Travel Distance Between Participants in US Telemedicine Sessions With Estimates of Emissions Savings: Observational Study.

BACKGROUND: Digital health and telemedicine are potentially important strategies to decrease health care's environmental impact and contribution to climate change by reducing transportation-related air pollution and greenhouse gas emissions. However, we currently lack robust national estimates of emissions savings attributable to telemedicine. OBJECTIVE: This study aimed to (1) determine the travel distance between participants in US telemedicine sessions and (2) estimate the net reduction in carbon dioxide (CO2) emissions attributable to telemedicine in the United States, based on national observational data describing the geographical characteristics of telemedicine session participants. METHODS: We conducted a retrospective observational study of telemedicine sessions in the United States between January 1, 2022, and February 21, 2023, on the doxy.me platform. Using Google Distance Matrix, we determined the median travel distance between participating providers and patients for a proportional sample of sessions. Further, based on the best available public data, we estimated the total annual emissions costs and savings attributable to telemedicine in the United States. RESULTS: The median round trip travel distance between patients and providers was 49 (IQR 21-145) miles. The median CO2 emissions savings per telemedicine session was 20 (IQR 8-59) kg CO2). Accounting for the energy costs of telemedicine and US transportation patterns, among other factors, we estimate that the use of telemedicine in the United States during the years 2021-2022 resulted in approximate annual CO2 emissions savings of 1,443,800 metric tons. CONCLUSIONS: These estimates of travel distance and telemedicine-associated CO2 emissions costs and savings, based on national data, indicate that telemedicine may be an important strategy in reducing the health care sector's carbon footprint.

Narrative review of telemedicine applications in decentralized research.

Telemedicine enables critical human communication and interaction between researchers and participants in decentralized research studies. There is a need to better understand the overall scope of telemedicine applications in clinical research as the basis for further research. This narrative, nonsystematic review of the literature sought to review and discuss applications of telemedicine, in the form of synchronous videoconferencing, in clinical research. We searched PubMed to identify relevant literature published between January 1, 2013, and June 30, 2023. Two independent screeners assessed titles and abstracts for inclusion, followed by single-reviewer full-text screening, and we organized the literature into core themes through consensus discussion. We screened 1044 publications for inclusion. Forty-eight publications met our inclusion and exclusion criteria. We identified six core themes to serve as the structure for the narrative review: infrastructure and training, recruitment, informed consent, assessment, monitoring, and engagement. Telemedicine applications span all stages of clinical research from initial planning and recruitment to informed consent and data collection. While the evidence base for using telemedicine in clinical research is not well-developed, existing evidence suggests that telemedicine is a potentially powerful tool in clinical research.

Will the United States pass on telemedicine progress?

Background: During the COVID-19 pandemic, federal and state health policies allowed temporary flexibilities for Medicare and Medicaid beneficiaries, leading to a sharp increase in telemedicine use. However, many of the flexibilities that enabled innovation and growth in telemedicine continue temporarily since the federal emergency declaration ended in May 2023, and the United States has not made permanent decisions about telemedicine policy. Analysts have raised concerns about increased spending, program integrity, safety, and equity, and recommend strengthening oversight. Methods: Here, we argue that we must continue the flexibilities to better understand telemedicine's quality, safety, and outcomes, and until the United States can develop an evidence-based digital health strategy. A premature regression to pre-pandemic telemedicine policies risks unintended consequences. Conclusion: We must continue the current policy flexibilities, safeguard against fraud and abuse, and immediately prioritize research and evaluation of telemedicine's quality, safety, and outcomes, to avoid unintended consequences and support more permanent policy decision-making.

A Reproducible Model Based on Clinical Text for Predicting Suicidal Behavior.

Suicide risk models are critical for prioritizing patients for intervention. We demonstrate a reproducible approach for training text classifiers to identify patients at risk. The models were effective in phenotyping suicidal behavior (F1=.94) and moderately effective in predicting future events (F1=.63).

Telemedicine from Home or the Office: Perceptions of Mental Health Providers.

