery arrangements have a broad potential scope; they can involve strategic changes in how care is delivered and by whom, or they can also involve the application of information and communication technologies, e.g., telemedicine. This paper highlights the specific challenges to healthcare system sustainability in Nepal and the potential for high-value, lower-cost alternative healthcare delivery models to improve system performance in the longer term.

The role of digital health in pandemic preparedness and response: securing global health?

BACKGROUND: Digital health technologies, such as mobile applications, wearable devices, and electronic health record systems, have significantly enhanced global health security by enabling timely data collection and analysis, identifying infectious disease trends, and reducing infection risk through remote services. OBJECTIVE: This study assesses the role of digital health in pandemic preparedness and global health security response. It examines the application of digital health to early detection, surveillance, and data management in patient care. METHODS: We gathered data from scholarly articles published between 2019 and 2024 (found in PubMed, Science Direct, Google Scholar, and Web of Science), reports from the WHO, and case studies of recent pandemics. Topics discussed include digital health technologies, their use, benefits, and issues. We paid special attention to gathering the informed opinions and perspectives of specialists from various fields, including public health, technology, and government. The commentary synthesises these findings to offer suggestions for incorporating digital health into future pandemic preparedness and response. RESULTS: Digital tools improve communication, combat fake news, and reach the public, but data protection and public health remain challenges. Integration requires extensive research and collaboration between governments and the private sector. CONCLUSION: The COVID-19 outbreak demonstrated the importance of digital technology in outbreak management, patient care, communication, and data sharing. As the world transitions into the post-pandemic phase, it will be important to build on these innovations and prepare for the challenges ahead in order to strengthen healthcare systems for future pandemics.

Main finding Digital health technology services like mobile health, big data analytics, and artificial intelligence are essential components of pandemic preparedness and response.Added knowledge This commentary integrates COVID-19 lessons and examines digital health's development in the global health security system, highlighting shortcomings and opportunities for further discoveries.Global health impact for policy and action This commentary highlights priorities for digital health in public health preparedness and makes the case for investment in infrastructure, workforce, and technology access. It highlights the need for international collaboration in combating global health threats and advancing a collaborative, equitable strategy for pandemic readiness.

Redesigning telemedicine: preliminary findings from an innovative assisted telemedicine healthcare model.

BACKGROUND: Telemedicine holds immense potential to revolutionise healthcare delivery, particularly in resource-limited settings and for patients with chronic diseases. Despite proven benefits and policy reforms, the use of telemedicine remains low due to several patient, technology, and system-level barriers. Assisted telemedicine employs trained health professionals to connect patients with physicians, which can improve access and scope of telemedicine. The study aims to describe the design, service utilisation and chronic disease outcomes following the implementation of an assisted telemedicine initiative. METHODS: This is an observational implementation study. Barriers and potential solutions to the implementation of telemedicine were identified through interviews with key stakeholders. The assisted telemedicine solution using an interoperable platform integrating electronic health records, point-of-care diagnostics, and electronic clinical decision support systems was designed and piloted at three telemedicine clinics in Tamil Nadu, India. Nurses were trained in platform use and facilitation of tele-consultations. Health records of all patients from March 2021 to June 2023 were included in the analysis. Data were analysed to assess the utilisation of clinic services and improvements in health outcomes in patients with diabetes mellitus and hypertension. RESULTS: Over 2.4 years, 11,388 patients with a mean age of 45 (± 20) years and median age of 48 years, predominantly female (59.3%), accessed the clinics. The team completed 15,437 lab investigations and 26,998 consultations. Among 5542 (48.6%) patients that reported chronic conditions, diabetes mellitus (61%) and hypertension (45%) were the most frequent. In patients with diabetes mellitus and hypertension, 43% and 75.3% were newly diagnosed, respectively. Diabetes mellitus and hypertension patients had significant reductions in fasting blood sugar (-33.0 mg/dL (95% CI (-42.4, -23.7, P < 0.001)), and systolic (-9.6 mmHg (95% CI (-12.1, -7.0), P < 0.0001)) and diastolic blood pressure (-5.5 mmHg (95% CI (-7.0, -4.08), P < 0.0001)) at nine months from first visit, respectively. CONCLUSIONS: The 'Digisahayam' model demonstrated feasibility in enhancing healthcare accessibility and quality by bridging healthcare gaps, diagnosing chronic conditions, and improving patient outcomes. The model presents a scalable and sustainable approach to revolutionising patient care and achieving digital health equity, with the potential for adaptation in similar settings worldwide.

