The virtual physical exam in the 21st century

Associations of clinical personnel characteristics and telemedicine practices

CONTEXT

The use of telemedicine strategies has been increasing in the United States for more than a decade, with physicians taking advantage of this new tool to reach more patients. Determining the specific demographics of physicians utilizing telemedicine most in their practice can inform recommendations for expanded telemedicine use among all physicians and aid in mitigating the need for local physicians in urban and rural populations.

OBJECTIVES

This study aims to assess the use of telemedicine by physicians in 2021, based on four demographics utilizing the National Electronic Health Record Survey (NEHRS): physician age, sex, specialty, and training.

METHODS

We performed a cross-sectional study of the 2021 NEHRS to determine the relationship between physician characteristics and telemedicine practices. Differences between groups were measured through design-based chi-square tests.

RESULTS

Compared to male physicians, female physicians were more likely to utilize telemedicine services (X 2=8.0; p=0.005). Compared to younger physicians, those over the age of 50 were less likely to utilize telemedicine services (X 2=4.1; p=0.04). Compared to primary care physicians, medical and surgical specialty physicians were less likely to utilize telemedicine services, with surgical specialty physicians being the least likely overall (X 2=11.5; p<0.001). We found no significant differences in telemedicine use based on degree (Osteopathic and Allopathic).

CONCLUSIONS

Our results showed a statistically significant difference between physician's age, sex, and specialty on telemedicine use in practice during 2021. Efforts to increase telemedicine use among physicians may be needed to provide more accessible care to patients. Thus, by increasing physician education on the importance of telemedicine for modern patients, more physicians may decide to utilize telemedicine services in practice.

Patient perspective on virtual prechemotherapy visits in gynecologic oncology

Objective

To assess gynecologic oncology patients' experiences with virtual prechemotherapy evaluation and determine preference for incorporating virtual visits into a chemotherapy schedule.

Methods

From June-August 2023, a survey was distributed to patients with gynecologic malignancies who had both an in-person and virtual prechemotherapy visit at a tertiary comprehensive cancer center. Patient satisfaction and preference for incorporating virtual visits was elicited. Patients who preferred ≥ 50 % of prechemotherapy visits to be virtual were classified as "virtual-leaning" and those who preferred < 50 % virtual as "in-person-leaning."

Results

Of 110 eligible patients, 93 agreed to participate and 73 completed the survey, yielding an overall 66.4% response rate and 78.5% (73/93) survey completion rate. Overall satisfaction with in-person and virtual visits were rated positively at similar rates (in-person 87.7%, virtual 87.2%). Sixty-four (88.4%) patients preferred some proportion of their visits to be virtual, 5 (7.0%) preferred no virtual care, and 4 (5.0%) had no preference. In a 6-cycle schedule of chemotherapy, the median number of preferred virtual visits was 3 (IQR 1.8-4.2). Forty-six (63.0%) patients were "virtual-leaning" and 23 (32.0%) were "in-person-leaning." When comparing groups, there was no difference in age, race, category of residence, commute, experience with technical difficulty, primary disease site, disease stage, number of prior chemotherapy cycles, or number of prior virtual visits.

Conclusions

Most patients are highly satisfied with virtual visits and prefer virtual care to be included when undergoing chemotherapy. A hybrid model should be offered to gynecological cancer patients undergoing chemotherapy, with patient preference dictating the cadence of virtual visits.

A complementary medicine student-led telehealth clinic: evaluating learning & teaching perceptions

OBJECTIVES

This study evaluates a multi-centered complementary medicine (CM) student-led telehealth clinic during the COVID-19 pandemic. Likert and qualitative responses explore student and educator learning and teaching perceptions of the implementation of a successful telehealth clinic.

RESULTS

51 students and 17 educators completed the survey. Respondents agreed that support from educators (90%) and orientation (70%) assisted effective performance. Over 90% (93%) of all respondents supported telehealth in student-led clinics, whilst 87% encountered barriers such as technical and infrastructure issues. Respondents agreed that telehealth practice skills improved in case history taking (90%), treatment (90%) and building patient rapport (60%). Respondents (61%) disagreed that physical examination was effectively performed, and 100% of respondents agreed telehealth was a valuable learning experience. This study is the first to explore student and educator perceptions of telehealth in an Australian University multi-centered CM student-led clinic. To be successful in an educational environment, students and educators require digital literacy and adequate telehealth practice infrastructure. Whilst some in-person practice skills are transferable to telehealth, educators need to adapt curriculum to ensure counselling and physical examination skills are specifically taught for virtual consultations. Telehealth in clinical practice requires continued investigation and educational development.

