Lessons From the Field From a Volunteer Telehealth Ambassador Program to Enhance Video Visits Among Low-Income Patients: Qualitative Improvement Study.

BACKGROUND: The prevalence of telehealth video use across the United States is uneven, with low uptake in safety-net health care delivery systems, which care for patient populations who face barriers to using digital technologies. OBJECTIVE: This study aimed to increase video visit use in an urban safety-net delivery system. We piloted a telehealth ambassador program, in which volunteers offered technical support to patients with access to digital technologies to convert primary care visits already scheduled as telehealth audio-only visits to telehealth video visits. METHODS: We used a descriptive approach to assess the feasibility, efficacy, and acceptability of the pilot telehealth ambassador program. Feasibility was quantified by the percentage of eligible patients who answered calls from telehealth ambassadors. Program efficacy was measured in two ways: (1) the percentage of patients with access to digital technology who interacted with the navigators and were successfully prepared for a telehealth video visit, and (2) the percentage of prepared patients who completed their scheduled video visits. Program acceptability was ascertained by a structured telephone survey. RESULTS: Telehealth ambassadors attempted to contact 776 eligible patients; 43.6% (338/776) were reached by phone, among whom 44.4% (150/338) were provided digital support between March and May 2021. The mean call duration was 8.8 (range 0-35) minutes. Overall, 67.3% (101/150) of patients who received support successfully completed a telehealth video visit with their provider. Among the 188 patients who were contacted but declined video visit digital support, 61% (114/188) provided a reason for their decline; 42% (48/114) did not see added value beyond a telehealth audio-only visit, 20% (23/114) had insufficient internet access, and 27% (31/114) declined learning about a new technology. The acceptability of the telehealth ambassador program was generally favorable, although some patients preferred having in-real-time technology support on the day of their telehealth video visit. CONCLUSIONS: This high-touch program reached approximately one-half of eligible patients and helped two-thirds of interested patients with basic video visit capability successfully complete a video visit. Increasing the program's reach will require outreach solutions that do not rely solely on phone calls. Routinely highlighting the benefits of video visits, partnering with community-based organizations to overcome structural barriers to telehealth use, and offering in-real-time technology support will help increase the program's efficacy.

Telemedicine and Depression Screening After the Start of the COVID-19 Pandemic.

This cohort study investigates the probability of depression screening by visit type and by patient demographic characteristics in a large health system during the early COVID-19 pandemic.

ChatGPT Influence on Medical Decision-Making, Bias, and Equity: A Randomized Study of Clinicians Evaluating Clinical Vignettes.

In a randomized, pre-post intervention study, we evaluated the influence of a large language model (LLM) generative AI system on accuracy of physician decision-making and bias in healthcare. 50 US-licensed physicians reviewed a video clinical vignette, featuring actors representing different demographics (a White male or a Black female) with chest pain. Participants were asked to answer clinical questions around triage, risk, and treatment based on these vignettes, then asked to reconsider after receiving advice generated by ChatGPT+ (GPT4). The primary outcome was the accuracy of clinical decisions based on pre-established evidence-based guidelines. Results showed that physicians are willing to change their initial clinical impressions given AI assistance, and that this led to a significant improvement in clinical decision-making accuracy in a chest pain evaluation scenario without introducing or exacerbating existing race or gender biases. A survey of physician participants indicates that the majority expect LLM tools to play a significant role in clinical decision making.

Association between language discordance and unplanned hospital readmissions or emergency department revisits: a systematic review and meta-analysis.

