A New Frontier in Telehealth Research: A National Telehealth Data Warehouse.

Importance: Given the rapid increase in telehealth utilization since the onset of the COVID-19 pandemic, it has become essential to examining the vast amount of available data on telehealth encounters to conduct more cogent, robust, and large-scope research studies to examine the utility, cost-impact, and effect on clinical outcomes that telehealth can potentially provide. However, the diversity of data collected by numerous telehealth organizations has made that type of analysis difficult. Objective: The University of Mississippi Medical Center (UMMC), a Telehealth Center of Excellence designated by the Health Resources and Services Administration, is creating a National Telehealth Data Warehouse. Design: UMMC will develop the data warehouse in Microsoft Azure and will use a data dictionary that was created by the Center for Telehealth and eHealth Law (CTeL) to support their national cost-benefit study on the use of telehealth during COVID-19. Impact: The data warehouse will provide unparalleled opportunities to conduct cost-benefit and cost-effectiveness analyses on telehealth, to develop and test quality measures specific to telehealth, and to understand how telehealth and reduce disparities in health care and expand access to care for everyone. The warehouse is expected to go live in the Summer of 2023.

Patient and Family Factors Associated with Use of Telemedicine Visits for Pediatric Acute Respiratory Tract Infections, 2018-2019.

Background: Pediatric acute respiratory tract infections (ARTIs) were a common reason for commercial direct-to-consumer (DTC) telemedicine use before the COVID-19 pandemic, but the factors associated with this use are unknown. Objective: To identify child and family factors associated with use of commercial DTC telemedicine for ARTIs in 2018-2019. Methods: We performed a retrospective cohort analysis of claims data from the Optum Clinformatics® Data Mart Database. Among children with ARTI visits, we fitted logit models to examine child and family characteristics associated with DTC telemedicine use. Results: Of 660,725 children with ARTI visits, 12,944 (2.0%) had ≥1 commercial DTC telemedicine encounter. The odds of DTC telemedicine use were higher for children with age ≥12 years, lower parent educational attainment, higher household income, white non-Hispanic race/ethnicity, and residency in the West South Central census division. Conclusion: In 2018-2019, commercial DTC telemedicine use varied with child age, child race/ethnicity parent educational attainment, household income, and geography.

Teleophthalmology and Inequities in Diabetic Eye Disease at Safety Net Hospitals.

Introduction: Teleophthalmology has emerged as a convenient and cost-effective intervention to increase access to screening for diabetic retinopathy (DR), a disease that disproportionately affects socially disadvantaged communities. However, a few studies have directly compared the detection of eye disease by teleophthalmology between socially and geographically diverse communities. This study compared the rates and severity of diabetic eye disease, as detected by teleophthalmology, between safety net and non-Safety Net Hospitals (non-SNHs). Methods: Retrospective chart review of patients screened for DR at county Safety Net Hospitals (SNHs) and non-SNHs in 150 cities and 30 states. The rates of DR, macular edema, suspected cataract, suspected glaucoma, and suspected age-related macular degeneration were compared. Relative risk and severity of disease in the county SNH population were calculated. Images were graded by the same group of IRIS readers, who used at least one image per eye with a 45° field centered between the optic disc and the macula. Participants with ungradable screening images were excluded. Results: Ninety-four thousand three hundred twenty-nine participants were screened for eye disease from September 1, 2016 to August 31, 2017. Among the screened participants (54% female; mean [SD] age, 58.7 [12.9] years), overall disease detection was 31% in the county SNH population and 23.6% in the non-SNH population. Compared with the non-SNH population, the county SNH population was twice as likely to screen positive for three or more concurrent eye conditions (1.2% vs. 0.7%) and had increased prevalence of DR (20.2% vs. 16.2%), macular edema (4.9% vs. 3.4%), suspected glaucoma (9.1% vs. 4.3%), suspected cataract (9.6% vs. 4.8%), and proliferative DR (2.1% vs. 1.0%). Conclusions: Increased diabetic eye disease prevalence and severity among people seen at SNHs highlights the need for continued resources to screen, treat, and manage disease. Teleophthalmology continues to be an important tool in efforts to mitigate health inequities and address barriers faced by underserved communities.