The hospital at home in the USA: current status and future prospects

The annual cost of hospital care services in the US has risen to over $1 trillion despite relatively worse health outcomes compared to similar nations. These trends accentuate a growing need for innovative care delivery models that reduce costs and improve outcomes. HaH-a program that provides patients acute-level hospital care at home-has made significant progress over the past two decades. Technological advancements in remote patient monitoring, wearable sensors, health information technology infrastructure, and multimodal health data processing have contributed to its rise across hospitals. More recently, the COVID-19 pandemic brought HaH into the mainstream, especially in the US, with reimbursement waivers that made the model financially acceptable for hospitals and payors. However, HaH continues to face serious challenges to gain widespread adoption. In this review, we evaluate the peer-reviewed evidence and discuss the promises, challenges, and what it would take to tap into the future potential of HaH.

Integration of e-Health Strategies for Post-COVID-19 Pandemic Pediatric Weight Management Programs

Background: The COVID-19 pandemic catalyzed a renewed urgency to address the obesity pandemic and accelerated the use of technology to treat pediatric obesity. Yet, there are significant incongruities between the existing literature on technology for obesity management and the current health care system that may lead to suboptimal outcomes and increased costs. This study reviewed the types of e-health strategies currently in use, highlighted inconsistencies and overlap in terminology, and identified future research directions in e-health for childhood obesity, including gaps in implementation science. Methods: This narrative literature review synthesized seminal articles from the literature, as well as recent articles, using PubMed and Google Scholar that focused on the use of technology in treating pediatric obesity. This inclusive strategy was intended to elucidate the heterogeneity in how different disciplines are using digital health terminology in pediatric obesity research. Results: Both the prevalence of e-health interventions and its associated terminology are increasing in the peer-reviewed literature, especially since the beginning of the COVID-19 pandemic. Yet, their definitions and usage are unstandardized, leading to a lack of cohesion in the research and between disciplines. There is a gap in implementation science outcomes, including reimbursement, that may significantly impact external validity and uptake. Conclusion: A more systematic and precise approach to researching e-health that can assess specific technologies and combinations of technologies, their short-term and long-term effect sizes, and feasibility can produce the necessary data that may lead to reimbursement policies and, ultimately, improved pediatric weight management outcomes.

Telemedicine and Cancer Clinical Research: Opportunities for Transformation

ABSTRACT

Telemedicine represents an established mode of patient care delivery that has and will continue to transform cancer clinical research. Through telemedicine, opportunities exist to improve patient care, enhance access to novel therapies, streamline data collection and monitoring, support communication, and increase trial efficiency. Potential challenges include disparities in technology access and literacy, physical examination performance, biospecimen collection, privacy and security concerns, coverage of services by insurance, and regulatory considerations. Coupled with artificial intelligence, telemedicine may offer ways to reach geographically dispersed candidates for narrowly focused cancer clinical trials, such as those targeting rare genomic subsets. Collaboration among clinical trial staff, clinicians, regulators, professional societies, patients, and their advocates is critical to optimize the benefits of telemedicine for clinical cancer research.

Challenges of Teleneurology in the Care of Complex Neurodegenerative Disorders: The Case of Parkinson's Disease with Possible Solutions

Teleneurology is a specialist field within the realm of telemedicine, which is dedicated to delivering neurological care and consultations through virtual encounters. Teleneurology has been successfully used in acute care (e.g., stroke) and outpatient evaluation for chronic neurological conditions such as epilepsy and headaches. However, for some neurologic entities like Parkinson's disease, in which an in-depth physical examination by palpating muscles and performing neurologic maneuvers is the mainstay of monitoring the effects of medication, the yield and feasibility of a virtual encounter are low. Therefore, in this prospective review, we discuss two promising teleneurology approaches and propose adjustments to enhance the value of virtual encounters by improving the validity of neurological examination: 'hybrid teleneurology', which involves revising the workflow of virtual encounters; and 'artificial intelligence (AI)-assisted teleneurology', namely the use of biosensors and wearables and data processing using AI.

Comparing the suitability of virtual versus in-person care: Perceptions from pediatricians

OBJECTIVES

The COVID-19 pandemic compelled a portion of healthcare to be delivered virtually. As the pandemic waned, health systems strived to find a balance between re-incorporating in-person care while maintaining virtual care. To find when virtual or in-person encounters are more appropriate, we surveyed pediatricians' perceptions when comparing the suitability of virtual care to in-person care.

METHODS

We surveyed a Canadian tertiary-level pediatric hospital where pediatricians assessed whether specific clinical encounters or tasks were more or less effective virtually than when performed in person. Pediatricians also rated the importance of clinical and patient factors when deciding if a patient needs to be seen in person.

RESULTS

Of 160 pediatrics faculty members, 56 (35%) responded to the survey. When assessing different types of clinical encounters, triage, multidisciplinary meetings, discharge, and follow ups were more likely to favor virtual encounters. However, first consultations and family meetings were more likely to favor in-person encounters. Regarding clinical tasks, pediatricians were more likely to endorse explaining test results, offering treatment recommendations, and obtaining patient histories virtually. On the contrary, there was a preference for physical examinations, assessing patients visually, and assessing developmental milestones to be performed in person. When deciding if a patient should be seen in person versus virtual, pediatricians rated the patient's condition and communication barriers as the most important factors favoring an in-person appointment.