BACKGROUND AND OBJECTIVE: Studies conflict about whether language discordance increases rates of hospital readmissions or emergency department (ED) revisits for adult and paediatric patients. The literature was systematically reviewed to investigate the association between language discordance and hospital readmission and ED revisit rates. DATA SOURCES: Searches were performed in PubMed, Embase and Google Scholar on 21 January 2021, and updated on 27 October 2022. No date or language limits were used. STUDY SELECTION: Articles that (1) were peer-reviewed publications; (2) contained data about patient or parental language skills and (3) included either unplanned hospital readmission or ED revisit as one of the outcomes, were screened for inclusion. Articles were excluded if: unavailable in English; contained no primary data or inaccessible in a full-text form (eg, abstract only). DATA EXTRACTION AND SYNTHESIS: Two reviewers independently extracted data using Preferred Reporting Items for Systematic Reviews and Meta-Analyses-extension for scoping reviews guidelines. We used the Newcastle-Ottawa Scale to assess data quality. Data were pooled using DerSimonian and Laird random-effects models. We performed a meta-analysis of 18 adult studies for 28-day or 30-day hospital readmission; 7 adult studies of 30-day ED revisits and 5 paediatric studies of 72-hour or 7-day ED revisits. We also conducted a stratified analysis by whether access to interpretation services was verified/provided for the adult readmission analysis. MAIN OUTCOMES AND MEASURES: Odds of hospital readmissions within a 28-day or 30-day period and ED revisits within a 7-day period. RESULTS: We generated 4830 citations from all data sources, of which 49 (12 paediatric; 36 adult; 1 with both adult and paediatric) were included. In our meta-analysis, language discordant adult patients had increased odds of hospital readmissions (OR 1.11, 95% CI 1.04 to 1.18). Among the 4 studies that verified interpretation services for language discordant patient-clinician interactions, there was no difference in readmission (OR 0.90, 95% CI 0.77 to 1.05), while studies that did not specify interpretation service access/use found higher odds of readmission (OR 1.14, 95% CI 1.06 to 1.22). Adult patients with a non-dominant language preference had higher odds of ED revisits (OR 1.07, 95% CI 1.004 to 1.152) compared with adults with a dominant language preference. In 5 paediatric studies, children of parents language discordant with providers had higher odds of ED revisits at 72 hours (OR 1.12, 95% CI 1.05 to 1.19) and 7 days (OR 1.02, 95% CI 1.01 to 1.03) compared with patients whose parents had language concordant communications. DISCUSSION: Adult patients with a non-dominant language preference have more hospital readmissions and ED revisits, and children with parents who have a non-dominant language preference have more ED revisits. Providing interpretation services may mitigate the impact of language discordance and reduce hospital readmissions among adult patients. PROSPERO REGISTRATION NUMBER: CRD42022302871.

Visit and Between-Visit Interaction Frequency Before and After COVID-19 Telehealth Implementation.

Importance: Telehealth implementation associated with the COVID-19 public health emergency (PHE) affected patient-clinical team interactions in numerous ways. Yet, studies have narrowly examined billed patient-clinician visits rather than including visits with other team members (eg, pharmacists) or between-visit interactions. Objective: To evaluate rates of change over time in visits (in-person, telehealth) and between-visit interactions (telephone calls, patient portal messages) overall and by key patient characteristics. Design, Setting, and Participants: This retrospective cohort study included adults with diabetes receiving primary care at urban academic (University of California San Francisco [UCSF]) and safety-net (San Francisco Health Network [SFHN]) health care systems. Encounters from April 2019 to March 2021 were analyzed. Exposure: Telehealth implementation over 3 periods: pre-PHE (April 2019 to March 2020), strict shelter-in-place (April to June 2020), and hybrid-PHE (July 2020 to March 2021). Main Outcomes and Measures: The main outcomes were rates of change in monthly mean number of total encounters, visits with any health care team member, visits with billing clinicians, and between-visit interactions. Key patient-level characteristics were age, race and ethnicity, language, and neighborhood socioeconomic status (nSES). Results: Of 15 148 patients (4976 UCSF; 8975 SFHN) included, 2464 (16%) were 75 years or older, 7734 (51%) were female patients, 9823 (65%) self-identified as racially or ethnically minoritized, 6223 (41%) had a non-English language preference, and 4618 (31%) lived in the lowest nSES quintile. After accounting for changes to care delivery through an interrupted time-series analysis, total encounters increased in the hybrid-PHE period (UCSF: 2.3% per patient/mo; 95% CI, 1.6%-2.9% per patient/mo; SFHN: 1.8% per patient/mo, 95% CI, 1.3%-2.2% per patient/mo), associated primarily with growth in between-visit interactions (UCSF: 3.1% per patient/mo, 95% CI, 2.3%-3.8% per patient/mo; SFHN: 2.9% per patient/mo, 95% CI, 2.3%-3.4% per patient/mo). In contrast, rates of visits were stable during the hybrid-PHE period. Although there were fewer differences in visit use by key patient-level characteristics during the hybrid-PHE period, pre-PHE differences in between-visit interactions persisted during the hybrid-PHE period at SFHN. Asian and Chinese-speaking patients at SFHN had fewer monthly mean between-visit interactions compared with White patients (0.46 [95% CI, 0.42-0.50] vs 0.59 [95% CI, 0.53-0.66] between-visit interactions/patient/mo; P < .001) and English-speaking patients (0.52 [95% CI, 0.47-0.58] vs 0.61 [95% CI, 0.56-0.66] between-visit interactions/patient/mo; P = .03). Conclusions and Relevance: In this study, pre-PHE growth in overall patient-clinician encounters persisted after PHE-related telehealth implementation, driven in both periods by between-visit interactions. Differential utilization based on patient characteristics was observed, which may indicate disparities. The implications for health care team workload and patient outcomes are unknown, particularly regarding between-visit interactions. Therefore, to comprehensively understand care utilization for patients with chronic diseases, research should expand beyond billed visits.

