Variations in Physician Telemedicine Provision.

This cross-sectional study assesses variation in the provision of telemedicine services among primary care physicians and quantifies the extent to which this variation may be explained by the individual physician vs temporal, patient, or visit factors.

The impact of COVID-19 on primary care accessibility and the role of telehealth for patients with chronic conditions.

Objectives: The objective of this study is to quantify how long patients took to complete their rescheduled primary care appointment pre-pandemic (2019) and during an initial pandemic period (2020). In doing so, the study evaluates telehealth's role in helping primary care patients - particularly in patients with chronic conditions - withstand COVID's significant disruption in care. Methods: Cancelled and completed primary care appointments for adult patients were extracted from the beginning of the pandemic (March 1 to July 31, 2020) and a similar period pre-pandemic (March 1 to July 31, 2019). Days to the subsequent completed visit after cancellation (through June 30, 2021) and appointment modality (in-person, phone, video) were examined. Statistical testing was done to determine statistical significance, and a linear regression was run to control for effects of other study variables. Results: Pre-pandemic patients with chronic conditions needed 52.3 days on average to reschedule their cancelled in-person appointment. During the early pandemic period, chronic condition patients who saw their provider in-person took on average 78.8 days. During the same pre-pandemic period, patients with chronic conditions had their average wait time decrease to 51.5 days when rescheduling via telehealth. These differences were similar for patients without chronic conditions. Conclusions: This analysis shows that telehealth created return to care timelines comparable to the pre-pandemic period which is especially important for patients with chronic conditions. Public interest summary: Telehealth visits (i.e., talking with a physician via phone or video call) help patients continue to receive the medical care they need - especially during disruptive periods such as the COVID pandemic. Access to telehealth is the strongest predictor in determining how soon a patient will complete their reschedule primary care appointment. Because telehealth is so important, health care providers and systems need to continue to offer patients the ability to talk with their physician via phone or video call.

Pilot assessment of an on-demand telehealth 'left without being seen' follow-up programme.

INTRODUCTION: On-demand telehealth can have a high rate of patients requesting visits and dropping off without being seen by a provider, especially during the COVID-19 pandemic. METHODS: On-demand telehealth requests made to a large healthcare system in the USA between 15 March 2020 and 31 May 2020 were included for analysis with a focus on patients who were defined as left without being seen (LWBS). As part of a pilot program a registered nurse attempted to call LWBS patients within 24 hours of their telehealth request and asked if they were ok, if they sought care for their original visit reason, what that care was, or if they still needed guidance. This information and patient demographics were analyzed. RESULTS: During the study period there were 21,610 completed on-demand telehealth visits and 1852 patients for whom there were LWBS attempted follow-ups. Most patients LWBS for a reason that originated from the patient and not associated with the provider or telehealth platform. The mean wait time for LWBS patients was 12.4 min compared to patients waiting 15.1 min before engaging with a provider to complete a visit. Of the 1852 total LWBS patients in the follow-up programme, 819 (44.2%) were successfully contacted with a follow-up phone call. Most of these patients (63.2%) already completed or planned to complete a telehealth visit, 13.6% indicated they no longer needed to see a provider, and 12.8% planned or already completed an in-person visit. Only 2.2% went to an emergency department. DISCUSSION: Results suggest patients can effectively self-manage their care needs.

Large-scale Implementation of a COVID-19 Remote Patient Monitoring Program.

Introduction: We implemented a large-scale remote patient monitoring (RPM) program for patients diagnosed with coronavirus 2019 (COVID-19) at a not-for-profit regional healthcare system. In this retrospective observational study, patients from nine emergency department (ED) sites were provided a pulse oximeter and enrolled onto a monitoring platform upon discharge. Methods: The RPM team captured oxygen saturation (SpO2), heart rate, temperature, and symptom progression data over a 16-day monitoring period, and the team engaged patients via video call, phone call, and chat within the platform. Abnormal vital signs were flagged by the RPM team, with escalation to in-person care and return to ED as appropriate. Our primary outcome was to describe study characteristics: patients enrolled in the COVID-19 RPM program; engagement metrics; and physiologic and symptomatic data trends. Our secondary outcomes were return-to-ED rate and subsequent readmission rate. Results: Between December 2020-August 2021, a total of 3,457 patients were referred, and 1,779 successfully transmitted at least one point of data. Patients on COVID-19 RPM were associated with a lower 30-day return-to-ED rate (6.2%) than those not on RPM (14.9%), with capture of higher acuity patients (47.7% of RPM 30-day returnees were subsequently hospitalized vs 34.8% of non-RPM returnees). Conclusion: Our program, one of the largest studies to date that captures both physiologic and symptomatic data, may inform others who look to implement a program of similar scope. We also share lessons learned regarding barriers and disparities in enrollment and discuss implications for RPM in other acute disease states.

The impact of expanded telehealth availability on primary care utilization.

The expanded availability of telehealth due to the COVID-19 pandemic presents a concern that telehealth may result in an unnecessary increase in utilization. We analyzed 4,114,651 primary care encounters (939,134 unique patients) from three healthcare systems between 2019 and 2021 and found little change in utilization as telehealth became widely available. Results suggest telehealth availability is not resulting in additional primary care visits and federal policies should support telehealth use.