DISCUSSION

These results offer an initial framework for pediatricians when choosing which encounter type may be most appropriate for their patients between virtual or in-person appointments.

Simulated Participants' Experiences and Challenges With Online and Face-to-Face Interactions During COVID-19: A Case Study in UAEU

INTRODUCTION

Direct patient contact is essential when training health professionals for future patient-centered interactions. Simulated participants (SPs) play a critical role during training; however, limited information is available about their personal perspectives. This study explored SPs at the College of Medicine and Health Sciences experiences, adaptations, and preferences regarding online and face-to-face encounters.

METHODS

After ethical approval, a qualitative research study using structured in-depth interviews was conducted online with 16 SPs, applying critical incident narratives and storytelling. Interview data were transcribed and encoded using thematic framework analysis, after which member checking was conducted to increase credibility.

RESULTS

All SPs acknowledged the benefits of online delivery models during the pandemic, including the convenience of working from home, continued clinical skills training, and personal protection from COVID infection. Participants preferred face-to-face delivery over online encounters, except for one SP, who saw no difference. Challenges included technical issues, communication problems, and lack of realism.

CONCLUSIONS

Although these results cannot be generalized, all participants acknowledged the relevance of online portrayals during the pandemic. Most preferred face-to-face delivery models for improving role-playing and enhancing personal communication to achieve better patient outcomes, while one SP had no preference. The use of concurrent online and face-to-face methods may more effectively engage SPs in simulation-based education. Before restructuring programs, further research is needed, including a deeper exploration of students' and educators' perspectives.

The Cost Impact of Telehealth Interventions in Pediatric Surgical Specialties: A Systematic Review

BACKGROUND

Telehealth is a rapidly expanding care modality in the United States. Pediatric surgical patients often require complex care which can incur significant expenses, some of which may be alleviated by telehealth. We performed a systematic review comparing telehealth and in-person visits, and telehealth's impacts on the cost of healthcare across pediatric surgical specialties.

METHODS

A systematic review was performed using the following databases: PubMed (MEDLINE), Scopus (Elsevier), and CINAHL (EBSCOHost), searched from inception to July 10th, 2022. Studies were included per the following criteria: (1) investigated a telehealth intervention for pediatric surgical care and (2) provided some metric of telehealth cost compared to an in-person visit. Non-English or studies conducted outside of the U.S. were excluded.

RESULTS

Fourteen manuscripts met inclusion criteria and presented data on 7992 visits, including patients with a weighted average age of 7.5 ± 3.5 years. Most (11/14) studies used telehealth in a synchronous, or "real-time" context. Of the studies which calculated dollar cost savings for telehealth visits compared to in-person appointments we found a substantial range of savings per visit, from $48.50 to $344.64. Cost savings were frequently realized in terms of reduced travel expenditures, lower opportunity costs (e.g. lost wages), and decreased hospital labor requirements.

CONCLUSIONS

This review suggests that telehealth provides cost incentives to pediatric surgical care in many scenarios, including post-operative visits and some routine clinic visits. Future work should focus on standardizing the metrics by which cost impacts are analyzed and detailing which visits are most appropriately facilitated by telehealth.

LEVEL OF EVIDENCE

V.

Barriers to Telemedicine Use: Qualitative Analysis of Provider Perspectives During the COVID-19 Pandemic

BACKGROUND

Though telemedicine is a promising approach for removing barriers to care and improving access for patients, telemedicine use for many medical specialties has decreased from its peak during the acute COVID-19 public health crisis. Understanding the barriers and facilitators to the maintenance of web-based visits-one key component of telemedicine-is critical for ensuring the continuous availability of this service for patients.

OBJECTIVE

The purpose of this study is to describe medical providers' perceived barriers and facilitators to the continued use of web-based visits to inform quality improvement efforts and promote sustainability.

METHODS

We performed a qualitative content analysis of free-text responses from a survey of medical providers administered from February 5-14, 2021, at a large, midwestern academic institution, including all providers from medical professions that offered telemedicine (eg, physicians, residents or fellows, nurse practitioners, physicians assistants, or nurses) who completed at least 1 web-based visit from March 20, 2020, to February 14, 2021. The primary outcome was the experience of providing web-based visits, including barriers and facilitators to continued usage of web-based visits. Survey questions included 3 major domains: quality of care, technology, and satisfaction. Responses were coded using qualitative content analysis and further analyzed through a matrix analysis to understand the providers' perspectives and elucidate key barriers and facilitators of web-based visit usage.