Best Practices in Telecritical Care: Expert Consensus Recommendations From the Telecritical Care Collaborative Network.

OBJECTIVES: Telecritical care (TCC) refers to the delivery of critical care using telehealth technologies. Despite increasing utilization, significant practice variation exists and literature regarding efficacy remains sparse. The Telecritical Care Collaborative Network sought to provide expert, consensus-based best practice recommendations for the design and delivery of TCC. DESIGN: We used a modified Delphi methodology. Following literature review, an oversight panel identified core domains and developed declarative statements for review by an expert voting panel. During three voting rounds, voters agreed or disagreed with statements and provided open-ended feedback, which the oversight panel used to revise statements. Statements met criteria for consensus when accepted by greater than or equal to 85% of voters. SETTING/SUBJECTS: The oversight panel included 18 multidisciplinary members of the TCC Collaborative Network, and the voting panel included 32 invited experts in TCC, emphasizing diversity of discipline, care delivery models, and geography. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We identified ten core domains: definitions/terminology; care delivery models; staffing and coverage models; technological considerations; ergonomics and workplace safety; licensing, credentialing, and certification; trust and relationship building; quality, safety, and efficiency, research agenda; and advocacy, leading to 79 practice statements. Of 79 original statements, 67 were accepted in round 1. After revision, nine were accepted in round 2 and two in round 3 (two statements were merged). In total, 78 practice statements achieved expert consensus. CONCLUSIONS: These expert consensus recommendations cover a broad range of topics relevant to delivery of TCC. Experts agreed that TCC is most effective when delivered by care teams with specific expertise and by programs with explicit protocols focusing on effective communication, technical reliability, and real-time availability. Interventions should be tailored to local conditions. Although further research is needed to guide future best practice statements, these results provide valuable and actionable recommendations for the delivery of high-quality TCC.

An evaluation of a virtual musculoskeletal podiatry service implemented to address prolonged National Health Service waiting times.

BACKGROUND: The COVID-19 pandemic had a substantial impact on healthcare systems globally, particularly in the public sector. To address the challenges posed by the pandemic, musculoskeletal (MSK) healthcare providers had to rapidly adopt virtual platforms for delivering care, representing a major shift in how healthcare was delivered. OBJECTIVE: This manuscript aims to retrospectively evaluate a virtual MSK podiatry service offered by a private provider under a National Health Service commission, in terms of patient access, waiting times and patient-reported pain. This service was developed and implemented in response to the COVID-19 pandemic and the extended waiting times. METHODS: A retrospective clinical service evaluation was conducted on MSK podiatry services delivered via telephone or virtual consultations. The evaluation covered a cohort of 574 referred patients over a 19-month period (July 2021 to January 2023). It analysed demographic data, initial and final visual analogue pain scores, pathology categories, orthoses prescriptions and exercise rehabilitation plans. RESULTS: Data from a total of 492 patients (male = 152 and female = 340) were analysed, with 82 patients excluded for non-attendance. The average waiting time from referral-to-first appointment and referral-to-discharge was 35 and 91 days, respectively. Results showed statistically significant improvement (p < 0.001) in the mean visual analogue scale when patients received orthoses with and without a rehabilitation plan (4.12 ± 2.55 and 3.33 ± 2.88, respectively). Most patients (61.5%) were aged 40-69, with "foot pain" being the main reported pathology category. Patients had an average of two appointments. 56.5% of patients remained virtual throughout their journey and were successfully discharged to self-management. 43.9% were discharged to other face-to face services. CONCLUSIONS: The study provided evidence that the virtual MSK podiatry service achieved a statistically significant reduction in patient-reported pain for various pathologies with reasonable waiting times. The service delivered favourable outcomes and complemented traditional services at a time with limited access due to the COVID-19 pandemic.

Enhancing the implementation and integration of mHealth interventions in resource-limited settings: a scoping review.