Perceptions of Telehealth Among Commercial Members Who Responded to a Patient-Experience Survey During the Onset of the Coronavirus-19 Pandemic.

Introduction: The body of literature on telehealth perception among commercial members is limited. Therefore, we administered a patient-experienced survey (Clinician and Group Consumer Assessment of Healthcare Providers and Systems [CG-CAHPS]) to determine member perceptions of telehealth, including willingness to pay for it and the likelihood to access it again. Methods: This study used a cross-sectional design, and members were assigned into two groups: those who had a telehealth visit with their primary care provider (PCP) or a provider in the same practice and those who had a telehealth visit with a provider outside of their PCP's practice. Logistic regression models were used to observe group differences in telehealth perception. Results: A total of 444 members replied to the CG-CAHPS survey and had a virtual visit; 21.1% had a telehealth visit with a provider outside of their PCP's practice, and 78.8% had a telehealth visit with their PCP or a provider in the same practice. Compared with members who saw a provider outside of their PCP's practice, members who saw their PCP or a provider in the same practice had 3.76 higher odds (confidence interval [95% CI]: 1.49-9.44) of rating in-person care as no different than virtual care; 2.29 higher odds (95% CI: 1.30-4.04) of reporting they would likely use telehealth again in the future; and 1.70 higher odds (95% CI: 0.99-2.91) of responding that they would be willing to pay an in-office visit copay for a telehealth visit. Conclusion: These results suggest that the familiarity of a member's PCP extends to the provider's practice and impacts member outlook on telehealth.

The Ideal Patient for Teleconsultation and Saving Resources.

Objectives: The main objectives of the study were to evaluate the level of patients' acceptance of teleconsultation (TC) and to define the ideal patient profile for this type of service. The secondary objectives were to estimate the impact in time and financial resources for the patient in relation to face-to-face medicine. Materials and Methods: This is a prospective, nonprobabilistic, and random sampling study using an uncontrolled selection process consisting of a 19-question survey for health care users in the general population, in which the patients' acceptance of TC was analyzed through the question: "If your doctor suggested that you have a video conference consultation, how attractive would the proposal be for you?" Results: Of the 400 patients, 73.8% were in favor of a TC service. The variables that were associated with the acceptance of TC were health care users who had previously purchased on the internet (odds ratio [OR] = 2.6 confidence interval [CI] 95% 1.31; 5.05) and whether they were willing to assume the economic cost for a TC (OR = 7.8 CI 95% 3.26; 18.6). In terms of face-to-face consultations per year, 50% of the patients spent 5 h (standard deviation [SD] 10.7) going to see the doctor, and on average they requested 8.9 h (SD 16.1) of time off work permission and assumed an economic cost of €29.8 (SD 82.9) on journey time. Conclusion: A high number of health care users accept the use of TC, and this percentage increases in patients who had previously purchased online and were willing to assume an economic cost for this service.

Effectiveness of a Cognitive Behavioral Coaching Program Delivered via Video in Real World Settings.

Background: Many employees experience high levels of stress in the workplace, which negatively impact their productivity and well-being. Effective stress management interventions exist, but are inaccessible due to insufficient numbers of mental health providers, long waiting times to initiate care, high out-of-pocket cost of care, and stigma related to receiving psychotherapy. Introduction: The purpose of this study was to test the efficacy, in real-world circumstances, of a structured, cognitive behavioral coaching (CBC) program delivered through video or telephone. Materials and Methods: Retrospective data on 289 subjects who had sought support for emotional health through a behavioral health benefit offered through employers were examined. Changes in perceived stress and well-being over the course of the program were measured using the Perceived Stress Scale (PSS) and Warwick-Edinburgh Mental Well-being Scale (WEMWBS), respectively. Rates of reliable change and satisfaction with the coaching program were also assessed. Results: Scores on both the PSS and WEMWBS improved between baseline and follow-up. Approximately 61.9% (n = 289) of participants demonstrated reliable improvement on either measure. Discussion: CBC is a promising intervention that has the potential to significantly expand access to effective and more affordable interventions for emotional health care. Conclusions: Coaching, when delivered by accredited professionals trained in cognitive behavioral theory and interventions and working in real-world settings, can be efficacious in decreasing perceived stress and increasing well-being when delivered through video or telephone.

