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.

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.

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.

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.

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.

An Exploration of Useful Telemedicine-Based Resources for Clinical Research.

Background: Clinical trials are key to ensuring high-quality, effective, and safe health care interventions, but there are many barriers to their successful and timely implementation. Difficulties with participant recruitment and enrollment are largely affected by difficulties with obtaining informed consent. Teleconsent is a telemedicine- based approach to obtaining informed consent and offers a unique solution to limitations of traditional consent approaches. Methods: We conducted a survey among 134 clinical trial researchers in academic/university-, industry-, and clinically based settings. The survey addressed important aspects of teleconsent, potential teleconsent enhancements, and other telehealth capabilities to support clinical research. Results: The majority of respondents viewed teleconsent as an important approach for obtaining informed consent and indicated that they would likely use teleconsent if available. Consenting participants at remote sites, increasing access to clinical trials, and consenting participants in their homes were viewed as the greatest opportunities for teleconsent. Features for building, validating, and assessing understanding of teleconsent forms, mobile capabilities, three-way teleconsent calls, and direct links to forms via recruitment websites were viewed as important teleconsent enhancements. Other telehealth capabilities to support clinical research, including surveys, file transfer, three-way video, screenshare, and photo capture during telemedicine visits, and proposed telemedicine capabilities such as video call recording, ID information capture, and integration of medical devices, were also viewed as important. Conclusions: Teleconsent and telemedicine are promising solutions to some common challenges to clinical trials. Many barriers to study recruitment and enrollment might be overcome by investing time and resources and further evaluating this technology.

Automatically identifying social isolation from clinical narratives for patients with prostate Cancer.

BACKGROUND: Social isolation is an important social determinant that impacts health outcomes and mortality among patients. The National Academy of Medicine recently recommended that social isolation be documented in electronic health records (EHR). However, social isolation usually is not recorded or obtained as coded data but rather collected from patient self-report or documented in clinical narratives. This study explores the feasibility and effectiveness of natural language processing (NLP) strategy for identifying patients who are socially isolated from clinical narratives. METHOD: We used data from the Medical University of South Carolina (MUSC) Research Data Warehouse. Patients 18 years-of-age or older who were diagnosed with prostate cancer between January 1, 2014 and May 31, 2017 were eligible for this study. NLP pipelines identifying social isolation were developed via extraction of notes on progress, history and physical, consult, emergency department provider, telephone encounter, discharge summary, plan of care, and radiation oncology. Of 4195 eligible prostate cancer patients, we randomly sampled 3138 patients (75%) as a training dataset. The remaining 1057 patients (25%) were used as a test dataset to evaluate NLP algorithm performance. Standard performance measures for the NLP algorithm, including precision, recall, and F-measure, were assessed by expert manual review using the test dataset. RESULTS: A total of 55,516 clinical notes from 3138 patients were included to develop the lexicon and NLP pipelines for social isolation. Of those, 35 unique patients (1.2%) had social isolation mention(s) in 217 notes. Among 24 terms relevant to social isolation, the most prevalent were "lack of social support," "lonely," "social isolation," "no friends," and "loneliness". Among 1057 patients in the test dataset, 17 patients (1.6%) were identified as having social isolation mention(s) in 40 clinical notes. Manual review identified four false positive mentions of social isolation and one false negatives in 154 notes from randomly selected 52 controls. The NLP pipeline demonstrated 90% precision, 97% recall, and 93% F-measure. The major reasons for a false positive included the ambiguities of the experiencer of social isolation, negation, and alternate meaning of words. CONCLUSIONS: Our NLP algorithms demonstrate a highly accurate approach to identify social isolation.

Correction to: Automatically identifying social isolation from clinical narratives for patients with prostate Cancer.

Following publication of the original article [1], the authors reported an error in one of the authors' names.

An Online Peer Educational Campaign to Reduce Stigma and Improve Help Seeking in Veterans with Posttraumatic Stress Disorder.

BACKGROUND: Although at least 1 in 10 veterans meet criteria for Posttraumatic Stress Disorder (PTSD) related to their military service, treatment seeking is strikingly low due to perceived stigma and other barriers. The National Center for PTSD produced AboutFace, * a web-based video gallery of veterans with PTSD who share their personal stories about PTSD and how treatment has turned their lives around. INTRODUCTION: We conducted a two-stage evaluation of AboutFace, which included (1) a usability testing phase and (2) a randomized, controlled trial phase to explore the feasibility of incorporating AboutFace into a specialized outpatient clinic for PTSD. MATERIALS AND METHODS: Twenty veterans participated in the usability testing phase in which they answered moderator posed questions regarding AboutFace, while actively exploring the website. Sixty veterans participated in the study after completing a PTSD clinic evaluation and were randomized to receive an educational booklet about PTSD treatment or AboutFace before starting treatment. Stigma and attitudes about treatment seeking were assessed at baseline and 2 weeks later. RESULTS: Veterans had positive attitudes about AboutFace and gave suggestions for improvement. Veterans in both conditions reported improved attitudes toward mental illness and treatment seeking from baseline to the 2-week follow-up. DISCUSSION: AboutFace is a promising peer-to-peer approach that can be used to challenge stigma and promote help seeking. CONCLUSIONS: This use of an online peer approach is innovative, relevant to a wide range of healthcare conditions, and has the potential to increase access to care through trusted narratives that promote hope in recovery.