Impact of standardized, language-concordant hospital discharge instructions on postdischarge medication questions.

Written instructions improve patient comprehension of discharge instructions but are often provided only in English even for patients with a non-English language preference (NELP). We implemented standardized written discharge instructions in English, Spanish, and Chinese for hospital medicine patients at an urban academic medical center. Using an interrupted time series analysis, we assessed the impact on medication-related postdischarge questions for patients with English, Spanish, or Chinese language preferences. Of 4013 patients, ∼15% had NELP. Preintervention, Chinese-preferring patients had a 5.6 percentage point higher probability of questions (adjusted odds ratio [aOR] = 1.55, 95% confidence interval [CI]: 1.08, 2.21) compared to English-preferring patients; Spanish-preferring and English-preferring patients had similar rates of questions. Postintervention, English-preferring and Spanish-preferring patients had no significant change; Chinese-preferring patients had a significant 10.9 percentage point decrease in the probability of questions (aOR = 0.38, 95% CI: 0.21, 0.69) thereby closing the disparity. Language-concordant written discharge instructions may reduce disparities in medication-related postdischarge questions for patients with NELP.

Experimental evidence for structured information-sharing networks reducing medical errors.

Errors in clinical decision-making are disturbingly common. Recent studies have found that 10 to 15% of all clinical decisions regarding diagnoses and treatment are inaccurate. Here, we experimentally study the ability of structured information-sharing networks among clinicians to improve clinicians' diagnostic accuracy and treatment decisions. We use a pool of 2,941 practicing clinicians recruited from around the United States to conduct 84 independent group-level trials, ranging across seven different clinical vignettes for topics known to exhibit high rates of diagnostic or treatment error (e.g., acute cardiac events, geriatric care, low back pain, and diabetes-related cardiovascular illness prevention). We compare collective performance in structured information-sharing networks to collective performance in independent control groups, and find that networks significantly reduce clinical errors, and improve treatment recommendations, as compared to control groups of independent clinicians engaged in isolated reflection. Our results show that these improvements are not a result of simple regression to the group mean. Instead, we find that within structured information-sharing networks, the worst clinicians improved significantly while the best clinicians did not decrease in quality. These findings offer implications for the use of social network technologies to reduce errors among clinicians.

Telehealth Policy, Practice, and Education: a Position Statement of the Society of General Internal Medicine.

Telehealth services, specifically telemedicine audio-video and audio-only patient encounters, expanded dramatically during the COVID-19 pandemic through temporary waivers and flexibilities tied to the public health emergency. Early studies demonstrate significant potential to advance the quintuple aim (patient experience, health outcomes, cost, clinician well-being, and equity). Supported well, telemedicine can particularly improve patient satisfaction, health outcomes, and equity. Implemented poorly, telemedicine can facilitate unsafe care, worsen disparities, and waste resources. Without further action from lawmakers and agencies, payment will end for many telemedicine services currently used by millions of Americans at the end of 2024. Policymakers, health systems, clinicians, and educators must decide how to support, implement, and sustain telemedicine, and long-term studies and clinical practice guidelines are emerging to provide direction. In this position statement, we use clinical vignettes to review relevant literature and highlight where key actions are needed. These include areas where telemedicine must be expanded (e.g., to support chronic disease management) and where guidelines are needed (e.g., to prevent inequitable offering of telemedicine services and prevent unsafe or low-value care). We provide policy, clinical practice, and education recommendations for telemedicine on behalf of the Society of General Internal Medicine. Policy recommendations include ending geographic and site restrictions, expanding the definition of telemedicine to include audio-only services, establishing appropriate telemedicine service codes, and expanding broadband access to all Americans. Clinical practice recommendations include ensuring appropriate telemedicine use (for limited acute care situations or in conjunction with in-person services to extend longitudinal care relationships), that the choice of modality be done through patient-clinician shared decision-making, and that health systems design telemedicine services through community partnerships to ensure equitable implementation. Education recommendations include developing telemedicine-specific educational strategies for trainees that align with accreditation body competencies and providing educators with protected time and faculty development resources.