Follow-Up Compliance for Patients Diagnosed with Diabetic Retinopathy After Teleretinal Imaging in Primary Care.

Background: Teleretinal imaging has been demonstrated to increase diabetic patient compliance with annual retinal examinations, but few studies have examined patient behavior after screening. Compliance with eye specialist follow-up is critical to ensure remote detection programs improve long-term vision outcomes for patients with diabetes. Introduction: The purpose of this study was to assess the rate of eye specialist follow-up compliance after referral for diabetic retinopathy (DR) from a teleretinal imaging program in a large primary care group practice. Materials and Methods: This is a retrospective chart review study of patients examined through a teleretinal imaging program between June 2015 and October 2017. Data from an electronic medical record were used to determine whether patients who were referred for management of DR requiring treatment attended follow-up eye care appointments. Reasons for nonattendance were also identified. Results: During the study time period, there were 110 patients referred for detected vision-threatening DR. Of those patients, 62 (56.3%) had an eye examination within 3 months, 83 (75.5%) had an examination within 1 year, and 92 (83.6%) had an examination within the 30-month study period. Of the patients who had follow-up eye examinations, 62.7% confirmed the diagnosis of vision-threatening DR and 89.2% had some level of DR. Discussion: Teleretinal imaging programs not only increase patient compliance with diabetic retinal examinations but can also generate accurate referrals and yield high rates of compliance with follow-up. Conclusions: These findings suggest that evaluating patients for DR in the primary care setting is an effective method of detecting vision-threatening retinopathy. However, assuring patient follow-up and treatment for vision-threatening DR detected in primary care telemedical networks remains a challenge.

Limiting Potential Exposure During a Pandemic: The Importance of Diagnostic Testing Options for COVID-19.

Introduction: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) altered the delivery of outpatient care and expanded the use of telehealth solutions. This research underscores the importance of providing options for accessing health care services and diagnostic testing in a clinically rigorous manner. Providing options for patients will be essential in curtailing the spread of COVID-19, and any concomitant confusion caused by the overlapping symptomology of the flu and other upper respiratory viruses. Methods: A survey was sent to patients to collect information related to their experience with testing, guidance, and consults in a telehealth model for SARS-CoV-2. Specifically, patients were asked where they would have sought testing and care had this model not been available, and their satisfaction level with the service itself. Results: More than 1,400 patients responded to the survey for a response rate of 15%. Results demonstrate that patients who underwent testing and received guidance/consults through this model would have visited other in-person clinical environments such as emergency rooms or urgent care centers. Although ∼70% of patients had never used telehealth services before, >90% were highly satisfied with their experience. Conclusion: Many health experts are predicting a second wave for COVID-19 infections around the country. Given the strong overlap of flu and other upper respiratory infections with COVID-19, the winter season could prove challenging both to contain the spread of the virus and to differentiate the cause. This research sheds additional light on the importance of providing patients with viable safe alternatives to obtain diagnostic testing, guidance, and consults.

Emergency Telemedicine: Achieving and Maintaining Compliance with the Emergency Medical Treatment and Labor Act.

