Finding Our Lanes: A Roadmap for Collaboration Between Academic Medical Centers and Behavioral Telehealth Companies.

ABSTRACT: Outpatient mental health care in the United States is delivered by an uncoordinated patchwork of public and private entities that struggle to effectively differentiate the care they provide. The COVID-19 pandemic catalyzed transformative changes in this space, including rapid adoption of telehealth and escalating private sector investment to provide services for individuals wishing to obtain care through insurance. In this article, we briefly review the current landscape of ambulatory mental health care. Utilizing Kissick's Iron Triangle model of health care delivery, we compare the relative strengths and weaknesses of academic medical centers and the growing private sector, entities potentially positioned to synergistically foster a mental health ecosystem with improved quality, access, and cost-effectiveness. A roadmap for strategic integration is presented for how academic centers-institutions frequently overwhelmed by patient volume-might leverage partnerships with a private sector eager to utilize novel technology to improve access, demonstrate data-driven outcomes, and advocate for improved reimbursement from payers. We also assess the potential risks and pitfalls of such collaboration. In return, academic institutions can refocus on their strengths, including research, systems knowledge, quality-improvement initiatives, education and training, and specialty clinical care.

Digital clinics for diagnosing and treating migraine.

PURPOSE OF REVIEW: Several innovative digital technologies have begun to be applied to diagnosing and treating migraine. We reviewed the potential benefits and opportunities from delivering migraine care through comprehensive digital clinics. RECENT FINDINGS: There are increasing applications of digitization to migraine diagnosis and management, including e-diaries, and patient self-management, especially after the COVID-19 pandemic. Digital care delivery appears to better engage chronic migraine sufferers who may struggle to present to physical clinics. SUMMARY: Digital clinics appear to be a promising treatment modality for patients with chronic migraine. They potentially minimize travel time, shorten waiting periods, improve usability, and increase access to neurologists. Additionally, they have the potential to provide care at a much lower cost than traditional physical clinics. However, the current state of evidence mostly draws on case-reports, suggesting a need for future randomized trials comparing digital interventions with standard care pathways.

Using telehealth for people at the end of life with chronic illness in Australia.

BACKGROUND: Traditional models of palliative care have been tested by the challenges of caring for increasing numbers of people at the end stages of a chronic non-malignant illness. The COVID-19 pandemic and consequent reliance on telehealth services, has enabled the development of creative models of care. AIMS: To improve home-based palliative care for people with chronic illness using telehealth, and this was demonstrated using quality-of-life measures. METHODS: A total of 35 non-cancer referrals to a community palliative care service were recommended for the pilot project, with one specialist palliative care nurse as their contact. All were offered a telehealth service with a specially designed app to self-monitor their symptoms, a session on advance care directives, and self-rated quality-of-life measures using the RAND 36-Item Health Survey (Version 1.0), consisting of 36 items that cover nine domains. Statistical analysis was performed using SPSS software. FINDINGS: Over the 21 months of the pilot study, 13 people chose to participate in the pilot. For participants, telehealth meant more control over their symptoms, fewer emergency presentations and appointment travel time was alleviated. Quality-of-life surveys highlighted physical impairments, which did not change over time. CONCLUSION: This pilot programme demonstrated an innovative approach to addressing the demands of people dying of chronic illness, with further work required to explore the place of telehealth consultations in the overall healthcare system.

Telecare in the Brazilian Unified Health System: where we are and where we are heading. / Teleassistência no Sistema Único de Saúde brasileiro: onde estamos e para onde vamos?

This article explores telecare from telehealth developments and the recent acceleration of the digital health transformation caused by the COVID-19 pandemic, focusing on the Brazilian Unified Health System (SUS). It addresses terminological issues, the scope of actions, the potential use for healthcare, and constraints and contingencies for telecare in Brazil, focusing on teleconsultations and interactions between health professionals and patients. Finally, it presents a set of propositions for the development of telecare policies and practices in Brazil, considering SUS principles, in two central themes: organizational political guidelines and operational propositions to organise services and healthcare delivery. The importance of clarifying the scope and limits of new technologies is highlighted in the attempt to avoid idealizations with proposed solutions to complex health problems. Telecare solutions should be compatible with SUS principles and with the recommended model of care, with the healthcare network coordinated and organised by primary care, ensuring access to health services and integrated and quality healthcare for the Brazilian society.