Implementation and Utility of an Automated Text Messaging System to Facilitate Symptom Self-Monitoring and Identify Risk for Post-Traumatic Stress Disorder and Depression in Trauma Center Patients.

Background and Introduction: Comprehensive monitoring and follow-up after traumatic injury is important for psychological recovery. However, scalable services to facilitate this are limited. Automated text message-based symptom self-monitoring (SSM) may be a feasible approach. This study examined its implementation and utility in identifying patients at risk for mental health difficulties after traumatic injury.Materials and Methods: Five hundred two patients admitted to a Level I trauma center between June 20, 2016 and July 31, 2017 were offered enrollment in a text message-based SSM service. Patients who enrolled received daily text message prompts over 30 days and most participated in a mental health screening 30 days postbaseline.Results: Approximately 67% of patients enrolled in the service; of these, 58% responded to the text messages, with an average response rate of 53%. Younger patients and those with elevated peritraumatic distress were more likely to enroll. Patients with higher levels of mental health stigma, who were White, or had been in a motor vehicle collision were more likely to enroll and respond to text messages once enrolled. Patients' daily ratings of distress detected clinically elevated 30-day mental health screens with high sensitivity (83%) and specificity (70%).Discussion and Conclusions: Text message-based SSM can be implemented as a clinical service in Level I trauma centers, and patient participation may increase engagement in mental health follow-up. Further, it can inform the use of risk assessments in practice, which can be used to identify patients with poor psychological recovery who require additional screening.

A review of sleep disturbance in children and adolescents with anxiety.

The present review examines the relations between sleep disturbance and anxiety in children and adolescents. The review begins with a detailed discussion of normative developmental trends in sleep, and the relation between sleep quality and emotion dysregulation in children. The extant literature on sleep disturbance in clinically anxious children with a focus on subjective versus objective measures of sleep is then summarized in detail. Finally, a review of the reciprocal relationship between sleep and emotion regulation is provided. The available research suggests that sleep disturbance is quite prevalent in children with anxiety disorders, although the directionality of the association between sleep disturbance and anxiety in children remains unclear. Despite this limitation, a reciprocal relationship between sleep quality and anxiety appears to be well established. Research using objective measures of sleep quality (e.g. polysomnography, sleep actigraphy, sleep bruxism) is warranted to better understand this relation. Further, complicating factors such as the environment in which sleep quality is measured, the developmental stage of participants, varying severity of anxiety and the timeframe during which assessment takes place should all be considered when examining sleep disturbance in this population.

Rural and Urban/Suburban Families' Use of a Web-Based Mental Health Intervention.

Background/Introduction: Access to mental healthcare among rural residents is a national concern because unique barriers (e.g., fewer providers, distance to services) create significant challenges for the 60 million Americans who live in these settings. There is now a large body of literature demonstrating the efficacy of a wide range of Internet-based interventions. However, little is known about the extent to which individuals in rural settings will use these approaches and find them acceptable. Research with youths and their caregivers within this scope is particularly limited and, therefore, of great importance. METHODS: We examined access and completion of a Web-based disaster mental health intervention in a population-based sample of 1,997 rural (n = 676) and urban/suburban (n = 1,321) adolescents and their caregivers who were affected by the Spring 2011 tornadoes that touched down in parts of Missouri and Alabama. RESULTS: Results indicated no differences in the rate of access or completion of Web-based modules based on geographical location. Furthermore, for those who did not access the Web-based resource, no differences were observed with respect to reasons for not accessing modules based on geographical location. DISCUSSION: These data have promising implications for the reach of Web-based resources to both rural and urban/suburban communities, as well as the willingness of adolescents and their caregivers to access and complete such resources, regardless of geographical location.

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).

User experience of a family health history chatbot: A quantitative analysis.

OBJECTIVE: Family health history (FHx) is an important tool in assessing one's risk towards specific health conditions. However, user experience of FHx collection tools is rarely studied. ItRunsInMyFamily.com (ItRuns) was developed to assess FHx and hereditary cancer risk. This study reports a quantitative user experience analysis of ItRuns. METHODS: We conducted a public health campaign in November 2019 to promote FHx collection using ItRuns. We used software telemetry to quantify abandonment and time spent on ItRuns to identify user behaviors and potential areas of improvement. RESULTS: Of 11,065 users who started the ItRuns assessment, 4305 (38.91%) reached the final step to receive recommendations about hereditary cancer risk. Highest abandonment rates were during Introduction (32.82%), Invite Friends (29.03%), and Family Cancer History (12.03%) subflows. Median time to complete the assessment was 636 s. Users spent the highest median time on Proband Cancer History (124.00 s) and Family Cancer History (119.00 s) subflows. Search list questions took the longest to complete (median 19.50 s), followed by free text email input (15.00 s). CONCLUSION: Knowledge of objective user behaviors at a large scale and factors impacting optimal user experience will help enhance the ItRuns workflow and improve future FHx collection.

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.

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.

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.