RESULTS

Of 2692 eligible providers, 1040 (38.6%) completed the survey, of whom 702 were providers from medical professions that offered telemedicine. These providers spanned 7 health care professions and 47 clinical departments. The most common professions represented were physicians (486/702, 46.7%), residents or fellows (85/702, 8.2%), and nurse practitioners (81/702, 7.8%), while the most common clinical departments were internal medicine (69/702, 6.6%), psychiatry (69/702, 6.6%), and physical medicine and rehabilitation (67/702, 6.4%). The following 4 overarching categories of provider experience with web-based visits emerged: quality of care, patient rapport, visit flow, and equity. Though many providers saw web-based visits as a tool for improving care access, quality, and equity, others shared how appropriate selection of web-based visits, support (eg, patient training, home devices, and broadband access), and institutional and nationwide optimization (eg, relaxation of licensing requirements across state borders and reimbursement for phone-only modalities) were needed to sustain web-based visits.

CONCLUSIONS

Our findings demonstrate key barriers to the maintenance of telemedicine services following the acute public health crisis. These findings can help prioritize the most impactful methods of sustaining and expanding telemedicine availability for patients who prefer this method of care delivery.

Building telehealth teams of the future through Interprofessional curriculum development: a five-year mixed methodology study

Building the next generation of telehealth enabled professionals requires a mixture of team-based, interprofessional practice with novel technologies that connect providers and patients. Effective telehealth education is critical for the development of multidisciplinary training curricula to ensure workforce preparedness. In this study, we evaluated the impact of a formal telehealth education curriculum for interprofessional students through an online elective. Over 12 semesters, 170 students self-selected to enroll in the 3-credit hour interprofessional elective and took part in structured didactic, experiential and interprofessional learning opportunities. Mixed-method assessments show significant knowledge and confidence gains with students reflecting on their roles as future healthcare providers. The results from five years' worth of course data shows not only an opportunity to advance the individual knowledge of trainees, but a larger movement to facilitate changes in practice toward population health goals. Recent global health events have further highlighted the need for a rapid response to public health emergencies by highly trained provider teams who are able to utilize technology as the cornerstone for the continuity of care.

A Systematic Review of Physical Examination Components Adapted for Telemedicine

Introduction: The COVID-19 pandemic ushered in a rapid, transformative adoption of telemedicine to maintain patient access to care. As clinicians made the shift from in-person to virtual practice, they faced a paucity of established and reliable clinical examination standards for virtual care settings. In this systematic review, we summarize the accuracy and reliability of virtual assessments compared with traditional in-person examination tools. Methods: We searched PubMed, Embase, Web of Science, and CINAHL from inception through September 2019 and included additional studies from handsearching of reference lists. We included studies that compared synchronous video (except allowing for audio-only modality for cardiopulmonary exams) with in-person clinical assessments of patients in various settings. We excluded behavioral health and dermatological assessments. Two investigators abstracted data using a predefined protocol. Results: A total of 64 studies were included and categorized into 5 clinical domains: neurological (N = 41), HEENT (head, eyes, ears, nose, and throat; N = 5), cardiopulmonary (N = 5), musculoskeletal (N = 8), and assessment of critically ill patients (N = 5). The cognitive assessment within the neurological exam was by far the most studied (N = 19) with the Mini-Mental Status Exam found to be highly reliable in multiple settings. Most studies showed relatively good reliability of the virtual assessment, although sample sizes were often small (<50 participants). Conclusions: Overall, virtual assessments performed similarly to in-person exam components for diagnostic accuracy but had a wide range of interrater reliability. The high heterogeneity in population, setting, and outcomes reported across studies render it difficult to draw broad conclusions on the most effective exam components to adopt into clinical practice. Further work is needed to identify virtual exam components that improve diagnostic accuracy.

A scoping review of the unassisted physical exam conducted over synchronous audio-video telemedicine

BACKGROUND

This scoping review aims to provide a broad overview of the research on the unassisted virtual physical exam performed over synchronous audio-video telemedicine to identify gaps in knowledge and guide future research.

METHODS

Searches for studies on the unassisted virtual physical exam were conducted in 3 databases. We included primary research studies in English on the virtual physical exam conducted via patient-to-provider synchronous, audio-video telemedicine in the absence of assistive technology or personnel. Screening and data extraction were performed by 2 independent reviewers.

RESULTS

Seventy-four studies met inclusion criteria. The most common components of the physical exam performed over telemedicine were neurologic (38/74, 51%), musculoskeletal (10/74, 14%), multi-system (6/74, 8%), neuropsychologic (5/74, 7%), and skin (5/74, 7%). The majority of the literature focuses on the telemedicine physical exam in the adult population, with only 5% of studies conducted specifically in a pediatric population. During the telemedicine exam, the patients were most commonly located in outpatient offices (28/74, 38%) and homes and other non-clinical settings (25/74, 34%). Both patients and providers in the included studies most frequently used computers for the telemedicine encounter.

