Measuring Telehealth Visit Length and Schedule Adherence Using Videoconferencing Data.

Background: The ability to measure clinical visit length is critical for operational efficiency, patient experience, and accurate billing. Despite the unprecedented surge in telehealth use in 2020, studies on visit length and schedule adherence in the telehealth setting are nonexistent in the literature. This article aims to demonstrate the use of videoconferencing data to measure telehealth visit length and schedule adherence. Materials and Methods: We used data from telehealth video visits at four clinical specialties at Nationwide Children's Hospital, including behavioral health (BH), speech pathology (SP), physical therapy/occupational therapy (PT/OT), and primary care (PC). We combined videoconferencing timestamp data with visit scheduling data to calculate the total visit length, examination length, and patient wait times. We also assessed schedule adherence, including patient on-time performance, examination on-time performance, provider schedule deviations, and schedule length deviations. Results: The analyses included a total of 175,876 telehealth video visits. On average, children with BH appointments spent a total of 57.2 min for each visit, followed by PT/OT (50.8 min), SP (42.1 min), and PC (25.0 min). The average patient wait times were 4.1 min (BH), 2.7 min (PT/OT), 2.8 min (SP), and 3.1 min (PC). The average examination lengths were 48.8 min (BH), 44.5 min (PT/OT), 34.9 min (SP), and 16.6 min (PC). Regardless of clinical specialty, actual examination lengths of most visits were shorter than the scheduled lengths, except that appointments scheduled for 15 min tended to run overtime. Conclusions: Videoconferencing data provide a low-cost, accurate, and readily available resource for measuring telehealth visit length and schedule adherence.

Capturing At-Home Health and Care Information for Children With Medical Complexity Using Voice Interactive Technologies: Multi-Stakeholder Viewpoint.

Digital health tools and technologies are transforming health care and making significant impacts on how health and care information are collected, used, and shared to achieve best outcomes. As most of the efforts are still focused on clinical settings, the wealth of health information generated outside of clinical settings is not being fully tapped. This is especially true for children with medical complexity (CMC) and their families, as they frequently spend significant hours providing hands-on medical care within the home setting and coordinating activities among multiple providers and other caregivers. In this paper, a multidisciplinary team of stakeholders discusses the value of health information generated at home, how technology can enhance care coordination, and challenges of technology adoption from a patient-centered perspective. Voice interactive technology has been identified to have the potential to transform care coordination for CMC. This paper shares opinions on the promises, limitations, recommended approaches, and challenges of adopting voice technology in health care, especially for the targeted patient population of CMC.

Structure and Funding of Clinical Informatics Fellowships: A National Survey of Program Directors.

BACKGROUND: In 2011, the American Board of Medical Specialties established clinical informatics (CI) as a subspecialty in medicine, jointly administered by the American Board of Pathology and the American Board of Preventive Medicine. Subsequently, many institutions created CI fellowship training programs to meet the growing need for informaticists. Although many programs share similar features, there is considerable variation in program funding and administrative structures. OBJECTIVES: The aim of our study was to characterize CI fellowship program features, including governance structures, funding sources, and expenses. METHODS: We created a cross-sectional online REDCap survey with 44 items requesting information on program administration, fellows, administrative support, funding sources, and expenses. We surveyed program directors of programs accredited by the Accreditation Council for Graduate Medical Education between 2014 and 2021. RESULTS: We invited 54 program directors, of which 41 (76%) completed the survey. The average administrative support received was $27,732/year. Most programs (85.4%) were accredited to have two or more fellows per year. Programs were administratively housed under six departments: Internal Medicine (17; 41.5%), Pediatrics (7; 17.1%), Pathology (6; 14.6%), Family Medicine (6; 14.6%), Emergency Medicine (4; 9.8%), and Anesthesiology (1; 2.4%). Funding sources for CI fellowship program directors included: hospital or health systems (28.3%), clinical departments (28.3%), graduate medical education office (13.2%), biomedical informatics department (9.4%), hospital information technology (9.4%), research and grants (7.5%), and other sources (3.8%) that included philanthropy and external entities. CONCLUSION: CI fellowships have been established in leading academic and community health care systems across the country. Due to their unique training requirements, these programs require significant resources for education, administration, and recruitment. There continues to be considerable heterogeneity in funding models between programs. Our survey findings reinforce the need for reformed federal funding models for informatics practice and training.

Quality Improvement to Eliminate Disparities in Developmental Screening for Patients Needing Interpreters.