O artigo explora a teleassistência a partir dos desenvolvimentos da telessaúde e da aceleração da transformação digital na saúde provocada pela pandemia de COVID-19, com foco no Sistema Único de Saúde (SUS). Aborda questões terminológicas, escopo de ações, potencialidades do uso para atenção à saúde e condicionantes e contingências para a utilização da teleassistência no Brasil, concentrando-se nas teleconsultas e nas interações entre profissionais de saúde e pacientes. Por fim, apresenta um conjunto de proposições para o desenvolvimento das políticas e práticas de teleassistência no Brasil, tendo em vista os princípios do SUS, organizados em dois eixos estratégicos centrais: diretrizes político organizacionais e proposições operacionais e de organização dos serviços e do cuidado. Destaca-se a importância de ponderar e elucidar os alcances e os limites das novas tecnologias para evitar idealizações e deslumbramentos com suas propostas de solução para os complexos problemas de saúde. As soluções de teleassistência devem ser compatíveis com princípios e diretrizes do SUS e com o modelo de atenção preconizado, que prevê a organização da rede a partir da atenção primária, para garantir acesso, integralidade e qualidade da atenção à saúde para a sociedade brasileira.

Strategies to strengthen the resilience of primary health care in the COVID-19 pandemic: a scoping review.

BACKGROUND: Primary Health Care (PHC) systems are pivotal in delivering essential health services during crises, as demonstrated during the COVID-19 pandemic. With varied global strategies to reinforce PHC systems, this scoping review consolidates these efforts, identifying and categorizing key resilience-building strategies. METHODS: Adopting Arksey and O'Malley's scoping review framework, this study synthesized literature across five databases and Google Scholar, encompassing studies up to December 31st, 2022. We focused on English and Persian studies that addressed interventions to strengthen PHC amidst COVID-19. Data were analyzed through thematic framework analysis employing MAXQDA 10 software. RESULTS: Our review encapsulated 167 studies from 48 countries, revealing 194 interventions to strengthen PHC resilience, categorized into governance and leadership, financing, workforce, infrastructures, information systems, and service delivery. Notable strategies included telemedicine, workforce training, psychological support, and enhanced health information systems. The diversity of the interventions reflects a robust global response, emphasizing the adaptability of strategies across different health systems. CONCLUSIONS: The study underscored the need for well-resourced, managed, and adaptable PHC systems, capable of maintaining continuity in health services during emergencies. The identified interventions suggested a roadmap for integrating resilience into PHC, essential for global health security. This collective knowledge offered a strategic framework to enhance PHC systems' readiness for future health challenges, contributing to the overall sustainability and effectiveness of global health systems.

Enhancing telehealth services development in Pakistani healthcare sectors through examining various medical service quality characteristics.

Introduction: The telehealth service increased attention both during and after the Covid-19 outbreak. Nevertheless, there is a dearth of research in developing countries, including Pakistan. Hence, the objective of this study was to examine telehealth service quality dimensions to promote the telehealth behavior intention and sustainable growth of telehealth in Pakistan. Methods: This study employed a cross-sectional descriptive design. Data were collected from doctors who were delivering telehealth services through a well-designed questionnaire. To examine the hypothesis of the study, we employed the Smart PLS structural equation modeling program, namely version 0.4. Results: The study findings indicate that medical service quality, affordability, information quality, waiting time, and safety have a positive impact on the intention to engage in telehealth behavior. Furthermore, the adoption of telehealth behavior has a significant favorable effect on the actual utilization of telehealth services, which in turn has a highly good impact on sustainable development. Conclusion: The study determined that telehealth services effectively decrease the amount of time and money spent on travel, while still offering convenient access to healthcare. Furthermore, telehealth has the potential to revolutionize payment methods, infrastructure, and staffing in the healthcare industry. Implementing a well-structured telehealth service model can yield beneficial results for a nation and its regulatory efforts in the modern age of technology.

[Abordaje y atención a la cronicidad con tecnologías digitales en las políticas sanitarias en España]. / Approach and attention to chronicity with digital technologies in health policies in Spain.