CONCLUSIONS

Research evaluating the unassisted virtual physical exam is at an early stage of maturity and is skewed toward the neurologic, musculoskeletal, neuropsychologic, and skin exam components. Future research should focus on expanding the range of telemedicine exam maneuvers studied and evaluating the exam in the most relevant settings, which for telemedicine is trending toward exams conducted through mobile devices and in patients' homes.

Virtual Care in Undergraduate Medical Education: perspectives beyond the pandemic. How medical education can support a change of culture towards virtual care delivery in Canada

The pandemic has led to further the importance of telemedicine, teleconsultation, and technology as essential components for delivering of care in all settings. Prior to the pandemic, the instruction surrounding the safe delivery of virtual care in undergraduate medical education was sparse and informal. For care to be delivered to the high standards expected of Canadian physicians, the University of Ottawa undergraduate medical program (UGME) made the decision to define virtual care as a series of tools to facilitate and support the safe delivery of care. By focusing on virtual care as a set of tools, it provides the framework for skill development for future clinicians early in their careers and provides a critical thinking pathway to support the ever-evolving landscape of digital technology in the provision of safe, effective, timely and patient-centered care. This white paper shares our experience creating a virtual care curriculum and the possible implications for medical education.

Parent and provider satisfaction of telehealth in pediatric surgical subspecialty care: A systematic review

INTRODUCTION

Telehealth is becoming an increasingly common presence in health care, particularly amidst the coronavirus disease 2019 pandemic. We aimed to investigate ways in which telehealth has been implemented in pediatric surgical specialties, as well as the success and satisfaction rates of these interventions.

METHODS

A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using PubMed, Scopus, and CINAHL databases for telehealth and pediatric surgical specialties on August 20th, 2021. There were 1227 studies screened and 17 studies met final inclusion criteria for patient, parent/guardian, or physician satisfaction measures of a telehealth intervention in the United States.

RESULTS

Studies implementing telehealth interventions included all major pediatric surgical subspecialties with a total of 2926 patients. Of the 17 studies, common themes were the use of telehealth for synchronous video and/or telephone virtual visits, including comparing virtual visits to in-person clinic visits (nine studies) and postoperative virtual visits (six studies). Telehealth was also used in the perioperative setting to deliver care instructions via mobile application or text message (two studies). Telehealth interventions had a high rate of parent satisfaction (75%-98%), and 57%-75% of parents stated they would choose or prefer virtual appointments in the future, often citing travel and cost savings as benefits. Provider satisfaction was also high with satisfaction scores ranging from 7.5 to 9.4/10.

DISCUSSION

This systematic review suggests that both parent and physician satisfaction with telehealth in pediatric surgical specialties is generally high. Expanding telehealth applications allow greater access to care, particularly for specialized surgical services which often pose significant costs and travel burdens.

A questionnaire for physical findings of malnutrition when physical exams are not possible

BACKGROUND

When nutrition assessments must be performed virtually, such as during the coronavirus pandemic, it is difficult to fully assess patients for malnutrition without the ability to perform a nutrition-focused physical exam. Practitioners may ask patients about their physical appearance, but there is currently no validated set of questions whose answers correlate with nutrition-focused physical findings for the diagnosis of malnutrition in such situations. The aim of this study was to evaluate correlations between patients' responses to verbalized questions and physical signs of malnutrition.

METHODS

Questions related to the physical findings of malnutrition were developed and evaluated for content validity. Thirty patients receiving nutrition assessments at an acute care veterans' hospital were asked the questions prior to a nutrition-focused physical exam. Patients' responses were compared with a diagnosis of malnutrition and physical findings of muscle, fat, fluid accumulation, and handgrip strength.

RESULTS

Four questions significantly correlated with malnutrition: "Does the area around your eyes appear sunken in?" (P = 0.03), "Are you able to see your ribs?" (P = 0.05), "Do you feel you are unusually skinny for you?" (P = 0.001), and "Do you find yourself eating less due to swelling in your belly?" (P = 0.008).

CONCLUSION

There are relationships between patients' responses to certain verbalized questions and their physical status. Such questions can be used to identify physical signs of malnutrition when nutrition-focused physical exams cannot be performed. Further research is needed to validate these questions in other populations.

Implementing Virtual Care in Neurology - Challenges and Pitfalls

Virtual care is here to stay. The explosive expansion of telehealth caused by the SARS-CoV-2 pandemic is more than a necessary measure of protection. The key drivers of this transition in healthcare delivery to a virtual setting are changes in patient behavior and expectations and societal attitudes, and prevailing technologies that are impossible to ignore. The younger population - Generation Z - is increasingly connected and mobile-first. We are heading to a world where we expect to see healthcare in general and neurology, in particular, delivered virtually. The medical community should prepare for this overhaul; proper implementation of virtual care from the ground up is the need of the hour. In an era of virtualization, it is up to the medical community to ensure a well-informed patient population, overcome cultural differences and build digital infrastructure with enhanced access and equity in care delivery, especially for the aging neurological patient population, which is not technologically savvy. Virtual care is a continuum of care that needs deeper integration at systematic levels. The design principles of a patient's journey need to be incorporated while simultaneously placing physician satisfaction with a better user experience at the center of implementation. In this paper, we discuss common challenges and pitfalls of virtual care implementation in neurology - logistical, technical, medicolegal, and those faced in incorporating health and medical education into virtual care - intending to provide solutions and strategies.