Introduction: The COVID-19 pandemic led to a rapid transition to telemedicine for mental health care and redefined many providers' work environments and practices. The purpose of the study was to investigate the impact of work location on telemental health (TMH) benefits, disruptions, and concerns to further understand the rapid implementation of telemedicine for mental health treatment. Methods: A sample of 175 practicing TMH providers completed an online survey between July and August 2020. Providers answered questions about personal demographics and practice characteristics. Next, they answered questions about benefits, disruptions, and concerns regarding the use of telemedicine in their practice. Chi-square and independent samples t-test were conducted to identify work location differences for personal demographics and clinical practice characteristics. Three multivariate analyses of covariance were conducted to examine overall differences in perceptions of telemedicine benefits, concerns, and disruptions based on work location while covarying for provider race, ethnicity, percentage of caseload seen through telemedicine, practice type, specialty, and primary method of reimbursement. Results: TMH providers who primarily work from an office reported more benefit of reduced costs/overhead (ηp2 = 0.039), less benefit of limiting the spread of the virus (ηp2 = 0.028), and more concern about reimbursement (ηp2 = 0.046) than those who primarily work from home. We observed no difference in disruptions, patient access to care, quality of care, and work-life balance. Discussion: Exploration into work location of TMH providers aids in understanding of clinical workflows and provider wellbeing. Our findings suggest that telemedicine may be easily integrated into different types of clinical workflows and work locations.

Consensus Guidelines for Teledermatology: Scoping Review.

BACKGROUND: Consensus guidelines and recommendations play an important role in fostering quality, safety, and best practices, as they represent an expert interpretation of the biomedical literature and its application to practice. However, it is unclear whether the recent collective experience of implementing telemedicine and the concurrent growth in the evidence base for teledermatology have resulted in more robust guidance. OBJECTIVE: The objective of this review was to describe the extent and nature of currently available guidance, defined as consensus guidelines and recommendations available for telemedicine in dermatology, with guidance defined as consensus or evidence-based guidelines, protocols, or recommendations. METHODS: We conducted a single-reviewer scoping review of the literature to assess the extent and nature of available guidance, consensus guidelines, or recommendations related to teledermatology. We limited the review to published material in English since 2013, reflecting approximately the past 10 years. We conducted the review in November and December of the year 2022. RESULTS: We identified 839 potentially eligible publications, with 9 additional records identified through organizational websites. A total of 15 publications met the inclusion and exclusion criteria. The guidelines focused on varied topics and populations about dermatology and skin diseases. However, the most frequent focus was general dermatology (8/15, 53%). Approximately half of the telemedicine guidance described in the publications was specific to dermatology practice in the context of the COVID-19 pandemic. The publications were largely published in or after the year 2020 (13/15, 87%). Geographical origin spanned several different nations, including Australia, the United States, European countries, and India. CONCLUSIONS: We found an increase in COVID-19-specific teledermatology guidance during 2020, in addition to general teledermatology guidance during the period of the study. Primary sources of general teledermatology guidance reported in the biomedical literature are the University of Queensland's Centre for Online Health and Australasian College of Dermatologists E-Health Committee, and the American Telemedicine Association. There is strong evidence of international engagement and interest. Despite the recent increase in research reports related to telemedicine, there is a relative lack of new guidance based on COVID-19 lessons and innovations. There is a need to review recent evidence and update existing recommendations. Additionally, there is a need for guidance that addresses emerging technologies.

A Systematic Approach to Treating Early Metabolic Disease and Prediabetes.