Children from households with a preferred language other than English are less likely to receive timely identification and treatment for developmental delay than children of native English speakers. In dismantling this inequity, the role of primary care pediatrics is to establish equitable systems for screening and referral. This project, conducted in a network of twelve pediatric primary care centers, focused on eliminating a small but systematic disparity in developmental screening rates between families who did and did not require interpreters (86% versus 92%). The specific aim was to increase developmental screen completion among patients needing interpreters from 86% to 92% of age-appropriate well-child visits. Methods: Data were extracted from the electronic health record (EHR) to measure the proportion of 9-, 18-, 24-, and 30-month well-child visits at which developmental screens were completed, stratified by interpreter need (n = 31,461 visits; 7500 needing interpreters). One primary care center tested small changes to standardize processes, eliminate workarounds, and leverage EHR features using the Institute for Healthcare Improvement's Model for Improvement. The QI team plotted screen completion on control charts and spread successful changes to all 12 clinics. Statistical process control evaluated the significance of changes in screening rates. Results: For patients needing interpreters, screen completion rose across all clinics from 86% to 93% when the clinics implemented the new process. Screen completion for patients not needing interpreters remained at 92%. Conclusion: A standardized process supported by the EHR improved developmental screening among patients needing interpreters, eliminating disparities.

Improving Primary Care Adolescent Depression Screening and Initial Management: A Quality Improvement Study.

Although recommended, adolescent depression screening with appropriate initial management is challenging. This project aimed to improve adolescent depression screening rates during preventive care visits in 12 primary care clinics from 65.4% to 80%, increase the proportion of documented initial management for those with a positive screen from 69.5% to 85%, then sustain improvements for 12 months. Methods: This quality improvement project involved 12 urban primary care clinics serving >120,000 mostly Medicaid-enrolled patients and targeted adolescents 12-17 years. Interventions included standardized depression screening using tablets with electronic health record (EHR) capture and automated scoring, embedding screening results and initial management actions into the EHR, provider education, and individual clinician and clinic performance feedback. Results: After standardizing the approach to screening, the process mean depression screening rate was 91.9%. However, after adopting tablets into the clinic flow, there was an unexpected initial decrease in proportion with appropriately documented initial management plans, from 89.7% to 67.6%. In response to this special cause variation, there was additional provider feedback and education, and a redesign of the EHR flow related to the presentation of results and prompts for action after a positive screen. As a result, the proportion with appropriately documented initial management was 87.3% by project completion. Conclusions: Tablet-based screening with EHR scoring capture effectively increased depression screening rates but required significant additional work to improve initial management after a positive screen. A full system approach, including EHR modification, clinician education, and performance feedback, is needed to make meaningful, sustained improvements in comprehensive adolescent depression screening.

Associations of Telehealth Care Delivery with Pediatric Health Care Provider Well-Being.

BACKGROUND: The rapid, large-scale deployment of new health technologies can introduce challenges to clinicians who are already under stress. The novel coronavirus disease 19 (COVID-19) pandemic transformed health care in the United States to include a telehealth model of care delivery. Clarifying paths through which telehealth technology use is associated with change in provider well-being and interest in sustaining virtual care delivery can inform planning and optimization efforts. OBJECTIVE: This study aimed to characterize provider-reported changes in well-being and daily work associated with the pandemic-accelerated expansion of telehealth and assess the relationship of provider perceptions of telehealth effectiveness, efficiency, and work-life balance with desire for future telehealth. METHODS: A cross-sectional survey study was conducted October through November 2020, 6 months after the outbreak of COVID-19 at three children's hospitals. Factor analysis and structural equation modeling (SEM) were used to examine telehealth factors associated with reported change in well-being and desire for future telehealth. RESULTS: A total of 947 nontrainee physicians, advanced practice providers, and psychologists were surveyed. Of them, 502 (53.0%) providers responded and 467 (49.3%) met inclusion criteria of telehealth use during the study period. Of these, 325 (69.6%) were female, 301 (65.6%) were physicians, and 220 (47.1%) were medical subspecialists. Providers were 4.77 times as likely (95% confidence interval [CI]: 3.29-7.06) to report improved versus worsened well-being associated with telehealth. Also, 95.5% of providers (95% CI: 93.2-97.2%) wish to continue performing telehealth postpandemic. Our model explains 66% of the variance in telehealth-attributed provider well-being and 59% of the variance for future telehealth preference and suggests telehealth resources significantly influence provider-perceived telehealth care effectiveness which in turn significantly influences provider well-being and desire to perform telehealth. CONCLUSION: Telehealth has potential to promote provider well-being; telehealth-related changes in provider well-being are associated with both provider-perceived effectiveness of telemedicine for patients and adequacy of telehealth resources.

Burnout in clinicians.

Burnout is a response to sustained job stressors manifesting as a classic triad of emotional exhaustion, depersonalization, and a sense of reduced accomplishment. With 42% of physicians demonstrating some symptoms of burnout, this has already reached epidemic proportions. The COVID-19 pandemic has only worsened this phenomenon.