Digitally Disconnected: Qualitative Study of Patient Perspectives on the Digital Divide and Potential Solutions.

BACKGROUND: As telemedicine utilization increased during the COVID-19 pandemic, divergent usage patterns for video and audio-only telephone visits emerged. Older, low-income, minority, and non-English speaking Medicaid patients are at highest risk of experiencing technology access and digital literacy barriers. This raises concern for disparities in health care access and widening of the "digital divide," the separation of those with technological access and knowledge and those without. While studies demonstrate correlation between racial and socioeconomic demographics and technological access and ability, individual patients' perspectives of the divide and its impacts remain unclear. OBJECTIVE: We aimed to interview patients to understand their perspectives on (1) the definition, causes, and impact of the digital divide; (2) whose responsibility it is to address this divide, and (3) potential solutions to mitigate the digital divide. METHODS: Between December 2020 and March 2021, we conducted 54 semistructured telephone interviews with adult patients and parents of pediatric patients who had virtual visits (phone, video, or both) between March and September 2020 at the University of Chicago Medical Center (UCMC) primary care clinics. A grounded theory approach was used to analyze interview data. RESULTS: Patients were keenly aware of the digital divide and described impacts beyond health care, including employment, education, community and social contexts, and personal economic stability. Patients described that individuals, government, libraries, schools, health care organizations, and even private businesses all shared the responsibility to address the divide. Proposed solutions to address the divide included conducting community technology needs assessments and improving technology access, literacy training, and resource awareness. Recognizing that some individuals will never cross the divide, patients also emphasized continued support of low-tech communication methods and health care delivery to prevent widening of the digital divide. Furthermore, patients viewed technology access and literacy as drivers of the social determinants of health (SDOH), profoundly influencing how SDOH function to worsen or improve health disparities. CONCLUSIONS: Patient perspectives provide valuable insight into the digital divide and can inform solutions to mitigate health and resulting societal inequities. Future work is needed to understand the digital needs of disconnected individuals and communities. As clinical care and delivery continue to integrate telehealth, studies are needed to explore whether having a video or audio-only phone visit results in different patient outcomes and utilization. Advocacy efforts to disseminate public and private resources can also expand device and broadband internet access, improve technology literacy, and increase funding to support both high- and low-tech forms of health care delivery for the disconnected.

National Survey of Wellness Programs in U.S. and Canadian Medical Schools.

PURPOSE: To describe the prevalence and scope of wellness programs at U.S. and Canadian medical schools. METHOD: In July 2019, the authors surveyed 159 U.S. and Canadian medical schools regarding the prevalence, structure, and scope of their wellness programs. They inquired about the scope of programming, mental health initiatives, and evaluation strategies. RESULTS: Of the 159 schools, 104 responded (65%). Ninety schools (93%, 90/97) had a formal wellness program, and across 75 schools, the mean full-time equivalent (FTE) support for leadership was 0.77 (standard deviation [SD] 0.76). The wellness budget did not correlate with school type or size (respectively, P = .24 and P = .88). Most schools reported adequate preventative programming (62%, 53/85), reactive programming (86%, 73/85), and cultural programming (52%, 44/85), but most reported too little focus on structural programming (56%, 48/85). The most commonly reported barrier was lack of financial support (52%, 45/86), followed by lack of administrative support (35%, 30/86). Most schools (65%, 55/84) reported in-house mental health professionals with dedicated time to see medical students; across 43 schools, overall mean FTE for mental health professions was 1.62 (SD 1.41) and mean FTE per student enrolled was 0.0024 (SD 0.0019). Most schools (62%, 52/84) evaluated their wellness programs; they used the Association of American Medical Colleges Graduation Questionnaire (83%, 43/52) and/or annual student surveys (62%, 32/52). The most commonly reported barrier to evaluation was lack of time (54%, 45/84), followed by lack of administrative support (43%, 36/84). CONCLUSIONS: Wellness programs are widely established at U.S. and Canadian medical schools, and most focus on preventative and reactive programming, as opposed to structural programming. Rigorous evaluation of the effectiveness of programs on student well-being is needed to inform resource allocation and program development. Schools should ensure adequate financial and administrative support to promote students' well-being and success.

Real-Time In Vivo Assessment of Retinal Reattachment in Humans Using Swept-Source Optical Coherence Tomography.