BACKGROUND: Although mobile health (mHealth) interventions have shown promise in improving health outcomes, most of them rarely translate to scale. Prevailing mHealth studies are largely small-sized, short-term and donor-funded pilot studies with limited evidence on their effectiveness. To facilitate scale-up, several frameworks have been proposed to enhance the generic implementation of health interventions. However, there is a lack of a specific focus on the implementation and integration of mHealth interventions in routine care in low-resource settings. Our scoping review aimed to synthesize and develop a framework that could guide the implementation and integration of mHealth interventions. METHODS: We searched the PubMed, Google Scholar, and ScienceDirect databases for published theories, models, and frameworks related to the implementation and integration of clinical interventions from 1st January 2000 to 31st December 2023. The data processing was guided by a scoping review methodology proposed by Arksey and O'Malley. Studies were included if they were i) peer-reviewed and published between 2000 and 2023, ii) explicitly described a framework for clinical intervention implementation and integration, or iii) available in full text and published in English. We integrated different domains and constructs from the reviewed frameworks to develop a new framework for implementing and integrating mHealth interventions. RESULTS: We identified eight eligible papers with eight frameworks composed of 102 implementation domains. None of the identified frameworks were specific to the integration of mHealth interventions in low-resource settings. Two constructs (skill impartation and intervention awareness) related to the training domain, four constructs (technical and logistical support, identifying committed staff, supervision, and redesigning) from the restructuring domain, two constructs (monetary incentives and nonmonetary incentives) from the incentivize domain, two constructs (organizational mandates and government mandates) from the mandate domain and two constructs (collaboration and routine workflows) from the integrate domain. Therefore, a new framework that outlines five main domains-train, restructure, incentivize, mandate, and integrate (TRIMI)-in relation to the integration and implementation of mHealth interventions in low-resource settings emerged. CONCLUSION: The TRIMI framework presents a realistic and realizable solution for the implementation and integration deficits of mHealth interventions in low-resource settings.

Ethical assessment of virtual consultation services: application of a practical ethical checklist to direct-to-consumer services in Aotearoa New Zealand.

Introduction Evaluating digital health services from an ethical perspective remains one of the more difficult challenges in telemedicine and health technology assessment. We have previously developed a practical ethical checklist comprising 25 questions covering six ethical themes: privacy, security, and confidentiality; equity; autonomy and informed consent; quality and standards of care; patient empowerment; and continuity of care. The checklist makes ethical analysis more easily accessible to a broader audience, including health care providers, technology developers, and patients. Aim This project applies the previously developed practical ethical checklist to direct-to-consumer virtual primary care consultation services in Aotearoa New Zealand to conduct an ethical assessment. Method We first mapped the available services. The ethical framework was then applied to assess these services based on publicly available information. Results Our findings show that the examined virtual consultation services adequately address ethical considerations, particularly regarding patient data privacy and informed consent. We identified areas for improvement in equity, patient empowerment, and continuity of care. Discussion The application of this framework raises fundamental questions on how continuity of care, equity, and comprehensive care can be protected when virtual care becomes more ubiquitous. The checklist can help virtual consultation services identify areas of improvement and ensure they meet ethical criteria, thus contributing to quality of care. The framework may be adapted to other digital health services and tools, providing ethical guidance to technology developers, clinicians, and patients and their whanau (family).

Place of telemedicine in the organization of emergency care: feasibility and benefits.