A descriptive analysis of an on-demand telehealth approach for remote COVID-19 patient screening.

INTRODUCTION: COVID-19 requires methods for screening patients that adhere to physical distancing and other Centers for Disease Control and Prevention guidelines. There is little data on the use of on-demand telehealth to meet this need. METHODS: The functional performance of on-demand telehealth as a COVID-19 remote patient screening approach was conducted by analysing 9270 patient requests. RESULTS: Most on-demand telehealth requests (5712 of 9270 total requests; 61.6%) had a visit reason that was likely COVID-19 related. Of these, 79.1% (4518 of 5712) resulted in a completed encounter and 20.9% (1194 of 5712) resulted in left without being seen. Of the 4518 completed encounters, 19.1% were referred to an urgent care centre, emergency department or COVID-19 testing centre. The average completed encounter wait time was 26.5 min and the mean visit length was 8.8 min. For patients that completed an encounter 42.8% (1935 of 4518) stated they would have sought in-person care and 9.1% stated they would have done nothing if on-demand telehealth was unavailable. DISCUSSION: On-demand telehealth can serve as a low-barrier approach to screen patients for COVID-19. This approach can prevent patients from visiting healthcare facilities, which reduces physical contact and reduces healthcare worker use of personal protective equipment.

Population subgroup differences in the use of a COVID-19 chatbot.

COVID-19 chatbots are widely used to screen for symptoms and disseminate information about the virus, yet little is known about the population subgroups that interact with this technology and the specific features that are used. An analysis of 1,000,740 patients invited to use a COVID-19 chatbot, 69,451 (6.94%) of which agreed to participate, shows differences in chatbot feature use by gender, race, and age. These results can inform future public health COVID-19 symptom screening and information dissemination strategies.

Preliminary Assessment of a Telehealth Approach to Evaluating, Treating, and Discharging Low-Acuity Patients With Suspected COVID-19.

BACKGROUND: Telemedicine is uniquely positioned to address challenges posed to emergency departments (EDs) by the Coronavirus Disease 2019 (COVID-19) pandemic. By reducing in-person contact, it should decrease provider risk of infection and preserve personal protective equipment (PPE). OBJECTIVES: To describe and assess the early results of a novel telehealth workflow in which remote providers collaborate with in-person nursing to evaluate and discharge well-appearing, low-risk ED patients with suspected COVID-19 infection. METHODS: Retrospective chart review was completed 3 weeks after implementation. Metrics include the number of patients evaluated, number of patients discharged without in-person contact, telehealth wait time and duration, collection of testing, ED length of stay (ED-LOS), 72-h return, number of in-person health care provider contacts, and associated PPE use. RESULTS: Among 302 patients evaluated by telehealth, 153 patients were evaluated and discharged by a telehealth provider with reductions in ED-LOS, PPE use, and close contact with health care personnel. These patients had a 62.5% shorter ED-LOS compared with other Emergency Severity Index level 4 patients seen over the same time period. Telehealth use for these 153 patients saved 413 sets of PPE. We observed a 3.9% 72-h revisit rate. One patient discharged after telehealth evaluation was hospitalized on a return visit 9 days later. CONCLUSION: Telehealth can be safely and efficiently used to evaluate, treat, test, and discharge ED patients suspected to have COVID-19. This workflow reduces infection risks to health care providers, PPE use, and ED-LOS. Additionally, it allows quarantined but otherwise well clinicians to continue working.

Rapid development of visualization dashboards to enhance situation awareness of COVID-19 telehealth initiatives at a multihospital healthcare system.

The COVID-19 pandemic has led to the rapid expansion of telehealth services as healthcare organizations aim to mitigate community transmission while providing safe patient care. As technology adoption rapidly increases, operational telehealth teams must maintain awareness of critical information, such as patient volumes and wait times, patient and provider experience, and telehealth platform performance. Using a model of situation awareness as a conceptual foundation and a user-centered design approach we describe our process for rapidly developing and disseminating dashboard visualizations to support telehealth operations. We used a 5-step process to gain domain knowledge, identify user needs, identify data sources, design and develop visualizations, and iteratively refine these visualizations. Through this process we identified 3 distinct stakeholder groups and designed and developed visualization dashboards to meet their needs. Feedback from users demonstrated the dashboard's support situation awareness and informed important operational decisions. Lessons learned are shared to provide other organizations with insights from our process.

Diagnostic accuracy of a rapid telemedicine encounter in the Emergency Department.