Patient and Clinician Perspectives of New and Return Ambulatory Teleneurology Visits

BACKGROUND AND OBJECTIVES

To evaluate the adoption and perceived utility of video visits for new and return patient encounters in ambulatory neurology subspecialties.

METHODS

Video visits were launched in an academic, multi-subspecialty, ambulatory neurology clinic in March 2020. Adoption of video visits for new and return patient visits was assessed using clinician-level scheduling data from March 22 to May 16, 2020. Perceived utility of video visits was explored via a clinician survey and semistructured interviews with clinicians and patients/caregivers. Findings were compared across 5 subspecialties and 2 visit types (new vs return).

RESULTS

Video visits were adopted rapidly; all clinicians (n = 65) integrated video visits into their workflow within the first 6 weeks, and 92% of visits were conducted via video, although this varied by subspecialty. Utility of video visits was higher for return than new patient visits, as indicated by surveyed (n = 48) and interviewed clinicians (n = 30), aligning with adoption patterns. Compared with in-person visits, clinicians believed that it was easier to achieve a similar physical examination, patient-clinician rapport, and perceived quality of care over video for return rather than new patient visits. Of the 25 patients/caregivers interviewed, most were satisfied with the care provided via video, regardless of visit type, with the main limitation being the physical examination.

DISCUSSION

Teleneurology was robustly adopted for both new and return ambulatory neurology patients during the COVID-19 pandemic. Return patient visits were preferred over new patient visits, but both were feasible. These results provide a foundation for developing targeted guidelines for sustaining teleneurology in ambulatory care.

A systematic review exploring pre-COVID-19 telehealthcare models used in the management of patients with rheumatological disease

Objective

The aim was to assess the use of telehealthcare in rheumatology before coronavirus disease 2019 (COVID-19), to which future comparisons of newer interventions adapted during the crisis can be made.

Methods

We performed a registered systematic literature search using MEDLINE, EMBASE, CENTRAL and PubMed databases. All full-length articles comparing telehealthcare delivery models with standard care (face-to-face consultation) in the management of patients with rheumatic conditions were assessed for inclusion.

Results

A total of 4809 studies were identified; 108 studies were suitable for review by full text, and 13 studies were appropriate to be included in this review. Five studies (38%) included patients with RA, four studies (31%) included patients with mixed disease cohorts, two studies (15%) included patients with OA, one study (8%) included patients with JIA, and one study (8%) included patients with FM. Six studies (46%) used telephone consultation, three studies (23%) used mixed method communication, three studies (23%) used videoconferencing, and one study (8%) used website-delivered telecommunication as their method of telehealthcare delivery. Overall, seven studies (54%) identified the telehealthcare intervention to be an effective method of consultation, and six studies (46%) identified the telehealthcare intervention as non-inferior when compared with standard care.

Conclusion

Current evidence for telehealthcare in rheumatology is lacking, and the evidence for effectiveness is limited by methodological bias and clinical heterogeneity of telehealthcare interventions, preventing definitive inferences. Scrutinous assessment of the current telehealthcare interventions used during COVID-19 is required to accommodate recommendations and guideline reviews directed from international working groups.

[Telemedicine in Palliative Care: Digital Communication in a Relationship-Based Speciality - Does It Make Sense?]

Telemedicine in Palliative Care: Digital Communication in a Relationship-Based Speciality - Does It Make Sense? Abstract. Telemedicine in palliative care is established especially in countries with large geographical distances. Digital forms of communication (virtual consultations) are most frequently used and well-accepted by patients and caregivers. The main benefit lies in the reduction of the access barrier in the outpatient setting. Advantages are stress reduction for patients (travel, accessibility) and reduction in the care burden for relatives. Additional benefits compared to the physical visit for symptom-control, quality of life and costs are unclear. Risks are influenced by the lack of physical interaction and data security. To what extent telepalliative care makes sense in a high-density health system is difficult to predict. It is therefore important to use these new tools in a carefully adapted and scientifically verified way.

Survey of Telemedicine by Pediatric Nephrologists During the COVID-19 Pandemic

Introduction

The slow increase in use of telemedicine began to expand rapidly, along with reimbursement changes, during the coronavirus disease-2019 (COVID-19) pandemic. Standardized protocols for these services are lacking but are needed for effective and equitable health care. In this study, we queried pediatric nephrologists and their patients about their telemedicine experiences during the pandemic.