At least 70% of US adults have metabolic disease. However, less is done to address early disease (e.g., overweight, obesity, prediabetes) versus advanced disease (e.g., type 2 diabetes mellitus, coronary artery disease). Given the burden of advanced metabolic disease and the burgeoning pandemics of obesity and prediabetes a systematic response is required. To accomplish this, we offer several recommendations: (A) Patients with overweight, obesity, and/or prediabetes must be consistently diagnosed with these conditions in medical records to enable population health initiatives. (B) Patients with early metabolic disease should be offered in-person or virtual lifestyle interventions commensurate with the findings of the Diabetes Prevention Program. (C) Patients unable to participate in or otherwise failing lifestyle intervention must be screened to assess if they require pharmacotherapy. (D) Patients not indicated for, refusing, or failing pharmacotherapy must be screened to assess if they need bariatric surgery. (E) Regardless of treatment approach or lack of treatment, patients must be consistently screened for the progression of early metabolic disease to advanced disease to enable early control. Progression of metabolic disease from an overweight yet otherwise healthy person includes the development of prediabetes, obesity ± prediabetes, dyslipidemia, hypertension, type 2 diabetes, chronic kidney disease, coronary artery disease, and heart failure. Systematic approaches in health systems must be deployed with clear protocols and supported by streamlined technologies to manage their population's metabolic health from early through advanced metabolic disease. Additional research is needed to identify and validate optimal system-level interventions. Future research needs to identify strategies to roll out systematic interventions for the treatment of early metabolic disease and to improve the metabolic health among the progressively younger patients being impacted by obesity and diabetes.

Communicating about online health information with patients: Exploring determinants among telemental health providers.

Objective: To investigate determinants of telemental health (TMH) providers' openness to discuss and confidence to use online mental health information with patients, focusing on providers' eHealth literacy and perceived usefulness of online MH information. Methods: TMH providers (N = 472) completed a web-based survey with questions about discussing and using online health information with patients, perceived usefulness of the Internet as a source of patient information, and eHealth literacy. Results: Providers were open to discussing online health information with patients if they were not treating substance abuse disorders (b = -0.83), felt the Internet was a useful resource (b = 0.18), and felt confident in their skills to evaluate the online information (b = 0.21). Providers were confident using online health information if they worked in a small clinic (b = 0.37), felt the Internet was a useful resource (b = 0.31), knew where to access relevant online health information (b = 0.13), and had skills to help their patients find (b = 0.17) and evaluate (b = 0.54) online information. Conclusion: TMH providers are likely to use online health information resources if they know where and how to find them and perceive the Internet as a useful resource. Innovation: To effectively discuss online health information with patients, providers require skills to evaluate the information with patients.

Older adults' experience with virtual conversational agents for health data collection.

Introduction: Virtual conversational agents (i.e., chatbots) are an intuitive form of data collection. Understanding older adults' experiences with chatbots could help identify their usability needs. This quality improvement study evaluated older adults' experiences with a chatbot for health data collection. A secondary goal was to understand how perceptions differed based on length of chatbot forms. Methods: After a demographic survey, participants (≥60 years) completed either a short (21 questions), moderate (30 questions), or long (66 questions) chatbot form. Perceived ease-of-use, usefulness, usability, likelihood to recommend, and cognitive load were measured post-test. Qualitative and quantitative analyses were used. Results: A total of 260 participants reported on usability and satisfaction metrics including perceived ease-of-use (5.8/7), usefulness (4.7/7), usability (5.4/7), and likelihood to recommend (Net Promoter Score = 0). Cognitive load (12.3/100) was low. There was a statistically significant difference in perceived usefulness between groups, with a significantly higher mean perceived usefulness for Group 1 than Group 3. No other group differences were observed. The chatbot was perceived as quick, easy, and pleasant with concerns about technical issues, privacy, and security. Participants provided suggestions to enhance progress tracking, edit responses, improve readability, and have options to ask questions. Discussion: Older adults found the chatbot to be easy, useful, and usable. The chatbot required low cognitive load demonstrating it could be an enjoyable health data collection tool for older adults. These results will inform the development of a health data collection chatbot technology.

Characterizing Consumer Smartphone Apps for Virtual Reality-Based Exposure Therapy: Content Analysis.