Randomized trial protocol for remote monitoring for equity in advancing the control of hypertension in safety net systems (REACH-SNS) study.

BACKGROUND: Self-measured blood pressure monitoring (SMBP) is essential to effective management of hypertension. This study aims to evaluate effectiveness and implementation of SMBP that leverages: cellular-enabled home BP monitors without a need for Wi-Fi or Bluetooth; simple communication modalities such as text messaging to support patient engagement; and integration into existing team-based workflows in safety-net clinics. METHODS: This study will be conducted with patients in San Francisco who are treated within a network of safety-net clinics. English and Spanish-speaking patients with diagnosed hypertension will be eligible for the trial if they have recent BP readings ≥140/90 mmHg and do not have co-morbid conditions that make home BP monitoring more complex to manage. This study will implement a three-arm randomized controlled trial to compare varying levels of implementation support: 1) cellular-enabled BP monitors (with minimal implementation support), 2) cellular-enabled BP monitors with protocol-based implementation support (text reminders for patients; aggregated BP summaries sent to primary care providers), and 3) cellular-enabled BP monitors and pharmacist-led support (pharmacist coaching and independent medication adjustments). RESULTS: For the main analysis, we will use mixed effects linear regression to compare the change in primary outcome of systolic BP. Secondary outcomes include BP control (<140/90 mmHg), medication intensification, patient-reported outcomes, and implementation processes (i.e., engagement with the intervention). DISCUSSION: This study will design and test a digital health intervention for use in marginalized populations treated within safety net settings, evaluating both effectiveness and implementation to advance more equitable health outcomes.

Evaluation of Commercially Available Machine Interpretation Applications for Simple Clinical Communication.

BACKGROUND: Accessing professional medical interpreters for brief, low risk exchanges can be challenging. Machine translation (MT) for verbal communication has the potential to be a useful clinical tool, but few evaluations exist. OBJECTIVE: We evaluated the quality of three MT applications for English-Spanish and English-Mandarin two-way interpretation of low complexity brief clinical communication compared with human interpretation. DESIGN: Audio-taped phrases were interpreted via human and 3 MT applications. Bilingual assessors evaluated the quality of MT interpretation on four assessment categories (accuracy, fluency, meaning, and clinical risk) using 5-point Likert scales. We used a non-inferiority design with 15% inferiority margin to evaluate the quality of three MT applications with professional medical interpreters serving as gold standards. MAIN MEASURES: Proportion of interpretation exchanges deemed acceptable, defined as a composite score of 16 or greater out of 20 based on the four assessment categories. KEY RESULTS: For English to Spanish, the proportion of MT-interpreted phrases scored as acceptable ranged from 0.68 to 0.84, while for English to Mandarin, the range was from 0.62 to 0.76. Both Spanish/Mandarin to English MT interpretation had low acceptable scores (range 0.36 to 0.41). No MT interpretation met the non-inferiority threshold. CONCLUSION: While MT interpretation was better for English to Spanish or Mandarin than the reverse, the overall quality of MT interpretation was poor for two-way clinical communication. Clinicians should advocate for easier access to professional interpretation in all clinical spaces and defer use of MT until these applications improve.

Extent of Follow-Up on Abnormal Cancer Screening in Multiple California Public Hospital Systems: A Retrospective Review.

BACKGROUND: Inequitable follow-up of abnormal cancer screening tests may contribute to racial/ethnic disparities in colon and breast cancer outcomes. However, few multi-site studies have examined follow-up of abnormal cancer screening tests and it is unknown if racial/ethnic disparities exist. OBJECTIVE: This report describes patterns of performance on follow-up of abnormal colon and breast cancer screening tests and explores the extent to which racial/ethnic disparities exist in public hospital systems. DESIGN: We conducted a retrospective cohort study using data from five California public hospital systems. We used multivariable robust Poisson regression analyses to examine whether patient-level factors or site predicted receipt of follow-up test. MAIN MEASURES: Using data from five public hospital systems between July 2015 and June 2017, we assessed follow-up of two screening results: (1) colonoscopy after positive fecal immunochemical tests (FIT) and (2) tissue biopsy within 21 days after a BIRADS 4/5 mammogram. KEY RESULTS: Of 4132 abnormal FITs, 1736 (42%) received a follow-up colonoscopy. Older age, Medicaid insurance, lack of insurance, English language, and site were negatively associated with follow-up colonoscopy, while Hispanic ethnicity and Asian race were positively associated with follow-up colonoscopy. Of 1702 BIRADS 4/5 mammograms, 1082 (64%) received a timely biopsy; only site was associated with timely follow-up biopsy. CONCLUSION: Despite the vulnerabilities of public-hospital-system patients, follow-up of abnormal cancer screening tests occurs at rates similar to that of patients in other healthcare settings, with colon cancer screening test follow-up occurring at lower rates than follow-up of breast cancer screening tests. Site-level factors have larger, more consistent impact on follow-up rates than patient sociodemographic traits. Resources are needed to identify health system-level factors, such as test follow-up processes or data infrastructure, that improve abnormal cancer screening test follow-up so that effective health system-level interventions can be evaluated and disseminated.