PURPOSE: Telemedicine is a growing and important platform for medical delivery in the emergency department. Emergency telemedicine outlays often confront and conflict with important federal healthcare regulations. Because of this, academic medical centers, critical access hospitals, and other providers interested in implementing emergency telemedicine have often delayed or forgone such services due to reasonable fears of falling out of compliance with regulatory restrictions imposed by the Emergency Medical Treatment and Labor Act ("EMTALA"). This article offers insights into methods for implementing emergency telemedicine services while maintaining EMTALA compliance. METHODOLOGY: Critical analysis of EMTALA and its attendant regulations. RESULTS: The primary means of ensuring EMTALA compliance while implementing emergency telemedicine programs include incorporating critical clinical details into the services contracts and implementing robust written policies that anticipate division of labor issues, the need for backup coverage, triaging, patient transfer protocols, and credentialing issues. With adequate up-front due diligence and meaningful contracting, hospitals and telemedicine providers can avoid common EMTALA liability pitfalls.

Telehealth Support of Managed Care for a Correctional System: The Open Architecture Telehealth Model.

INTRODUCTION: The intent was to evaluate time to match initial investment of a new, statewide correctional system telehealth program based upon cumulative savings by avoidance of transportation and custody-related costs. MATERIALS AND METHODS: The setting was a statewide correctional system where prisoners received medical care through enhanced telemedicine technology supported by newly recruited specialty providers delivered through an open architecture system. The patients were incarcerated persons requiring nonemergent consultations in 10 specialties. A financial model was created to estimate transportation expenses, including vehicular use and custody staff, during the out of prison travel for traditional face-to-face care. Cost savings were then estimated by multiplying transportation expenses by the number of telehealth encounters (avoided cost) and summed cumulatively. Savings were mapped monthly. Private sector specialists were recruited, provided security clearance, trained in the use of the technology, and provided a secure site to provide services. MEASUREMENTS AND MAIN RESULTS: Based on the financial model, 1.2 million dollars in savings, equaling the initial capital investment, were achieved at 32 months. The total number of patient telemedicine encounters increased from 2,365 (±98/month) to 3,748 during the first 32 months of operation (July 2013 through January 2016: ±117/month) with 89% of the established specialties performed by telemedicine technologies. DISCUSSION: It was initially estimated to require 48 months to achieve the investment savings, but savings were achieved in 32 months, demonstrating greater adoption than expected. While finances were quantifiable, enhanced public safety by avoidance of out of prison time is unquantifiable, but judged to be significant.

Telemedicine for a General Screening of Retinal Disease Using Nonmydriatic Fundus Cameras in Optometry Centers: Three-Year Results.

PURPOSE: Describe the first 3 years of highly specialized retinal screening through a web platform using a retinologists' network for image reading. METHODS: All patients who came to centers in the network and consented to fundus photography were included. Images were evaluated by ophthalmologists. We describe number of patients, age, visual acuity, retinal abnormalities, medical recommendations, and factors associated with abnormal retinographies. RESULTS: Fifty thousand three hundred eighty-four patients were included; mean age 52.3 years (range 3-99). Mean visual acuity 20/25. Of the total cohort, 75% had normal retinographies, 22% had abnormalities, 1% referred acute floaters, 1% referred acute symptoms with normal retinography, and 1% could not be assessed. Ophthalmological referral was recommended in 12,634 patients: 9% urgent visit, 11% preferential (2-3 weeks), and 80% an ordinary visit. Age-related maculopathy signs were the most common abnormalities (2,456 patients, 4.8%). Epiretinal membrane was the second (764 cases, 1.5%). Diabetic retinopathy was suspected in 543 patients (1%), and nevi in 358 patients (0.7%). Patients older than 50 years had significantly more retinal abnormalities (31.5%) than younger ones (11.1%) (p < 0.0001; odds ratio [OR] 2.47; confidence interval [CI] 2.37-2.57). Patients with almost one eye with a myopic defect greater than -5 spherical equivalent had a higher risk of presenting abnormalities (p < 0.001; OR 1.04; CI 1.03-1.05). CONCLUSIONS: A high rate of asymptomatic retinal abnormalities was detected in this general screening, justifying this practice. Many patients who visit optometrists in Spain are unaware that they would benefit from ophthalmological monitoring. The ophthalmic community should lead initiatives of the type presented to preserve and guarantee quality standards.

Using Mobile-Health to Connect Women with Cardiovascular Disease and Improve Self-Management.