BACKGROUND: In vivo exposure therapy is the most effective treatment for phobias but is often impractical. Virtual reality exposure therapy (VRET) can help overcome critical barriers to in vivo exposure therapy. However, accessible mobile software related to VRET is not well understood. OBJECTIVE: The purpose of our study is to describe the landscape of accessible smartphone apps with potential utility for clinical VRET. METHODS: We conducted a content analysis of publicly available smartphone apps related to virtual reality on the Google Play Store and the Apple App Store as of March 2020. RESULTS: The initial search yielded 525 apps, with 84 apps (52 on the Google Play Store and 32 on the Apple App Store) included for analysis. The most common phobic stimulus depicted was bodies of water or weather events (25/84, 29.8%), followed by heights (24/84, 28.6%), and animals (23/84, 27.4%). More than half of the apps were visually abstract (39/84, 53.5%). Most apps were free to use (48/84, 57.1%), while the rest were free to try (22/84, 26.2%) or required payment for use (14/84, 16.7%), with the highest cost for use being US $6. The average overall app rating was 2.9 stars out of 5, but the number of ratings ranged from 0 to 49,233. None of the 84 apps advertised compliance with the Health Insurance Portability and Accountability Act, offered the ability to monitor data, provided clinician control over variables in the app experiences, or explicitly stated use by or development with clinicians. CONCLUSIONS: None of the smartphone apps reviewed were explicitly developed for phobia therapy. However, 16 of the 84 included apps were considered ideal candidates to investigate further as part of treatment due to their accessibility, depiction of phobia-relevant stimuli, low or no cost, and high user scores. Most of these apps were visually abstract and free to use, making them accessible and potentially flexible as part of clinical exposure hierarchies. However, none of the apps were designed for clinical use, nor did they provide tools for clinician workflows. Formal evaluation of these accessible smartphone apps is needed to understand the clinical potential of accessible VRET solutions.

Clinical and Information Services Needed by Telemental Health Providers.

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

Decentralized research technology use in multicenter clinical research studies based at U.S. academic research centers.

Introduction: During the COVID-19 pandemic, research organizations accelerated adoption of technologies that enable remote participation. Now, there's a pressing need to evaluate current decentralization practices and develop appropriate research, education, and operations infrastructure. The purpose of this study was to examine current adoption of decentralization technologies in a sample of clinical research studies conducted by academic research organizations (AROs). Methods: The setting was three data coordinating centers in the U.S. These centers initiated coordination of 44 clinical research studies during or after 2020, with national recruitment and enrollment, and entailing coordination between one and one hundred sites. We determined the decentralization technologies used in these studies. Results: We obtained data for 44/44 (100%) trials coordinated by the three centers. Three technologies have been adopted across nearly all studies (98-100%): eIRB, eSource, and Clinical Trial Management Systems. Commonly used technologies included e-Signature (32/44, 73%), Online Payments Portals (26/44, 59%), ePROs (23/44, 53%), Interactive Response Technology (22/44, 50%), Telemedicine (19/44, 43%), and eConsent (18/44, 41%). Wearables (7/44,16%) and Online Recruitment Portals (5/44,11%) were less common. Rarely utilized technologies included Direct-to-Patient Portals (1/44, 2%) and Home Health Nurse Portals (1/44, 2%). Conclusions: All studies incorporated some type of decentralization technology, with more extensive adoption than found in previous research. However, adoption may be strongly influenced by institution-specific IT and informatics infrastructure and support. There are inherent needs, responsibilities, and challenges when incorporating decentralization technology into a research study, and AROs must ensure that infrastructure and informatics staff are adequate.

Providers' Perspectives on Telemental Health Usage After the COVID-19 Pandemic: Retrospective Analysis.

BACKGROUND: Mental health care pivoted to telemedicine during the COVID-19 pandemic, and there is uncertainty around the sustainability of this rapid shift. OBJECTIVE: This study examined how intentions to continue using telemedicine after the COVID-19 pandemic are influenced by provider perceptions of usefulness, ease of use, and professional social influence, facilitating organizational conditions. METHODS: We conducted a web-based, cross-sectional survey of 369 telemental health providers between February and March 2021. A hierarchical linear regression analysis was conducted to predict intentions to continue using telemedicine after the COVID-19 pandemic. RESULTS: Most providers began using telemedicine in March 2020 or later (257/369, 69.6%) and attended to ≥50% of their clients via telemedicine (299/369, 81.0%). Intention to continue using telemedicine after the COVID-19 pandemic was predicted by the telemedicine caseload (ß=.10; P=.005), perceived usefulness in general (ß=.10; P=.008), ease of use (ß=.08; P=.04), social influence (ß=.68; P<.001), and facilitating conditions (ß=.08; P=.047). CONCLUSIONS: Exploration of the predictors of telemedicine usage beyond the COVID-19 pandemic aids in surveillance of telemedicine usage, integration with future clinic workflows, and the shaping of public policy. It is important to consider telemedicine services as not only a response to a crisis but also an effective and useful solution for everyday life. Our results suggest widespread, sustainable telemedicine adoption.