INTRODUCTION: Telemedicine encompasses all medical practices that allow patients to be remotely cared for through new information and communication technologies. This study aims to assess the remote management of patients consulting emergency services and not requiring in-hospital care during both pre-pandemic and pandemic periods of COVID-19. METHODS: This was a prospective, randomized, controlled study. The telemedicine group received follow-up at home after emergency room discharge according to a predefined protocol, with telephone calls on days 2, 7, 15, and 30. The control group received standard care without regular telephone follow-up (only a call on day 30). The study was conducted with patients consulting the emergency department of FarhatHached Hospital in Sousse. Patient inclusion occurred between November 1, 2019, and April 30, 2020. The primary outcome measures were the re-consultation rate and treatment adherence. The secondary outcome measure was patient satisfaction.SPSS version 23.0 for Windows was used for data analysis. Descriptive statistics calculated frequencies, percentages, means, standard deviations, medians, and range. Analytical study involved Student's t-test and Pearson chi-square test for mean and frequency comparisons, respectively. Significance threshold (p) for all tests was set at 0.05. RESULTS: A total of 400 patients were included. The average age of patients was 40 years. Both groups were comparable in terms of demographics and clinical characteristics. Diagnoses included mainly benign infectious diseases, trauma, mild decompensations of chronic conditions (asthma, COPD, heart failure), and suspected COVID cases. Patients in the telemedicine group tended to reconsult less in the month following their initial emergency room visit (14% versus 26.5%) (p = 0.004). There was a significant difference in treatment adherence between the telemedicine group and the control group (97.5% versus 92%; p = 0.014). The satisfaction with telemedicine was higher than satisfaction with regard to an in-person consultation at the emergency department (90% versus 37.5%). CONCLUSION: It is necessary to implement telemedicine in Tunisia, especially in emergency services. It ensures better remote patient care by reducing re-consultation rates, increasing treatment adherence, and improving patient satisfaction.

Telehealth insights from an integrated care system.

The COVID-19 pandemic accelerated telehealth expansion trends as policy makers instituted flexibilities and coverage changes. Federal telehealth flexibilities expire, however, at the end of 2024. To decide whether to extend those flexibilities, policy makers need information about consumer telehealth preferences, impacts of telehealth on care usage and quality, and telehealth accessibility for the full diversity of patients. Research from one of the nation's largest integrated, value-based health systems provides insights. Findings suggest that telehealth utilization has dropped since the peak of the pandemic but remains higher than prepandemic levels. Telehealth appears to be replacing in-person visits rather than leading to more total visits. Patients generally prefer in-person care but many like having the option to use video- and phone-based telehealth, and both video- and phone-based care appear to be helping patients access primary care. An integrated, value-based care approach may assist a diverse range of patients in accessing telehealth services. Action is still needed, however, to ensure that the full diversity of patients can easily access telehealth offerings. Based on experiences within our health system, we recommend that policy makers maintain public and private payer coverage for video- and phone-based telehealth services; encourage well-designed value-based payment models to simplify and expand telehealth access; improve broadband accessibility and broadband and device affordability so that all patients can access telehealth services; and hold digital health to equivalent high standards for care quality, safety, patient satisfaction, clinical outcomes, and health equity as in-person care.

Effectiveness, implementation settings, and research priorities of telemedicine-delivered interventions for children and adolescents with autism spectrum disorder: A systematic review.

This systematic review aims to examine evidence on telemedicine-delivered interventions for autistic children and adolescents, considering diverse approaches, settings, and modalities used to address core symptoms and co-occurring conditions. A comprehensive search strategy consulted PubMed and PsycInfo databases from inception to March 2023. PROSPERO registration: CRD42023404111. Each work was screened, and two blind authors extracted data. Out of 6010 studies, 19 publications with 366 participants (305 carers and 61 autistic children/adolescents) were included. Combined findings from observational and experimental studies indicate telemedicine-delivered interventions are comparable in effectiveness to traditional "in-person" treatments and involve lower costs. Tele-intervention outcomes show promise in facilitating interventions, actively engaging parents, and generalizing the socio-communicative behaviors of children. While the enforced adoption of telemedicine during the COVID-19 pandemic has prompted clinicians to assess its role in the field of autism, a comprehensive understanding of its efficacy, benefits, and associated costs has yet to be fully established. Future studies should prioritize rigorous experimental methodologies, including subgroup analyses based on child/adolescent and family characteristics, aiding intervention implementation.

A Quality Improvement-based Approach to Implementing a Remote Monitoring-Based Bundle in Transitional Care Patients for Heart Failure.

