Effects of Telemedicine on Pediatric Clinical Care During COVID-19.

Coronavirus disease 2019 (COVID-19) has provided unprecedented opportunity for the growth of telemedicine in pediatrics. Clinics rapidly expanded their telemedicine capabilities and converted in-person visits to virtual visits to offer patients continued care while limiting infection risks. Although the transition to video visits has several benefits-patient convenience, versatility of care, ease of follow up, and management of chronic conditions-these gains are only available to those who have the requisite technology access and literacy needed to conduct a video visit. The need for technology-dependent care stands to further widen preexisting disparities in access to care for those who cannot use or afford the necessary technology. Our article explores some of these benefits and challenges and reminds us that although telemedicine has proven to have high utility for many patients, there are improvements that must still be made to ensure equitable accessibility and durability of virtual visits. [Pediatr Ann. 2021;50(12):e503-e508.].

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

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

Clinician Perspectives on Telemedicine: Observational Cross-sectional Study.

BACKGROUND: Since the COVID-19 pandemic onset, telemedicine has increased exponentially across numerous outpatient departments and specialties. Qualitative studies examining clinician telemedicine perspectives during the pandemic identified challenges with physical examination, workflow concerns, burnout, and reduced personal connection with patients. However, these studies only included a relatively small number of physicians or were limited to a single specialty, and few assessed perspectives on integrating trainees into workflows, an important area to address to support the clinical learning environment. As telemedicine use continues, it is necessary to understand a range of clinician perspectives. OBJECTIVE: This study aims to survey pediatric and adult medicine clinicians at the University of Chicago Medical Center to understand their telemedicine benefits and barriers, workflow impacts, and training and support needs. METHODS: In July 2020, we conducted an observational cross-sectional study of University of Chicago Medical Center faculty and advanced practice providers in the Department of Medicine (DOM) and Department of Pediatrics (DOP). RESULTS: The overall response rate was 39% (200/517; DOM: 135/325, 42%; DOP: 65/192, 34%); most respondents were physicians (DOM: 100/135, 74%; DOP: 51/65, 79%). One-third took longer to prepare for (65/200, 33%) and conduct (62/200, 32%) video visits compared to in-person visits. Male clinicians reported conducting a higher percentage of telemedicine visits by video than their female counterparts (P=.02), with no differences in the number of half-days per week providing direct outpatient care or supervising trainees. Further, clinicians who conducted a higher percentage of their telemedicine by video were less likely to feel overwhelmed (P=.02), with no difference in reported burnout. Female clinicians were "more overwhelmed" with video visits compared to males (41/130, 32% vs 12/64, 19%; P=.05). Clinicians 50 years or older were "less overwhelmed" than those younger than 50 years (30/85, 35% vs 23/113, 20%; P=.02). Those who received more video visit training modalities (eg, a document and webinar on technical issues) were less likely to feel overwhelmed by the conversion to video visits (P=.007) or burnt out (P=.009). In addition, those reporting a higher ability to technically navigate a video visit were also less likely to feel overwhelmed by video visits (P=.02) or burnt out (P=.001). The top telemedicine barriers were patient-related: lack of technology access, lack of skill, and reluctance. Training needs to be focused on integrating learners into workflows. Open-ended responses highlighted a need for increased support staff. Overall, more than half "enjoyed conducting video visits" (119/200, 60%) and wanted to continue using video visits in the future (150/200, 75%). CONCLUSIONS: Despite positive telemedicine experiences, more support to facilitate video visits for patients and clinicians is needed. Further, clinicians need additional training on trainee education and integration into workflows. Further work is needed to better understand why gender and age differences exist. In conclusion, interventions to address clinician and patient barriers, and enhance clinician training are needed to support telemedicine's durability.

Teaching Telemedicine: The Next Frontier for Medical Educators.

The COVID-19 pandemic has pushed telemedicine to the forefront of health care delivery, and for many clinicians, virtual visits are the new normal. Although telemedicine has allowed clinicians to safely care for patients from a distance during the current pandemic, its rapid adoption has outpaced clinician training and development of best practices. Additionally, telemedicine has pulled trainees into a new virtual education environment that finds them oftentimes physically separated from their preceptors. Medical educators are challenged with figuring out how to integrate learners into virtual workflows while teaching and providing patient-centered virtual care. In this viewpoint, we review principles of patient-centered care in the in-person setting, explore the concept of patient-centered virtual care, and advocate for the development and implementation of patient-centered telemedicine competencies. We also recommend strategies for teaching patient-centered virtual care, integrating trainees into virtual workflows, and developing telemedicine curricula for graduate medical education trainees by using our TELEMEDS framework as a model.

Development and testing of a module to promote generic oral contraceptive prescribing among nurse practitioners.