OBJECTIVES: Emergency Department crowding is an increasing problem, leading to treatment delays and higher risk of mortality. Our institution recently implemented a telemedicine physician intake ("tele-intake") process as a mitigating front-end strategy. Previous studies have focused on ED throughput metrics such as door to disposition; our work aimed to specifically assess the tele-intake model for clinical accuracy. METHODS: We retrospectively reviewed ED visits at a high acuity, tertiary care academic hospital before and after tele-intake implementation. We defined the primary outcome as the degree of additional laboratory, imaging, and medication orders placed by the subsequent ED provider. Our secondary outcomes were the cancellation rate of intake orders and the percentage of encounters where no additional second provider orders were necessary. RESULTS: For in-person and tele-intake physician encounters between September 2015 and February 2017, most labs and diagnostic radiology studies, and approximately half of CT, ultrasound, and pharmacy orders were initiated by the intake physician. We found no significant difference for our primary outcome (p = 0.2449). For both tele-intake and in-person encounters, <1% of orders were cancelled by the second provider. Additionally, 30.8% of in-person and 31.5% of telemedicine patient encounters required no additional orders to make a disposition decision. DISCUSSION: This novel analysis of an innovative patient care model suggests that the benefits of tele-intake as a replacement for in-person physician directed intake are not at the cost of over or under utilization of diagnostic testing or interventions.

Sepsis, severe sepsis, and septic shock: current evidence for emergency department management.

In the middle of a busy shift, a patient arrives by ambulance from a local long-term care facility with a report of altered mental status. You enter the room to find a chronically ill-appearing 85-year-old man with fever, tachycardia, and hypotension, and it is instantly apparent that this patient is septic. What is not clear is what the source is, what modifications in treatment might be necessary based on preexisting microbial resistance, and which of the array of invasive resuscitation techniques are appropriate when meaningful recovery is questionable and efforts may not be desired by the patient and family. You order IV fluids and broad-spectrum antibiotics; send lab tests, including lactate and cultures of blood, urine, and sputum; and begin to review his extensive history to discuss goals of care with his family and primary doctor. While reviewing these issues, a 54-year-old woman with a history of asthma is brought straight back from triage with respiratory distress. You listen to her lungs, expecting wheezes, but hear decreased lung sounds at the right base, preserved air movement elsewhere, and her skin radiates heat. Now, on the monitor, she has a heart rate of 135 beats per minute, blood pressure of 90/60 mm Hg, O2 saturation of 86%, and a temperature of 39.4 degrees C (103 degrees F). You again identify sepsis and instruct your team that you will be using your department's severe sepsis protocol. Equipment for monitoring and procedures is assembled, your staff provides preprinted order and monitoring flow sheets, and the ICU is alerted. Within an hour, the patient is intubated, has a central line placed, and has received IV fluids, broad-spectrum antibiotics and norepinephrine, and you are pleased to see a MAP of 67 mm Hg, a lactate decreasing from an initial value of 7.0, CVP of 10, and ScvO2 of 78%.

Alcohol use self report in chronic back pain--relationships to psychosocial factors, function performance, and medication use.

BACKGROUND CONTEXT: Alcohol consumption is a known risk factor for spinal disability, but there is no data on the relationship between reported alcohol consumption and behaviours in persons who are disabled. PURPOSE: To determine the interaction between reported alcohol consumption, physical performance, and medication use in this group. To determine psychosocial correlates of reported alcohol consumption in this group. METHODS: A retrospective review 147 men and 136 women with more than 3 months disability who underwent a multidisciplinary physical, functional and psychosocial Spine Team Assessment. Questions about alcohol consumption were related to outcome measures. RESULTS: None of the women reported more than 5 drinks/week. Ten men reported more than 12 drinks per week. These performed significantly better on the Progressive Isoinertial Lifting Evaluation (PILE) low lift and the Functional Assessment Screening Test (FAST) 5 minute twisting test, and trended towards better performance on all other tests (the PILE high lift, all 4 other FAST components, Sorenson trunk extension test, and bicycle ergometer submaximal stress test). They had less back pain disability (Quebec p = 0.061), but no difference in depression (CESD), pain (visual analog scale) or fear (Tampa). They used fewer Non-steroidal medications, but similar narcotic medications as the others. No significant differences in the SF-36 were noted. CONCLUSIONS: This first assessment of the relationship of alcohol consumption with back pain disability suggests that women with chronic back pain disability seldom report heavy alcohol consumption. Men with back pain disability who consume large amounts of alcohol have less physical disability despite similar pain. Despite potential interactions, heavy drinkers with pain do not use fewer narcotic analgesics than light drinkers.

The effect of order of testing in functional performance in persons with and without chronic back pain.

Batteries of individually standardized physical and functional tests are commonly used to assess persons with chronic back pain disability. The order of testing may affect performance on later tests. One hundred and fifty patients with > 3 months of back pain disability underwent a multidisciplinary Spine Team Assessment involving Physical Therapy, Occupational Therapy, Pain Psychology, and Vocational Rehabilitation Counselor assessments at a university spine clinic. Seventeen back healthy volunteers performed the physical component of the assessment. For the volunteers the order of testing was randomized to OT tests first or PT test first, with 0.5 h rest between the tests. For patients the order of testing was arbitrarily set by an alternating schedule, with 1 h psychological testing between the two components. For both the patients and volunteers, among the 14 test components, there was no significant difference (p > 0.05) in performance with order of testing. This held true for the subgroup of patients who put out good cardiac effort. Volunteers performed better than patients on all individual tests (p < 0.001). Results suggest that the order of physical testing during a Spine Team Assessment does not affect test performance either in chronic low back disabled patients or in volunteers.