Multilevel Determinants of Digital Health Equity: A Literature Synthesis to Advance the Field.

Current digital health approaches have not engaged diverse end users or reduced health or health care inequities, despite their promise to deliver more tailored and personalized support to individuals at the right time and the right place. To achieve digital health equity, we must refocus our attention on the current state of digital health uptake and use across the policy, system, community, individual, and intervention levels. We focus here on (a) outlining a multilevel framework underlying digital health equity; (b) summarizingfive types of interventions/programs (with example studies) that hold promise for advancing digital health equity; and (c) recommending future steps for improving policy, practice, and research in this space.

Assessing Medical Student Readiness to Navigate Language Barriers in Telehealth: Cross-sectional Survey Study.

BACKGROUND: The COVID-19 pandemic has greatly increased telehealth usage in the United States. Patients with limited English proficiency (LEP) face barriers to health care, which may be mitigated when providers work with professional interpreters. However, telehealth may exacerbate disparities if clinicians are not trained to work with interpreters in that setting. Although medical students are now involved in telehealth on an unprecedented scale, no educational innovations have been published that focus on digital care across language barriers. OBJECTIVE: The aim of this study is to investigate advanced medical students' confidence in caring for patients with LEP during telehealth encounters. METHODS: We administered a written survey to medical students on clinical clerkships at one US institution in August and September 2020. We assessed students' overall confidence in working with interpreters; confidence in performing 8 clinical tasks during in-person versus telehealth encounters; and frequency of performing 5 different clinical tasks with patients with LEP compared to English-speaking patients during in-person versus telehealth encounters. Wilcoxon signed-rank tests and chi-square tests were used to compare confidence and task performance frequency, respectively, for patients with LEP versus English-speaking patients during telehealth encounters. Students were also asked to identify barriers to care for patients with LEP. The free-response questions were qualitatively analyzed using open coding to identify key themes. RESULTS: Of 300 medical students surveyed, 121 responded. Furthermore, 72 students answered >50% of questions and were included in the analyses. Compared to caring for patients with LEP during in-person encounters, respondents were less confident in working with interpreters (P<.001), developing trust (P<.001), identifying agenda (P=.005), eliciting preferences for diabetes management (P=.01), and empowering patients in lifestyle modifications (P=.04) during telehealth encounters. During both in-person and telehealth encounters, approximately half of students (40%-78%) reported engaging less frequently in every clinical task with patients with LEP and this was as low as 22% (13/59) for some tasks. Students identified these key barriers to care for patients with LEP: time pressure, interpretation quality and access, technical difficulties, cultural differences, and difficulty with rapport building. CONCLUSIONS: Advanced medical students were significantly less confident caring for patients with LEP via telehealth than in person. Broader implementation of training around navigating language barriers is necessary for telehealth care, which has rapidly expanded in the United States. Our study identified potential key areas for curricular focus, including creating patient-centered agendas and management plans within the constraints of virtual settings. These developments must take place simultaneously with systems-level improvements in interpreter infrastructure to ensure high-quality care for linguistically diverse patients.

Use of Self-Measured Blood Pressure Monitoring to Improve Hypertension Equity.

PURPOSE OF REVIEW: To evaluate how self-measured blood pressure (SMBP) monitoring interventions impact hypertension equity. RECENT FINDINGS: While a growing number of studies have recruited participants from safety-net settings, racial/ethnic minority groups, rural areas, or lower socio-economic backgrounds, few have reported on clinical outcomes with many choosing to evaluate only patient-reported outcomes (e.g., satisfaction, engagement). The studies with clinical outcomes demonstrate that SMBP monitoring (a) can be successfully adopted by historically excluded patient populations and safety-net settings and (b) improves outcomes when paired with clinical support. There are few studies that explicitly evaluate how SMBP monitoring impacts hypertension disparities and among rural, low-income, and some racial/ethnic minority populations. Researchers need to design SMBP monitoring studies that include disparity reduction outcomes and recruit from broader populations that experience worse hypertension outcomes. In addition to assessing effectiveness, studies must also evaluate how to mitigate multi-level barriers to real-world implementation of SMBP monitoring programs.