Although generic oral contraceptives (OCPs) can improve adherence and reduce health care expenditures, use of generic OCPs remains low, and the factors that affect generic prescribing are not well understood. We aimed to understand the barriers and facilitators of generic OCP prescribing and potential solutions to increase generic OCP prescribing, as well as pilot an educational module to address clinician misconceptions about generic OCPs. We developed focus group scripts using the 4D model of appreciative inquiry. A total of four focus groups occurred, two at the American Association of Nurse Practitioners (AANP) national conference and two at the American College of Physicians (ACP) Internal Medicine meeting. Focus group transcripts were analyzed using a constant comparative method with no a priori hypothesis to generate emerging and reoccurring themes. Findings from these focus groups were used to develop an educational module promoting generic OCP prescribing. Participants were recruited from the AANP Network for Research and the ACP Research Panel. This study demonstrates that health system factors, workflow factors, clinician factors, and patient factors were the main barriers to and facilitators of generic OCP prescribing. Nurse practitioners were responsive to an educational module and reported increased willingness to discuss and prescribe generic OCPs after completing the module. Interventions to increase generic OCP prescribing must address clinician and patient factors within the context of workflow and larger health system factors.

Development and testing of a web module to IMPROVE generic prescribing of oral contraceptives among primary care physicians.

WHAT IS KNOWN AND OBJECTIVE: The use of generic oral contraceptives (OCPs) can improve adherence and reduce healthcare costs, yet scepticism of generic drugs remains a barrier to generic OCP discussion and prescription. An educational web module was developed to reduce generic scepticism related to OCPs, improve knowledge of generic drugs and increase physician willingness to discuss and prescribe generic OCPs. METHODS: A needs assessment was completed using in-person focus groups at American College of Physicians (ACP) Annual Meeting and a survey targeting baseline generic scepticism. Insights gained were used to build an educational web module detailing barriers and benefits of generic OCP prescription. The module was disseminated via email to an ACP research panel who completed our baseline survey. Post-module evaluation measured learner reaction, knowledge and intention to change behaviour along with generic scepticism. RESULTS AND DISCUSSION: The module had a response rate of 56% (n = 208/369). Individuals defined as generic sceptics at baseline were significantly less likely to complete our module compared to non-sceptics (responders 9.6% vs non-responders 16.8%, P = 0.04). The majority (85%, n = 17/20) of baseline sceptics were converted to non-sceptics (P < 0.01) following completion of the module. Compared to non-sceptics, post-module generic sceptics reported less willingness to discuss (sceptic 33.3% vs non-sceptic 71.5%, P < 0.01), but not less willingness to prescribe generic OCPs (sceptic 53.3% vs non-sceptic 67.9%, P = 0.25). Non-white physicians and international medical graduates (IMG) were more likely to be generic sceptics at baseline (non-white 86.9% vs white 69.9%, P = 0.01, IMG 13.0% vs USMG 5.0% vs unknown 18.2%, P = 0.03) but were also more likely to report intention to prescribe generic OCPs as a result of the module (non-white 78.7% vs white 57.3%, P < 0.01, IMG 76.1% vs USMG 50.3% vs unknown 77.3%, P = 0.03). WHAT IS NEW AND CONCLUSION: A brief educational web module can be used to promote prescribing of generic OCPs and reduce generic scepticism.

Design and application of a fluorogenic assay for monitoring inflammatory caspase activity.

Various fluorogenic assays exist for monitoring the activity of inflammatory caspases. However, there are no continuous assays that provide C-terminal substrate sequence specificity for inflammatory caspases. As a first step towards this, we have developed a continuous in vitro assay that relies on monitoring emission from tryptophan after cleavage of a quenching coumarin chromophore. The coumarin can be attached as an amino acid side chain or capping the C-terminus of the peptide. When the coumarin is a side chain, it allows for C-terminal and N-terminal sequence specificities to be explored. Using this assay, we obtained Michaelis-Menten kinetic data for four proof-of-principle peptides: WEHD-AMC (KM = 15 ± 2 µM), WEHD-MCA (KM = 93 ± 19 µM), WEHDG-MCA (KM = 21 ± 6 µM) and WEHDA-MCA (KM = 151 ± 37 µM), where AMC is 7-amino-4-methylcoumarin and MCA is ß-(7-methoxy-coumarin-4-yl)-Ala. The results indicate the viability of this new assay approach in the design of effective fluorogenic substrates for inflammatory caspases.

Variation of the aryl substituent on the piperazine ring within the 4-(piperazin-1-yl)-2,6-di(pyrrolidin-1-yl)pyrimidine scaffold unveils potent, non-competitive inhibitors of the inflammatory caspases.

The inflammatory caspases (caspase-1, -4 and -5) are potential therapeutic targets for autoimmune and inflammatory diseases due to their involvement in the immune response upon inflammasome formation. A series of small molecules based on the 4-(piperazin-1-yl)-2,6-di(pyrrolidin-1-yl)pyrimidine scaffold were synthesized with varying substituents on the piperazine ring. Several compounds were pan-selective inhibitors of the inflammatory caspases, caspase-1, -4 and -5, with the ethylbenzene derivative CK-1-41 displaying low nanomolar Ki values across this family of caspases. Three analogs were nearly 10 fold selective for caspase-5 over caspase-1 and -4. The compounds display non-competitive, time dependent inhibition profiles. To our knowledge, this series is the first example of small molecule inhibitors of all three inflammatory caspases.