BACKGROUND: Congestive heart failure (HF) is a leading cause of hospitalization and readmission, leading to increased health care utilization and cost. This is complicated by high incidence, prevalence, and hospitalization rates among racial and ethnic minorities, with a widening in the mortality disparity gap. Remote patient monitoring (RPM) has the potential to proactively engage patients after discharge to optimize medication management and intervene to avoid rehospitalization. However, it also may widen the equity gap due to technological barriers and bias. METHODS: A prospective, observational quality improvement (QI) initiative leveraging an amended tool from the Institute for Healthcare Improvement Model for Improvement was incorporated with an equity lens and five Plan-Do-Study-Act (PDSA) cycles at a single site. The intervention used an HF bundle that included RPM, clinical telepharmacy, remote therapeutic monitoring, and community paramedicine. RESULTS: Between May 2022 and March 2023, five PDSA cycles were run involving 90 enrolled patients. In total, 38 (42.2%) patients received the complete HF bundle, 42 (46.7%) a partial bundle, and 10 (11.1%) only RPM. The patients with the complete bundle had a readmission rate of 2.6% compared to 14.3% in the partial bundle and 20.0% in RPM alone. The biggest impact of this program was the incorporation of community paramedicine. The program also noted an improvement in equitable enrollment after adjusting mid-program by avoiding cellular phone-enabled devices and transitioning to a hub-based model. CONCLUSION: This single-site QI-based initiative implemented an HF-based RPM program that leveraged clinical telepharmacy and community paramedicine. This program identified a disparity of care gap regarding the equitable distribution of services and made mid-study adjustments to improve the disparity gap. The program found that use of the HF bundle resulted in a decreased hospital readmission rate.

Patient Engagement With and Perceptions of the COVIDA Project, a Volunteer-Led Telemonitoring and Teleorientation Service for COVID-19 Community Management: Mixed Methods Study.

BACKGROUND: During the pandemic in Peru, the COVIDA (Collaboration Network of Volunteer Brigade Members for the Investigation, Detection, and Primary Management of Community Cases Affected by COVID-19) project proposed an innovative way to provide telemonitoring and teleorientation to COVID-19 patients, led by health care student volunteers. However, it has not been described how this interaction is perceived from the patient's perspective and which factors increase their engagement with this service. OBJECTIVE: The aim of this study is to describe the perceptions of patients about COVIDA and identify factors associated with their engagement with this service. METHODS: A mixed methods study was conducted to evaluate perceptions of patients that participated in the COVIDA project. This telehealth intervention organized by the National University of San Marcos was implemented in Peru from August to December 2020. The service involved daily phone calls by volunteer students to monitor registered COVID-19 patients until the completion of the 14th day of the illness or if a warning sign was identified. The volunteers also provided teleorientation to address the patients' needs and concerns. Quantitative analysis was performed to describe the characteristics of the patients and to assess the factors related to their engagement with the service, which was defined by the percentage of participants who completed the follow-up according to their individual schedule. Qualitative analysis through semistructured interviews evaluated the patients' perceptions of the service regarding the aspects of communication, interaction, and technology. RESULTS: Of the 770 patients enrolled in COVIDA, 422 (55.7%) were female; the median age was 39 (IQR 28-52) years. During the monitoring, 380 patients (49.4%) developed symptoms, and 471 (61.2%) showed warning signs of COVID-19. The overall median for engagement was 93% (IQR 35.7%-100%). Among those patients who did not develop warning signs, engagement was associated with the presence of symptoms (OR 3.04, 95% CI 2.22-4.17), a positive COVID-19 test at the start of follow-up (OR 1.97, 95% CI 1.48-2.61), and the presence of comorbidities (OR 1.83, 95% CI 1.29-2.59). Patients reported that the volunteers provided clear and valuable information and emotional support. Communication via phone calls took place smoothly and without interruptions. CONCLUSIONS: COVIDA represents a well-accepted and well-perceived alternative model for student volunteers to provide telemonitoring, teleorientation, and emotional support to patients with COVID-19 in the context of overwhelmed demand for health care services. The deployment of this kind of intervention should be prioritized among patients with symptoms and comorbidities, as they show more engagement with these services.

Challenges and opportunities in the Polish healthcare sector from the implementation of telemedicine solutions in the field of gerontology and geriatric medicine: own experience.