OBJECTIVE: From the healthcare policies that support Public Health strategies, technology implementation in healthcare is an innovative element to address chronicity. Its introduction is not uniform across Spain, despite of the existence of digital strategic implementation and national chronicity plans. The aim of this paper was to explore the current deployment of autonomic strategies for chronicity and the implementation of digital tools for telemonitoring and user support. METHODS: A descriptive cross-sectional study was conducted through documental review of autonomous strategies in digital health and chronicity care, available until 2020. Consequently, a consultation was carried out to eighteen experts addressing autonomic availability, benefits and barriers to healthcare digitalization. RESULTS: The expert consultation revealed that, in fifteen autonomous communities, the use and the enhancement of digital technologies were addressed and in nine the focus was on promoting digital transformation. Eleven communities are working on updates, fourteen have health-related digital applications, thirteen allow users checking their test results, ten allow them to carry out administrative procedures, nine deliver patient support resources, and three provide telematic communication channels. 38.89% of the consulted refered not knowing about the existence of any follow-up and monitoring programs in their community. The 60% identified a gap in digital competencies among citizens and the lack of resources, as main barriers to implementation. CONCLUSIONS: There exists disparity in the update of strategies to address chronicity and the introduction of digital technologies. Many of them are currently updating, which is an opportunity to provide efficient responses that incorporate digital tools.

OBJECTIVE: La implementación de tecnologías digitales supone un elemento innovador para el abordaje de la cronicidad, como parte de las estrategias de Salud Pública. Su implantación es variable a nivel autonómico, pese a existir un plan nacional. Este trabajo pretendió conocer el despliegue de las estrategias autonómicas sobre cronicidad, así como de la implementación de opciones de telemonitorización y apoyo al usuario. METHODS: Se realizó un estudio descriptivo transversal mediante revisión documental de las estrategias autonómicas de salud digital y abordaje de la cronicidad disponibles hasta 2020. Se realizó una posterior consulta a dieciocho personas expertas sobre disponibilidad autonómica, beneficios y barreras a la digitalización de la atención sanitaria. RESULTS: La consulta a personas expertas reveló que quince comunidades autónomas abordaron el uso y la potenciación de tecnologías digitales y nueve trabajaron en favorecer la trasformación digital. Once comunidades trabajan en actualizaciones, catorce tienen aplicaciones digitales de salud, trece permiten a los ciudadanos consultar resultados de pruebas, diez permiten trámites administrativos, nueve ofrecen recursos de apoyo al paciente y tres disponen de canales telemáticos de comunicación. El 38,89% de los consultados refirió no conocer los programas de seguimiento y monitorización en su comunidad. El 60% identificó a la falta de competencias digitales de la ciudadanía y a la falta de recursos como barreras de su implantación. CONCLUSIONS: Existe disparidad en la actualización de estrategias para el abordaje de la cronicidad y la implantación de tecnologías digitales. Muchas de ellas se están actualizando, lo que supone una oportunidad para dar respuestas eficientes que incorporen las herramientas digitales.

Centering Digital Health Equity During Technology Innovation: Protocol for a Comprehensive Scoping Review of Evidence-Based Tools and Approaches.

BACKGROUND: In the rush to develop health technologies for the COVID-19 pandemic, the unintended consequence of digital health inequity or the inability of priority communities to access, use, and receive equal benefits from digital health technologies was not well examined. OBJECTIVE: This scoping review will examine tools and approaches that can be used during digital technology innovation to improve equitable inclusion of priority communities in the development of digital health technologies. The results from this study will provide actionable insights for professionals in health care, health informatics, digital health, and technology development to proactively center equity during innovation. METHODS: Based on the Arksey and O'Malley framework, this scoping review will consider priority communities' equitable involvement in digital technology innovation. Bibliographic databases in health, medicine, computing, and information sciences will be searched. Retrieved citations will be double screened against the inclusion and exclusion criteria using Covidence (Veritas Health Innovation). Data will be charted using a tailored extraction tool and mapped to a digital health innovation pathway defined by the Centre for eHealth Research roadmap for eHealth technologies. An accompanying narrative synthesis will describe the outcomes in relation to the review's objectives. RESULTS: This scoping review is currently in progress. The search of databases and other sources returned a total of 4868 records. After the initial screening of titles and abstracts, 426 studies are undergoing dual full-text review. We are aiming to complete the full-text review stage by May 30, 2024, data extraction in October 2024, and subsequent synthesis in December 2024. Funding was received on October 1, 2023, from the Centre for Health Equity Incubator Grant Scheme, University of Melbourne, Australia. CONCLUSIONS: This paper will identify and recommend a series of validated tools and approaches that can be used by health care stakeholders and IT developers to produce equitable digital health technology across the Centre for eHealth Research roadmap. Identified evidence gaps, possible implications, and further research will be discussed. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/53855.