The Impact of the COVID-19 Pandemic on Internet Use and the Use of Digital Health Tools: Secondary Analysis of the 2020 Health Information National Trends Survey.

BACKGROUND: The COVID-19 pandemic increased the use of digital tools in health care (eg, patient portal, telemedicine, and web-based scheduling). Studies have shown that older individuals, racial/ethnic minority groups, or populations with lower educational attainment or income have lower rates of using digital health tools. Digitalization of health care may exacerbate already existing access barriers in these populations. OBJECTIVE: This study evaluated how use of digital tools to asynchronously communicate with clinicians, schedule appointments, and view medical records changed near the beginning of the pandemic. METHODS: Using 2020 Health Information National Trends Survey (HINTS) data, we examined internet use and 7 digital health technology use outcomes (electronic communication with a provider, electronic appointment scheduling, electronic test result viewing, patient portal access, portal use to download health records, portal use for patient-provider communication, and portal use to view test results). The HINTS surveyors designated surveys received after March 11, 2020, as postpandemic responses. Using weighted logistic regression, we investigated the impact of the pandemic after adjusting for sociodemographic traits (age, race/ethnicity, income, education, and gender), digital access (having ever used the internet and smartphone/tablet ownership), and health-related factors (insurance coverage, caregiver status, having a regular provider, and chronic diseases). To explore differences in changes in outcomes among key sociodemographic groups, we tested for significant interaction terms between the pandemic variable and race/ethnicity, age, income, and educational attainment. RESULTS: There were 3865 respondents (1437 prepandemic and 2428 postpandemic). Of the 8 outcomes investigated, the pandemic was only significantly associated with higher odds (adjusted odds ratio 1.99, 95% CI 1.18-3.35) of using electronic communication with a provider. There were significant interactions between the pandemic variable and 2 key sociodemographic traits. Relative to the lowest income group (

Diagnostic Trajectories in Primary Care at 12 Months: An Observational Cohort Study.

BACKGROUND: Little is known about the epidemiology of diagnosis in primary care. METHODS: A prospective observational cohort study was conducted of adults presenting between August and December 2018 to primary care clinics across two health systems with an undiagnosed medical problem. Primary outcomes were (1) likelihood of a definitive diagnosis by 12 months and (2) time to diagnosis. Multivariate logistic regression was used to assess for factors associated with the likelihood of reaching a diagnosis, and multivariable Cox regression was used to assess for factors associated with time to diagnosis. Bivariate models were used to explore unadjusted relationships between the cases' organ systems and likelihood of and time to diagnosis. RESULTS: Among 410 cases in a diverse patient population, 206 (50.2%) reached a final diagnosis within 12 months, with a median time to diagnosis of 5 days (interquartile range = 0-46). Among these cases, 32.4% reached a diagnosis within the first month. A majority of cases not diagnosed within a month of the first presentation remained undiagnosed at 12 months. The likelihood of diagnosis and time to diagnosis did not differ by clinician or patient characteristics, clinicians' level of diagnostic uncertainty, chronicity of the medical issue, or visit type. There were no significant associations between organ system and likelihood of time to diagnosis. CONCLUSION: Patients presenting with new or unresolved problems in ambulatory primary care often remain undiagnosed after a year. There were no provider or patient-level variables associated with such lack of diagnosis. The causes, contributors, and consequences of lack of timely diagnosis and potential solutions require further research.

Policy Considerations To Ensure Telemedicine Equity.

Telemedicine use has exploded during the past two years, but it has done so without sufficient attention to disparities by payer, age, race and ethnicity, income, English language proficiency, and geography. The process of designing permanent, postpandemic telehealth policies must center on equity. Current conversations on equity have focused on broadband access and payment parity between telemedicine modalities (audio only and audiovisual) and in-person care. However, creating telehealth policies that ensure equity will require a more comprehensive, cautious approach that acknowledges the unknowns about how to implement telemedicine to improve health, addresses the multilevel barriers to equity, and reconsiders the purpose and value of telemedicine.