PURPOSE: To assess the in vivo physiology of retinal reattachment in humans using swept-source optical coherence tomography (SS-OCT) in real time. DESIGN: Prospective case series. METHODS: Fifteen consecutive patients with fovea-involving rhegmatogenous retinal detachment were undergoing pneumatic retinopexy. SS-OCT was performed at presentation and frequent intervals immediately after pneumatic retinopexy. The primary outcome was longitudinal assessment of early postoperative SS-OCT to establish stages of reattachment. RESULTS: Most patients (93.3%, 14/15) achieved successful reattachment at the median follow-up duration of 13 weeks (interquartile range 7.5-18.0). Reattachment occurred in 5 specific stages: 1) redistribution of fluid and approach of the neurosensory retina toward the retinal pigment epithelium occurred in 100% (15/15); 2) reduction in cystoid macular edema and improvement of outer retinal corrugations was achieved in 100% (15/15); 3) initial contact of the neurosensory retina to the retinal pigment epithelium occurred completely in 66.7% (10/15); 4) deturgescence of the inner and outer segments of the photoreceptors occurred in 66.7% (10/15); and 5) recovery of photoreceptor integrity occurred in 3 specific substages: 5A) external limiting membrane recovery (10/15, 66.6%); 5B) ellipsoid zone recovery (9/15, 60%); and 5C) interdigitation zone/foveal bulge recovery (3/15, 20%). Twenty percent (3/15) had delayed progression through stage 2, characterized by formation of outer retinal folds. Similarly, 33.3% (5/15) developed residual subfoveal fluid blebs (delayed progression to stage 3). CONCLUSIONS: This study characterizes the in vivo physiology of retinal reattachment in humans using high-resolution SS-OCT that occurs in 5 specific stages. Delayed progression through certain stages was characterized by postoperative anatomic abnormalities. Am J Ophthalmol 2021;221:•••-•••. © 2021 Elsevier Inc. All rights reserved.

The Productivity Requirements of Implementing a Medical Scribe Program.

BACKGROUND: Economic analyses of medical scribes have been limited to individual, specialty-specific clinics. OBJECTIVE: To determine the number of additional patient visits various specialties would need to recover the costs of implementing scribes in their practice at 1 year. DESIGN: Modeling study based on 2015 data from the Centers for Medicare & Medicaid Services (CMS) and National Ambulatory Medical Care Survey. Scribe costs were based on literature review and a third-party contractor model. Revenue was calculated from direct visit billing, CPT (Current Procedural Terminology) billing, and data from the National Ambulatory Medical Care Survey. DATA SOURCES: 2015 data from CMS and the National Ambulatory Medical Care Survey. TARGET POPULATION: Health care providers. TIME HORIZON: 1 year. PERSPECTIVE: Office-based clinic. OUTCOME MEASURES: The number of additional patient visits a physician must have to recover the costs of a scribe program at 1 year. RESULTS OF BASE-CASE ANALYSIS: An average of 1.34 additional new patient visits per day (295 per year) were required to recover scribe costs (range, 0.89 [cardiology] to 1.80 [orthopedic surgery] new patient visits per day). For returning patients, an average of 2.15 additional visits per day (472 per year) were required (range, 1.65 [cardiology] to 2.78 [orthopedic surgery] returning visits per day). The addition of 2 new patient (or 3 returning) visits per day was profitable for all specialties. RESULTS OF SENSITIVITY ANALYSIS: Results were not sensitive to most inputs, with the exception of hourly scribe cost and inclusion of CPT revenue. LIMITATION: Use of Medicare data and failure to account for indirect costs, downstream revenue, or changes in documentation quality. CONCLUSION: For all specialties, modest increases in productivity due to scribes may allow physicians to see more patients and offset scribe costs, making scribe programs revenue-neutral. PRIMARY FUNDING SOURCE: University of Chicago Medicine's Center for Healthcare Delivery Science and Innovation and the Bucksbaum Institute.

Supporting Inclusive Learning Environments and Professional Development in Medical Education Through an Identity and Inclusion Initiative.

In 2015, the Pritzker School of Medicine experienced increasing student interest in the changing sociopolitical landscape of the United States and the interaction of these events with student and patient identity. To address this interest, an Identity and Inclusion Steering Committee was formed and formally charged with "providing ongoing direction for programs and/or curricula at Pritzker that support an inclusive learning environment and promote respectful and effective communication with diverse patients and colleagues around issues of identity." The authors describe this committee's structure and steps taken by the committee to create an inclusive community of students at Pritzker characterized by learning through civil discourse. Initiatives were guided by a strategy of continuous quality improvement consisting of regular iterative evaluation, ongoing school-wide engagement, and responsiveness to issues and concerns as they emerged. Data collected over the committee's 4-year existence demonstrate significant improvement in students' sense of inclusion and respect for different perspectives on issues related to identity, such as access to health care, racialized medicine, safe spaces, and nursing labor strikes. The authors discuss several principles that support the development of an inclusive community of students as well as challenges to the implementation of such programming. They conclude that a strategy of continuous quality improvement guided by values of social justice, tolerance, and civil discourse can build community inclusion and enhance medical training for the care of diverse patient populations.