Long-Term Adoption of Televisits in Nursing Homes During the COVID-19 Crisis and Following Up Into the Postpandemic Setting: Mixed Methods Study.

BACKGROUND: There is growing evidence that telemedicine can improve the access to and quality of health care for nursing home residents. However, it is still unclear how to best manage and guide the implementation process to ensure long-term adoption, especially in the context of a decline in telemedicine use after the COVID-19 crisis. OBJECTIVE: This study aims to identify and address major challenges for the implementation of televisits among residents in a nursing home, their caring nurses, and their treating general practitioners (GPs). It also evaluated the impact of televisits on the nurses' workload and their nursing practice. METHODS: A telemedical system with integrated medical devices was introduced in 2 nursing homes and their cooperating GP offices in rural Germany. The implementation process was closely monitored from the initial decision to introduce telemedicine in November 2019 to its long-term routine use until March 2023. Regular evaluation was based on a mixed methods approach combining rigorous qualitative approaches with quantitative measurements. RESULTS: In the first phase during the COVID-19 pandemic, both nursing homes achieved short-term adoption. In the postpandemic phase, an action-oriented approach made it possible to identify barriers and take control actions for long-term adoption. The implementation of asynchronous visits, strong leadership, and sustained training of the nurses were critical elements in achieving long-term implementation in 1 nursing home. The implementation led to enhanced clinical skills, higher professional recognition, and less psychological distress among the nursing staff. Televisits resulted in a modest increase in time demands for the nursing staff compared to organizing in-person home visits with the GPs. CONCLUSIONS: Focusing on health care workflow and change management aspects depending on the individual setting is of utmost importance to achieve successful long-term implementation of telemedicine.

Can digital innovation transform rural primary health care? A systematic review protocol.

INTRODUCTION: Digital technology is increasingly being adopted within primary healthcare services to improve service delivery and health outcomes; however, the scope for digital innovation within primary care services in rural areas is currently unknown. This systematic review aims to synthesise existing research on the use and integration of digital health technology within primary care services for rural populations across the world. METHODS AND ANALYSIS: A systematic approach to the search strategy will be conducted. Relevant medical and healthcare-focused electronic databases will be searched using key search terms between January 2013 and December 2023. Searches will be conducted using specific inclusion and exclusion criteria. A systematic study selection and data extraction process will be implemented, using standardised templates. Outcomes will be reported using the Preferred Reporting Items for Systematic Reviews and Meta-analyses- Protocol statement guidelines. Quality assessment and risk of bias appraisal will be conducted using the Mixed Methods Appraisal Tool. ETHICS AND DISSEMINATION: Ethical approval will not be required because there is no individual patient data collected or reviewed. The finding of this review will be disseminated through peer-reviewed publications and conference presentations. Outcomes will help to understand existing knowledge and identify gaps in delivering digital healthcare services, while also providing potential future practice and policy recommendations. PROSPERO REGISTRATION NUMBER: CRD42023477233.

Innovations produced in Primary Health Care during the COVID-19 pandemic: an integrative literature review. / Inovações produzidas na Atenção Primária à Saúde durante a pandemia do COVID-19: uma revisão integrativa da literatura.