Methods

Surveys that were in compliance with the Health Insurance Portability and Accountability Act were deployed online to patients and physicians.

Results

We collected survey responses from 400 patients and 197 pediatric nephrologists. Patients reported positive experiences with telemedicine visits as it was logistically easier than in-person visits. Patients also felt that the quality of their visits were equivalent to what they would receive in person. Physicians used a wide variety of online systems to conduct synchronous telemedicine with Zoom (23%), EPIC (9%), Doxy.me (7%), services not specified (37%), or a mix of local or smaller services (24%). Most physicians' concerns were related to technological issues and the ability to procure physical exams and/or laboratory results.

Conclusions

There is a paucity of published trials on telemedicine services in pediatric nephrology. Virtual care was feasible and acceptable for patients, caregivers, and providers during the COVID-19 pandemic.

Pediatric Intensive Care Hybrid-Style Clinical Round During COVID-19 Pandemic: A Pilot Study

Objectives: With the evolving COVID-19 pandemic and the emphasis on social distancing to decrease the spread of SARS-CoV-2 among healthcare workers (HCWs), our pediatric intensive care unit (PICU) piloted the integration of Zoom meetings into clinical rounds. We aimed to explore the feasibility of these hybrid virtual and physical clinical rounds for PICU patients. Design: Mixed quantitative and qualitative deductive thematic content analysis of narrative responses. Setting: PICU, single tertiary-care academic center. Participants: Multidisciplinary PICU HCWs. Interventions: Integration of Zoom meeting into clinical daily PICU rounds. Measurements: For the quantitative part, we gathered the details of daily PICU hybrid rounds in terms of times, number of HCWs, and type of files shared through Zoom. For the qualitative part, open-ended questions were used. Main Results: The physical round took statistically significantly less time (34.68 ± 14.842 min) as compared with the Zoom round (72.45 ± 22.59 min), p < 0.001. The most shared component in the virtual round was chest X-rays (93.5%). Thirty-one HCWs participated in focus group discussions and were included in the analysis. Some of the HCWs' perceived advantages of the hybrid rounds were enabling multidisciplinary discussions, fewer round interruptions, and practicality of virtual discussions. The perceived challenges were the difficulty of the bedside nurse attending the virtual round, decreased teaching opportunities for the trainees, and decreased interactions among the team members, especially if video streaming was not utilized. Conclusions: Multidisciplinary hybrid virtual and physical clinical rounds in the PICU were perceived as feasible by HCWs. The virtual rounds decreased the physical contact between the HCWs, which could decrease the possibility of SARS-CoV-2 spread among the treating team. Still, several components of the hybrid round should be optimized to facilitate the virtual team-members' interactions and enhance the teaching experience.

Foundational Telemedicine Workshop for First-Year Medical Students Developed During a Pandemic

INTRODUCTION

In response to the COVID-19 pandemic and the need for social distancing, medical education curricula across the country had to be quickly transitioned from in-person experiences to remote sessions. Simultaneously, use of telemedicine in clinical practice skyrocketed. Despite telemedicine expansion and the opportunity afforded to teach these skills virtually, many institutions lacked telemedicine curricula.

METHODS

We developed and evaluated a foundational telemedicine workshop during a pandemic (158 students in 28 groups) guided by principles to maximize learner engagement during remote learning, including use of discrete, time-limited activities (self-assessment, templated group exercises, review of brief multimedia, and active role-play.).

RESULTS

Students completed pre- and postsession surveys to assess session impact. Of 158 students, 92 (58%) completed the presession survey, and 36 (23%) completed the postsession survey. There was an increase in confidence in all areas, particularly in skills related to starting the encounter, minimizing barriers, and taking the medical history. Learners reported the physical examination content as more useful than any other area and valued the exemplar videos provided.

DISCUSSION

The pandemic highlighted our own institution's need to develop telemedicine curricula to prepare medical students to provide this increasingly essential service. We developed a foundational telemedicine skills session that increased students' reported confidence in their telemedicine knowledge and skills. The session could be easily adapted by other schools interested in incorporating telemedicine into their preclerkship curriculum. Additional experiences providing opportunities to practice and receive feedback on telemedicine skills with standardized and real patients are warranted.

Patient and surgeon experiences with video visits in plastic surgery-toward a data-informed scheduling triage tool

BACKGROUND

Coronavirus disease 2019 provided the impetus for unprecedented adoption of telemedicine. This study aimed to understand video visit adoption by plastic surgery providers; and patient and surgeon perceptions about its efficacy, value, accessibility, and long-term viability. A secondary aim was to develop the proposed 'Triage Tool for Video Visits in Plastic Surgery' to help determine visit video eligibility.

METHODS

This mixed-methods evaluation assessed provider-level scheduling data from the Division of Plastic and Reconstructive Surgery at Stanford Health Care to quantify telemedicine adoption and semi-structured phone interviews with patients (n = 20) and surgeons (n = 10) to explore stakeholder perspectives on video visits.