Virtual conversational agents versus online forms: Patient experience and preferences for health data collection.

Objective: Virtual conversational agents, or chatbots, have emerged as a novel approach to health data collection. However, research on patient perceptions of chatbots in comparison to traditional online forms is sparse. This study aimed to compare and assess the experience of completing a health assessment using a chatbot vs. an online form. Methods: A counterbalanced, within-subject experimental design was used with participants recruited via Amazon Mechanical Turk (mTurk). Participants completed a standardized health assessment using a chatbot (i.e., Dokbot) and an online form (i.e., REDCap), each followed by usability and experience questionnaires. To address poor data quality and preserve integrity of mTurk responses, we employed a thorough data cleaning process informed by previous literature. Quantitative (descriptive and inferential statistics) and qualitative (thematic analysis and complex coding query) approaches were used for analysis. Results: A total of 391 participants were recruited, 185 of whom were excluded, resulting in a final sample size of 206 individuals. Most participants (69.9%) preferred the chatbot over the online form. Average Net Promoter Score was higher for the chatbot (NPS = 24) than the online form (NPS = 13) at a statistically significant level. System Usability Scale scores were also higher for the chatbot (i.e. 69.7 vs. 67.7), but this difference was not statistically significant. The chatbot took longer to complete but was perceived as conversational, interactive, and intuitive. The online form received favorable comments for its familiar survey-like interface. Conclusion: Our findings demonstrate that a chatbot provided superior engagement, intuitiveness, and interactivity despite increased completion time compared to online forms. Knowledge of patient preferences and barriers will inform future design and development of recommendations and best practice for chatbots for healthcare data collection.

Perceptions of Telemental Health Care Delivery During COVID-19: A Cross-Sectional Study With Providers, February-March 2021.

The COVID-19 pandemic accelerated adoption of telemental health (TMH). Providers with limited TMH experience faced challenges during the rapid switch to remote patient care. We investigated TMH providers' perceptions about remote care one year into the pandemic according to when providers adopted telemedicine (i.e., before vs. after March 2020) and how much of their caseloads were served remotely (i.e., < 50% vs. ≥ 50%). Between February-March 2021, 472 TMH providers completed a cross-sectional, web-based survey that measured perceived benefits and satisfaction with telemedicine, therapeutic alliance, patient-centered communication, eHealth literacy, multicultural counseling self-efficacy, and facilitating factors of using telemedicine. Providers who began using telemedicine before the pandemic reported having better training, task-related therapeutic alliance with patients, and ability to conduct multicultural interventions, assessments, and session management. Providers who served ≥ 50% of their caseload remotely reported greater satisfaction with their practice, stronger beliefs about the benefits of telemedicine, and greater perceived effects of telemedicine on alleviating the impact of COVID-19. There were no differences in reports of patient-centered communication nor eHealth literacy. In conclusion, providers who adopted TMH more recently may require additional training and support to successfully establish a working alliance with their patients, especially with multicultural aspects of care.

Web-based provider training of cognitive behavioral therapy of insomnia: engagement rates, knowledge acquisition, and provider acceptability.

Insomnia is common but severely underreported and undertreated. One possible reason for this problem is the lack of providers in cognitive behavioral therapy for insomnia (CBT-I). To address this we created CBTIweb.org, an online training platform for providers to learn the basics of sleep, assessing insomnia, and CBT-I. The present study assessed the reach of CBTIweb by examining engagement, knowledge acquisition, and perceived acceptability. Participants who registered for CBTIweb self-reported their practice setting and personal characteristics (i.e. degree, profession, licensure status). Knowledge acquisition was assessed with pre- and post-tests, and provider acceptability was assessed via a survey. In the first three months after launching CBTIweb, 2586 providers registered and 624 of these completed the training within three months of registering. Chi-square tests of independence revealed no differences in completion rates by education or profession, though trainees were more likely to initiate and complete treatment than licensed providers. Paired t tests revealed significant knowledge acquisition, and most providers positively rated the website navigation, content, aesthetics, and understanding of core CBT-I skills. This study demonstrated CBTIweb is an effective platform for training health professionals to be minimally proficient in the gold standard treatment for insomnia disorder.