Primary Health Care (PHC) proved to be an important part of the prevention, control and treatment measures against COVID-19, a situation in which it was challenged to keep up its provision of regular services as well. This article identifies the main arrangements made to provide PHC care in the context of the COVID-19 pandemic. An integrative literature review of articles found in PubMed, SciELO and LILACS databases was performed using the descriptors "Primary Health Care" and "COVID-19". Findings were analyzed considering three questions: Information and Communication Technologies (ICT), Organizations of Work Processes and Non-COVID Chronic Diseases. The use of different forms of ICT to provide PHC is highlighted regarding patients with respiratory symptoms and chronic patients. Changes in team composition, service flows, physical spaces and working hours were also introduced. Although strategies aimed at monitoring chronic patients and at remote care may have helped minimize deterioration of their health, the decrease in the number of visits performed during this period could have resulted in an increased demand for PHC in post-pandemic years.

A Atenção Primária à Saúde (APS) demonstrou ser parte importante das medidas de prevenção, controle e tratamento do COVID-19, ao mesmo tempo em que foi desafiada a manter a oferta dos serviços regulares. O objetivo deste artigo é identificar os principais arranjos desenvolvidos para ofertar cuidados na APS na pandemia do COVID-19. A revisão integrativa foi realizada nas bases de dados PubMed, SciELO e LILACS por meio dos descritores "Atenção Primária à Saúde" e "COVID-19". Os resultados foram analisados por meio de três questões: Tecnologias de Informação e Comunicação (TIC), Organizações dos Processos de Trabalho e Doenças Crônicas Não-COVID. Ganha grande destaque o uso das TIC no cuidado ofertado na APS, tanto para pacientes com sintomas respiratórios quanto para pacientes crônicos. Alterações na composição das equipes, fluxos de atendimento, espaços físicos e horários de atendimento também foram implantadas. Ainda que estratégias que visaram o monitoramento dos pacientes crônicos e o atendimento remoto podem ter contribuído para minimizar os agravos à saúde desses usuários, a diminuição dos atendimentos realizados neste período poderá resultar em uma grande demanda para a APS nos anos pós-pandemia.

Health Care Needs of Individuals with Parkinson's Disease Living in Eastern North Carolina: Insights for Multidisciplinary Care and Telemedicine.

Parkinson's disease (PD) is a complex condition, and individuals living in rural areas often face challenges accessing the specialized care they require. To better understand the specific healthcare needs of individuals with PD in Eastern North Carolina (ENC), the present study investigated three key areas: access to a multidisciplinary care team, access to PD-specific resources, and access to resources for establishing telemedicine services. Participants were recruited through email invitations to Parkinson's Foundation members and the distribution of postcards in the region, and 106 individuals with PD in ENC completed the online survey. Only 28.3% of respondents reported access to an interdisciplinary care team, with approximately 50% stating that their healthcare provider had not informed them of the availability of such a team. Nevertheless, the quality of care received was generally perceived as high, and 41.5% of participants were part of a PD support group. Approximately half of the respondents expressed a willingness to have telemedicine appointments with a movement disorder specialist. These findings offer valuable insights for healthcare providers and policymakers in rural areas to better understand the needs of people with PD. Several strategies, including community building and increased access to telemedicine, are recommended to address these needs.

Switching to a 100% remote follow-up of implantable cardiac electronic devices: Organizational model and results of a single center experience.

INTRODUCTION: During the SARS-CoV-2 COVID-19 pandemic, the global health system needed to review important processes involved in daily routines such as outpatient activities within the hospital, including follow-up visits of implantable cardiac electronic devices (CIEDs) carried out in office. The aim of this study is to describe our 3.5 years of real-world experience of a full remote CIED follow-up, evaluate the success rate of remote transmissions, and verify the adopted organizational model. METHODS: From April 2020 to November 2023, all patients with an activated and well-functioning remote monitoring (RM) system and automatic algorithms, like autocapture and autosensing, underwent exclusive RM follow-up. Unscheduled in-office visits were only prompted by remote yellow or red alerts. Patients were divided into two groups, based on available technology: Manual Transmission System (MTS) and Automatic Transmission System (ATS). The ATS group, in addition to ensuring a daily transmission of any yellow or red alerts, was checked at least every 15 days to ensure a valid connection. An automatic transmission was scheduled once a year, irrespective of alerts occurred. The MTS group provided a manual transmission every 6 months. RESULTS: One thousand nine hundred thirty-seven consecutive patients were included in the study. By the end of November 2023, a total of 1409 patients (1192 in the ATS and 217 in the MTS group) were still actively followed by our remote clinic (384 expired, 137 dismissed, 7 transferred). The overall success rate of transmissions with the adopted organizational model was 96.6% in the ATS group (connection index) and 87% in the MTS group. Conventional in-hospital follow-up visits decreased by 44%. Total clinic working time, resulting from the sum of the time spent during in-hospital and remote follow-up, after an initial increase, was progressively reduced to the actual -25%. Mortality rate for any cause was 7.5% per year in remote follow-up patients and 8.3% (p=NS) in in-office patients. In the ATS group, no device malfunctions were notified to our remote clinic, before we had already realized it through appropriate alerts. CONCLUSIONS: The available technology makes moving to a 100% remote clinic possible, without overwhelming clinic workflow, safely. Adopting an appropriate organizational model, it is possible to maintain high transmission success rates. The automatic transmissions allow a more frequent control of patients with CIED.