Background/Introduction: Self-management approaches are regarded as appropriate methods to support patients with cardiovascular disease (CVD) and to prevent secondary complications and hospitalizations. Key to successful self-management is the ability of individuals to enlist peer supports to help sustain motivation and efforts to manage their condition. The purpose of this study was to investigate the proof of concept of a peer-support mobile-health (m-health) program, called Healing Circles, and explore the program's effect on self-management, social support, and health-related quality of life in women with CVD. MATERIALS AND METHODS: Healing Circles is a consumer m-health solution developed to facilitate peer support and self-management by connecting people with CVD in groups of five to nine people. Women with CVD (obstructive coronary artery disease) were included in this single group, pre/post study if they owned an iPhone/iPad with at least iOS 7.0. Participants (n = 21) used the Healing Circles program for a 10-week period. Self-management, social support, and health-related quality-of-life outcomes were assessed before and after the use of the program. User experiences and satisfaction were obtained during an exit interview. RESULTS: After 10 weeks of using the Healing Circles program, statistically significant improvements were observed in the participants' health behaviors (p = 0.04), self-monitoring (p = 0.04), social support (p = 0.01), and social integration (p = 0.002). As well, many women had a level of high satisfaction with the concept of using m-health for the delivery of peer support. CONCLUSION: The delivery of peer and self-management support using m-health technologies is well received and may improve self-management and social support. More research is needed to test hypotheses of the effect of the Healing Circles program on clinical outcomes.

Access and Quality of Care in Direct-to-Consumer Telemedicine.

BACKGROUND: Direct-to-consumer (DTC) telemedicine serves millions of patients; however, there is limited research on the care provided. This study compared the quality of care at Teladoc ( www.teladoc.com ), a large DTC telemedicine company, with that at physician offices and compared access to care for Teladoc users and nonusers. MATERIALS AND METHODS: Claims from all enrollees 18-64 years of age in the California Public Employees' Retirement System health maintenance organization between April 2012 and October 2013 were analyzed. We compared the performance of Teladoc and physician offices on applicable Healthcare Effectiveness Data and Information Set measures. Using geographic information system analyses, we compared Teladoc users and nonusers with respect to rural location and available primary care physicians. RESULTS: Of enrollees offered Teladoc (n = 233,915), 3,043 adults had a total of 4,657 Teladoc visits. For the pharyngitis performance measure (ordering strep test), Teladoc performed worse than physician offices (3% versus 50%, p < 0.01). For the back pain measure (not ordering imaging), Teladoc and physician offices had similar performance (88% versus 79%, p = 0.20). For the bronchitis measure (not ordering antibiotics), Teladoc performed worse than physician offices (16.7 versus 27.9%, p < 0.01). In adjusted models, Teladoc users were not more likely to be located within a healthcare professional shortage area (odds ratio = 1.12, p = 0.10) or rural location (odds ratio = 1.0, p = 0.10). CONCLUSIONS: Teladoc providers were less likely to order diagnostic testing and had poorer performance on appropriate antibiotic prescribing for bronchitis. Teladoc users were not preferentially located in underserved communities. Short-term needs include ongoing monitoring of quality and additional marketing and education to increase telemedicine use among underserved patients.

Feasibility of popular m-health technologies for activity tracking among individuals with serious mental illness.