OBJECTIVE: Aim: To analyze and summarize the implementation of telemedical solutions in geriatrics and gerontology within the Polish healthcare sector, aiming to develop innovative strategies for improving elderly care through telemedical technologies. PATIENTS AND METHODS: Materials and Methods: An interdisciplinary pilot project in geriatrics was implemented, focusing on health, organizational, and technological areas. The project involved continuous monitoring of health parameters, remote consultations, and the use of telemedical devices and platforms. Key data collection tools included digital clinimetric outcomes from the FRA-MNA-SARC model, with data transmitted to a telemedical platform. RESULTS: Results: The pilot project demonstrated significant positive outcomes for senior participants. Continuous monitoring of health parameters allowed for early detection and timely intervention, leading to noticeable improvements in chronic disease management. This proactive approach reduced emergency hospital visits and enhanced overall health stability. The medication adherence support system, with automated reminders, ensured patients took their medications as prescribed, resulting in improved compliance and health outcomes. Telemedical solutions efficiently reduced the need for frequent in-person visits, allowing healthcare providers to monitor progress and adjust therapies in real-time. The project also effectively engaged patients and caregivers, increasing confidence in health management and providing valuable support and real-time information. CONCLUSION: Conclusions: Implementing telemedical solutions in geriatrics within the Polish healthcare sector shows significant potential to improve elderly care. Telemedicine can effectively support chronic disease management, enhance seniors' quality of life through continuous health monitoring, and provide a practical framework for personalized and efficient healthcare delivery.

A Post-Acute COVID-19 Syndrome (PACS) Clinic in Rural New England.

This article explores the demand and utilization of a rural post-acute COVID syndrome clinic. Electronic health records were used to identify referrals between April 2021 and April 2022 and to describe characteristics of referred patients and referrals generated to specialty services. Of the 747 referrals received, 363 (48.6%) met the criteria for an appointment and were seen, the vast majority (89.6%) via Telehealth. Most patients resided in rural communities (63.1%) and were female (75.2%); mean age was 49, and 17% were hospitalized during their acute illness. Nearly half of patients (49%) had at least one pre-existing mental health diagnosis. Referrals to specialty care for further evaluation and/or intervention were most commonly to occupational therapy (27.3%), physical therapy (24.8%), psychiatry (19.8%), and neurology (17%). Telehealth expanded the availability of health care resources. Additional research on how to meet care needs, ameliorate symptoms, and aid recovery in rural communities is warranted.

Barriers and Facilitators to the Implementation of Digital Health Services for People With Musculoskeletal Conditions in the Primary Health Care Setting: Systematic Review.

BACKGROUND: In recent years, the effectiveness and cost-effectiveness of digital health services for people with musculoskeletal conditions have increasingly been studied and show potential. Despite the potential of digital health services, their use in primary care is lagging. A thorough implementation is needed, including the development of implementation strategies that potentially improve the use of digital health services in primary care. The first step in designing implementation strategies that fit the local context is to gain insight into determinants that influence implementation for patients and health care professionals. Until now, no systematic overview has existed of barriers and facilitators influencing the implementation of digital health services for people with musculoskeletal conditions in the primary health care setting. OBJECTIVE: This systematic literature review aims to identify barriers and facilitators to the implementation of digital health services for people with musculoskeletal conditions in the primary health care setting. METHODS: PubMed, Embase, and CINAHL were searched for eligible qualitative and mixed methods studies up to March 2024. Methodological quality of the qualitative component of the included studies was assessed with the Mixed Methods Appraisal Tool. A framework synthesis of barriers and facilitators to implementation was conducted using the Consolidated Framework for Implementation Research (CFIR). All identified CFIR constructs were given a reliability rating (high, medium, or low) to assess the consistency of reporting across each construct. RESULTS: Overall, 35 studies were included in the qualitative synthesis. Methodological quality was high in 34 studies and medium in 1 study. Barriers (-) of and facilitators (+) to implementation were identified in all 5 CFIR domains: "digital health characteristics" (ie, commercial neutral [+], privacy and safety [-], specificity [+], and good usability [+]), "outer setting" (ie, acceptance by stakeholders [+], lack of health care guidelines [-], and external financial incentives [-]), "inner setting" (ie, change of treatment routines [+ and -], information incongruence (-), and support from colleagues [+]), "characteristics of the healthcare professionals" (ie, health care professionals' acceptance [+ and -] and job satisfaction [+ and -]), and the "implementation process" (involvement [+] and justification and delegation [-]). All identified constructs and subconstructs of the CFIR had a high reliability rating. Some identified determinants that influence implementation may be facilitators in certain cases, whereas in others, they may be barriers. CONCLUSIONS: Barriers and facilitators were identified across all 5 CFIR domains, suggesting that the implementation process can be complex and requires implementation strategies across all CFIR domains. Stakeholders, including digital health intervention developers, health care professionals, health care organizations, health policy makers, health care funders, and researchers, can consider the identified barriers and facilitators to design tailored implementation strategies after prioritization has been carried out in their local context.