5G-enabled smart hospitals: Innovations in patient care and facility management.

Smart hospitals represent the pinnacle of healthcare innovation, leveraging cutting-edge technologies to transform patient care and facility management. This article addresses the pressing need for effective implementation of 5G technology in smart hospitals, aiming to enhance connectivity, improve patient outcomes, and drive operational efficiency. The methodology employed involves a comprehensive review of existing literature, case studies, and expert insights to analyze the impact of 5G on various aspects of smart hospital operations. The article highlights the significance of 5G technology in enabling real-time data analytics, remote monitoring, and telemedicine, thus revolutionizing healthcare delivery. By providing high-speed, low-latency connectivity, 5G facilitates seamless communication and collaboration among healthcare providers, leading to more efficient diagnosis, treatment, and patient care. Additionally, the adoption of 5G enables smart hospitals to leverage artificial intelligence (AI)-based solutions for predictive analytics, personalized medicine and enhanced patient engagement. Furthermore, the article explores the potential of 5G-enabled smart hospitals in enhancing disaster preparedness and emergency response efforts. Case studies and examples demonstrate how 5G technology can improve situational awareness, coordinate resources, and deliver timely care during natural disasters and pandemics. Overall, this article underscores the transformative impact of 5G technology on smart hospitals and emphasizes the importance of embracing innovation to meet the evolving needs of patients and communities. By adopting 5G technology, smart hospitals can usher in a new era of healthcare delivery characterized by enhanced connectivity, improved patient outcomes, and unparalleled efficiency.

Telehealth Medication Abortion in Primary Care: A Comparison to Usual in-Clinic Care.

INTRODUCTION: Providing abortion in primary care expands access and alleviates delays. The 2020 COVID-19 public health emergency (PHE) led to the expansion of telehealth, including medication abortion (MAB). This study evaluates the accessibility of novel telehealth MAB (teleMAB) initiated during the PHE, with the lifting of mifepristone restrictions, compared with traditional in-clinic MAB offered before the PHE at a Massachusetts safety-net primary care organization. METHODS: We conducted a retrospective electronic medical record review of 267 MABs. We describe sociodemographic, care access, and complete abortion characteristics and compare differences between teleMAB and in-clinic MABs using Chi-squared test, fisher's exact test, independent t test, and Wilcoxon rank sum. We conducted logistic regression to examine differences in time to care (6 days or less vs 7 days or more). RESULTS: 184 MABs were eligible for analysis (137 in-clinic, 47 teleMAB). Patients were not significantly more likely to receive teleMAB versus in-clinic MAB based on race, ethnicity, language, or payment. Completed abortion did not significantly differ between groups (P = .187). Patients received care more quickly when accessing teleMAB compared with usual in-clinic MAB (median 3 days, range 0 to 20 vs median 6 days, range 0 to 32; P < . 001). TeleMAB patients had 2.29 times the odds of having their abortion appointment within 6 days compared with in-clinic (95% CI: 1.13, 4.86). CONCLUSION: TeleMAB in primary care is as effective, timelier, and potentially more accessible than in-clinic MAB when in-person mifepristone regulations were enforced. TeleMAB is feasible and can promote patient-centered and timely access to abortion care.

Managing Multiple Chronic Conditions during COVID-19 Among Patients with Social Health Risks.