Obesity prevalence is nearly double among individuals with serious mental illness (SMI), including schizophrenia spectrum disorders, bipolar disorder, or major depressive disorder, compared with the general population. Emerging mobile health (m-health) technologies are increasingly available and offer the potential to support lifestyle interventions targeting weight loss, yet the practical feasibility of using these technologies in this high-risk group has not been established. We evaluated the feasibility and acceptability of popular m-health technologies for activity tracking among overweight and obese individuals with SMI. We provided wearable activity monitoring devices (FitBit [San Francisco, CA] Zip™ or Nike Inc. [Beaverton, OR] FuelBand) and smartphones (Apple [Cupertino, CA] iPhone(®) 4S) for accessing the smartphone application for each device to participants with SMI enrolled in a weight loss program. Feasibility of these devices was measured by the frequency of use over time. Acceptability was measured through qualitative follow-up interviews with participants. Ten participants with SMI wore the devices for a mean of 89% (standard deviation=13%) of the days in the study. Five participants wore the devices 100% of the time. Participants reported high satisfaction, stating the devices were easy to use, helpful for setting goals, motivational, and useful for self-monitoring. Several participants liked the social connectivity feature of the devices where they could see each other's progress on the smartphone application, noting that "friendly" competition increased motivation to be more physically active. This study supports using popular m-health technologies for activity tracking among individuals with SMI. These findings can inform the design of weight loss interventions targeting this vulnerable patient population.

Development of a telehealthcare decision support system for patients discharged from the hospital.

OBJECTIVE: This article presents the development of a telehealthcare decision support system (TDSS) for patients discharged from the hospital, where symptom data are important indications of the recovery progress for patients. Symptom data are difficult to quantify in a telehealthcare application scenario because the observations and perceptions on symptoms by the patient themselves are subjective. In the TDSS, both symptom data from patients and clinical histories from the hospital information system are collected. Machine learning algorithms are used to build a predictive model for classifying patients according to their symptom data and clinical histories, to provide a degree of urgency for the patient to return to the hospital. MATERIALS AND METHODS: During a 1-year period, 1,467 patient cases were collected. Symptom data and clinical histories were preprocessed into 49 parameters for machine learning. The training data of patients were validated manually with their actual clinical histories of returning to the hospital. The performances of predictive models trained by five different machine learning algorithms were evaluated and compared. RESULTS: The Bayesian network algorithm had the best performance among the machine learning algorithms tested in this application scenario and was selected to be implemented in the TDSS. On the 1,467 patient cases collected, its precision in 10-fold cross-validation was 79.3%. The most important six parameters were also selected from the 49 parameters by feature selection. The performance of correct prediction by the TDSS is comparable to that by the nursing team at the call center. CONCLUSIONS: The TDSS provides a degree of urgency for patients to return to the hospital and thereby assists the telehealthcare nursing team in making such decisions. The performance of the TDSS is expected to improve as more cases of patient data are collected and input into the TDSS. The TDSS has been implemented in one of the largest commercialized telehealthcare practices in Taiwan administered by Min-Sheng General Hospital.

New hospital telemedicine services: potential market for a nighttime telehospitalist service.

BACKGROUND: A critical shortage in the supply of physicians in the United States has necessitated innovative approaches to physician service delivery. Telemedicine is a viable service delivery model for a variety of physician and health services. Telemedicine is most effective when applied where physician resources are scarce, patient care is time sensitive, and service volume may be distributed across a network. Shortages in critical care and neurology specialists have led to the use of tele-intensive care unit and telestroke services in hospital settings. These hospital-based telemedicine services have gained acceptance and recommendation. Hospitalist staffing shortages may provide an opportunity to apply similar telemedicine models to hospitalist medicine. This study assesses the potential market for a nighttime telehospitalist service. MATERIALS AND METHODS: An analysis of the Florida state hospital discharge dataset investigated the potential market for a new nighttime telehospitalist service. Admissions were filtered and stratified for common hospitalist metrics, time of day, and age of patients. Admissions were further expressed by hour of day and location. RESULTS: Nineteen percent of common hospitalist admissions occurred between 7:00 p.m. and 7:00 a.m., with a range of 17%-27% or 0.23-10.09 admissions per night per facility. Eighty percent of admissions occurred prior to midnight. Nonrural facilities averaged 6.69 hospitalist admissions per night, whereas rural facilities averaged 1.35 admissions per night. CONCLUSIONS: The low volume of nighttime admissions indicates an opportunity to leverage a telehospitalist physician service to deliver inpatient medical admission services across a network. Lower volumes of nighttime admissions in rural facilities may indicate a market for telehospitalist solutions to address the dilemma of hospitalist staffing shortages.