Description of a telehealth mental health programme in the framework of the COVID-19 pandemic in Colombia.

BACKGROUND: A telehealth mental health programme was designed at the LivingLab of the Faculty of Medicine of the Universidad de Antioquia [University of Antioquia]. OBJECTIVES: To describe the development and operation of the programme and evaluate the satisfaction of the patients treated during the COVID-19 pandemic in 2020 and 2021. METHODS: Descriptive study that details the development of the programme. Data were extracted from medical records to describe the patients who were treated. A satisfaction scale was applied to a random sample and the data were summarised with descriptive statistics. RESULTS: In March 2020 and August 2021, 10,229 patients were treated, with 20,276 treated by telepsychology and 4,164 by psychiatry, 1,808 by telepsychiatry and 2,356 by tele-expertise, with a total of 6,312 visits. The most frequent diagnoses were depressive (36.8%), anxiety (12.0%), and psychotic (10.7%) disorders. Respondents were satisfied to the point that more than 93% would recommend it to another person. CONCLUSIONS: The LivingLab telehealth mental health programme allowed for the care of patients with mental health problems and disorders in Antioquia during the first two years of the COVID-19 pandemic, and there was a high degree of satisfaction among the beneficiaries. Therefore it could be adopted in mental health care.

Clinical and Practice Innovation Improving the Practice of Family Medicine.

Quite a lineup showcasing JABFM's emphasis on research and information for family medicine to improve patients' lives. Articles cover many topics: telemedicine, a clinical decision support tool, control of cardiovascular risk factors, opioid dose reduction, cancer survivorship care, patient engagement with case management/navigation, primary care physician capacity and usual source of care, marketing practices of Medicare Advantage programs, review articles (new diabetes medicine and treatment CHF with reduced ejection fraction), and more.

Telemedicine Adoption During COVID-19 Pandemic: Perspectives from Primary Care Clinicians in Safety-Net Settings.

OBJECTIVE: The objective of this study is to describe the facilitators and barriers of telemedicine during the COVID-19 pandemic for primary care clinicians in safety-net settings. METHODS: We selected 5 surveys fielded between September 2020 and March 2023 from the national "Quick COVID-19 Primary Care Survey" by the Larry A. Green Center, with the Primary Care Collaborative. We used an explanatory sequential mixed method approach. We compared safety-net practices (free & charitable organization, federally qualified health center (FQHC), clinics with a 50% or greater Medicaid) to all other settings. We discuss: 1) telemedicine services provided; 2) clinician motivations; 3) and telemedicine access. RESULTS: All clinicians were similarly motivated to implement telemedicine. Safety-net clinicians were more likely to report use of phone visits. These clinicians felt less "confident in my use of telemedicine" (covariate-adjusted OR = 0.611, 95% CI 0.43 - 0.87) and were more likely to report struggles with televisits in March 2023 (covariate-adjusted OR = 1.73, 95% CI 1.16 - 2.57), particularly with physical examinations. Safety-net clinicians were more likely to endorse reductions in no-shows (covariate-adjusted OR = 1.77, 95% CI 1.17 - 2.68). Telemedicine increased access and new patient-facing demands including portal communications. CONCLUSIONS: This study enhances our understanding of the use of telemedicine within the safety-net setting. Clinician perceptions are important for identifying barriers to telemedicine following the end of the Federal COVID-19 Public Health Emergency. Clinicians highlighted significant limitations to its use including clinical appropriateness, quality of physical examinations, and added patient-facing workload.