The Symbiosis of Virtual Reality Exposure Therapy and Telemental Health: A Review.

Phobias and related anxiety are common and costly mental health disorders. Experts anticipate the prevalence of phobias will increase due to the COVID-19 pandemic. Exposure therapies have been established as effective and reliable treatments for anxiety, including recent innovations in virtual reality-based exposure therapy (VRET). With the recent advent of telemental health (TMH), VRET is poised to become mainstream. The combination of VRET and TMH has the potential to extend provider treatment options and improve patient care experiences. In this narrative review, we describe how recent events have accelerated VRET + TMH, identify barriers to VRET + TMH implementation, and discuss strategies to navigate those barriers.

Disparities in Patient-Centered Communication via Telemedicine.

Purpose: This study investigated disparities in the uptake of telemedicine and the degree of patient-centeredness of telemedicine consultations among vulnerable patient populations. The focus includes rural adults and adults living with psychological distress and a high risk for chronic obstructive pulmonary disease (COPD). Materials and Methods: In August 2020, a random sample of 932 U.S. adults ≥35 years old with a history of smoking tobacco completed an online survey. Chi-squared analyses were conducted to compare the sociodemographics of participants who did and did not use telemedicine. A series of analysis of variance tests were conducted to examine whether satisfaction with patient-centeredness of telemedicine consultations (i.e., open-endedness, expressed empathy, provider's ability, 5-point Likert scale) differs by rural/urban residence, psychological distress, and COPD risk. Results: About 25% of the sample (n = 240) reported having used telemedicine. Telemedicine use was associated with younger age, Hispanic ethnicity, and moderate-to-high psychological distress, but not rurality. Participants reported high general satisfaction with the patient-centeredness of telemedicine consultations (M = 4.42 ± 0.73). However, high psychological distress and identifying as a current smoker were associated with less satisfaction across all domains. High COPD risk was uniquely associated with less satisfaction in how providers express empathy remotely. Conclusion: Individuals with moderate-to-high psychological distress and a high risk for COPD experience challenges accessing high-quality, patient-centered care via telemedicine. As telemedicine becomes ubiquitous in health care, innovative solutions are needed to overcome barriers that prevent providers from delivering patient-centered care and patients from feeling satisfied with their remote consultations.

Quantifying the Impact of COVID-19 on Telemedicine Utilization: Retrospective Observational Study.

BACKGROUND: While telemedicine has been expanding over the past decade, the COVID-19-related restrictions regarding in-person care have led to unprecedented levels of telemedicine utilization. To the authors' knowledge, no studies to date have quantitatively analyzed both national and regional trends in telemedicine utilization during the pandemic, both of which have key implications for informing health policy. OBJECTIVE: This study aimed to investigate how trends in telemedicine utilization changed across the course of the COVID-19 pandemic. METHODS: Using data from doxy.me, the largest free telemedicine platform, and the NIH (National Institutes of Health) Clinical Center, the largest clinical research hospital in the United States, we assessed changes in total telemedicine minutes, new provider registrations, monthly sessions, and average session length from March to November 2020. We also conducted a state-level analysis of how telemedicine expansion differed by region. RESULTS: National telemedicine utilization peaked in April 2020 at 291 million minutes and stabilized at 200 to 220 million monthly minutes from May to November 2020. Surges were strongest in New England and weakest in the South and West. Greater telemedicine expansion during the COVID-19 pandemic was geographically associated with fewer COVID-19 cases per capita. The nature of telemedicine visits also changed, as the average monthly visits per provider doubled and the average visit length decreased by 60%. CONCLUSIONS: The COVID-19 pandemic led to an abrupt and subsequently sustained uptick in telemedicine utilization. Regional and institute-level differences in telemedicine utilization should be further investigated to inform policy and procedures for sustaining meaningful telemedicine use in clinical practice.