BACKGROUND: Optimal care for persons with multiple chronic conditions (MCC) requires primary and specialty care continuity, access to multiple providers, social risk assessment, and self-management support. The COVID-19 pandemic abruptly changed primary care delivery to increase reliance on telehealth and virtual care. We report on the experiences of individuals with MCC and their family caregivers on managing their health and receiving health care during the initial pandemic. METHODS: Semistructured qualitative interviews with 30 patients (19 English speaking, 11 Spanish speaking) plus 9 accompanying care partners, who had 2+ primary care encounters between March 1, 2020, and November 30, 2020, 2+ chronic conditions, and 1 or more self-reported social risks. Questions focused on access to and experiences with care, roles for care partners, and self-management during the first 6 months of the pandemic. RESULTS: Participants experienced substantial changes in care delivery. The most commonly reported changes were a shift to more virtual relative to in-person care and shifting roles for care partners. Changes fostered new perspectives on self-management and an appreciation of personal resilience and self-reliance. Virtual care was an acceptable complement to in-person care, though not a substitute for periodic in-person visits. It was more acceptable for English speakers and with a usual provider. CONCLUSION: New models of care delivery that recognize patient and family resilience and resourcefulness, emphasize provider continuity, and combine virtual and in-person care may support self-management for individuals with MCC and social needs.

Implementing team-based telemedicine workflows in safety-net primary care.

OBJECTIVES: Challenges in implementing telemedicine disproportionately affect patients served in safety-net settings. Few studies have elucidated pragmatic, team-based strategies for successful telemedicine implementation in primary care, especially with a safety-net population. STUDY DESIGN: We conducted in-depth, semistructured qualitative interviews with primary care clinicians and staff in a large urban safety-net health care system on the facilitators, challenges, and impact of implementing team workflows for synchronous telemedicine video and audio-only visits. METHODS: Interviews were analyzed using modified grounded theory with multistage coding. Common themes were identified and reviewed to describe within-group and between-group variations. We used the Practical, Robust Implementation Sustainability Model framework to organize the final themes with an implementation science lens. RESULTS: Four themes emerged from 11 interviews: (1) having a dedicated individual preparing patients for video visits is a prerequisite for the successful introduction of video visits to patients with limited digital literacy; (2) health care maintenance during video and audio-only visits benefits from standardized workflows and communication; (3) the increased flexibility and accessibility of telemedicine visits were perceived benefits to patient care, despite barriers for subsets of patients; and (4) telemedicine visits generally have a positive impact on work experience for clinicians and staff due to increased efficiency, despite audio-only visits feeling less engaging. CONCLUSIONS: Understanding how to strategically use team-based workflows to expand video visit access while ensuring care quality of all telemedicine visits will allow primary care practices to maximize telemedicine's benefits to patients in the safety-net setting.

Navigating privacy and security in telemedicine for primary care.

OBJECTIVE: To examine patient and provider perspectives on privacy and security considerations in telemedicine during the COVID-19 pandemic. STUDY DESIGN: Qualitative study with patients and providers from primary care practices in 3 National Patient-Centered Clinical Research Network sites in New York, New York; North Carolina; and Florida. METHODS: Semistructured interviews were conducted, audio recorded, transcribed verbatim, and coded using an inductive process. Data related to privacy and information security were analyzed. RESULTS: Sixty-five patients and 21 providers participated. Patients and providers faced technology-related security concerns as well as difficulties ensuring privacy in the transformed shared space of telemedicine. Patients expressed increased comfort doing telemedicine from home but often did not like their providers to offer virtual visits from outside an office setting. Providers initially struggled to find secure and Health Insurance Portability and Accountability Act-compliant platforms and devices to host the software. Whereas some patients preferred familiar platforms such as FaceTime, others recognized potential security concerns. Audio-only encounters sometimes raised patient concerns that they would not be able to confirm the identity of the provider. CONCLUSIONS: Telemedicine led to novel concerns about privacy because patients and providers were often at home or in public spaces, and they shared concerns about software and hardware security. In addition to technological safeguards, our study emphasizes the critical role of physical infrastructure in ensuring privacy and security. As telemedicine continues to evolve, it is important to address and mitigate concerns around privacy and security to ensure high-quality and safe delivery of care to patients in remote settings.