RESULTS

During the 13-week period after the local stay-at-home orders due to coronavirus disease 2019, 21.4% of preoperative visits and 45.5% of postoperative visits were performed via video. Video visits were considered acceptable by patients and surgeons in plastic surgery in terms of quality of care but were limited by the inability to perform a physical examination. Interviewed clinicians reported that long-term viability needs to be centered around technology (eg, connection, video quality, etc) and physical examinations. Our findings informed a proposed triage tool to determine the appropriateness of video visits for individual patients that incorporates visit type, anesthesia, case, surgeon's role, and patient characteristics.

CONCLUSION

Video technology has the potential to facilitate and improve preoperative and postoperative patient care in plastic surgery but the following components are needed: patient education on taking high-quality photos; standardized clinical guidelines for conducting video visits; and an algorithm-assisted triage tool to support scheduling.

Patient Use of Low-cost Digital Videoscopes and Smartphones for Remote Ear and Oropharyngeal Examinations

Importance

During the novel coronavirus disease 2019 pandemic, telehealth has become a vital component of health care delivery. For otolaryngology evaluations, examination of the ear and oropharynx is important but difficult to achieve remotely.

Objective

To assess the feasibility of patient use of low-cost digital videoscopes and smartphones for examination of the ear and oropharynx.

Design, Setting, and Participants

A prospective quality improvement study was conducted in an academic adult otolaryngology clinic including 23 patients who presented for an in-person appointment and owned a smartphone device. The study was conducted from July 1 to 15, 2020.

Interventions

Participants were asked to capture pictures and videos of their ear canals and oropharynx with digital videoscopes and their smartphones under real-time guidance over a telehealth platform. They were then surveyed about their experience.

Main Outcomes and Measures

The primary outcomes were ratings by health care clinicians and a blinded otolaryngologist reviewer of image acceptability. Secondary outcomes included participant time to image acquisition and willingness to purchase digital videoscopes for telehealth use.

Results

Of the 23 participants included, 14 were women (61%); mean age was 50 years (range, 21 to 80 years). Of the images obtained using the digital otoscope ear examination, 95% were considered acceptable by the health care clinicians and 91% were considered acceptable by the blinded reviewer; 16 participants (70%) reported that the otoscope was easy to use. The mean time to acquire images for both ears was 114 seconds (95% CI, 84-145 seconds). Twenty-one participants (91%) were willing to pay for a digital otoscope for telehealth use. For the oropharyngeal examination, a greater proportion of smartphone video examinations were considered acceptable by clinicians (63% acceptability) and the blinded reviewer (55%) compared with the digital endoscope (clinicians, 40%; blinded reviewer, 14%). The mean time required for the oropharyngeal examination smartphone video capture was shorter at 35 seconds compared with both the digital endoscope (difference, -27 seconds; 95% CI, -7 to -47 seconds) and smartphone photo capture (difference, -53 seconds; 95% CI, -20 to -87 seconds).

Conclusions and Relevance

Digital otoscopes and smartphones apparently can facilitate remote head and neck physical examination in telehealth. Digital otoscopes were useful for ear examinations, and smartphone videos appeared to be the most useful for oropharyngeal examinations. Further studies are required to determine specific diagnostic capabilities in various telehealth practice settings.

Best Practices for Integrating Medical Students Into Telehealth Visits

Telehealth has become an increasingly important part of health care delivery, with a dramatic rise in telehealth visits during the COVID-19 pandemic. Telehealth visits will continue to be a part of care delivery after the pandemic subsides, and it is important that medical students receive training in telehealth skills to meet emerging telehealth competencies. This paper describes strategies for successfully integrating medical students into telehealth visits in the ambulatory setting based on existing literature and the extensive experience of the authors teaching and learning in the telehealth environment.

An Overview of Telehealth in Total Joint Arthroplasty

With the increase in technological advances over the years, telehealth services in orthopedic surgery have gained in popularity, yet adoption among surgeons has been slow. With the onset of the COVID-19 pandemic, however, orthopedic surgery practices nationwide have accelerated adaptation to telemedicine. Telehealth can be effectively applied to total joint arthroplasty, with the ability to perform preoperative consultations, postoperative follow-up, and telerehabilitation in a virtual, remote manner with similar outcomes to in-person visits. New technologies that have emerged, such as virtual goniometers, wearable sensors, and app-based patient questionnaires, have improved clinicians' ability to conduct telehealth visits. Benefits of using telehealth include high patient satisfaction, cost-savings, increased access to care, and more efficiency. Notably, some challenges still exist, including widespread accessibility and adaptation of new technologies, inability to conduct an in-person orthopedic physical examination, and regulatory barriers, such as insurance reimbursement, increased medicolegal risk, and privacy and confidentiality concerns. Despite these hurdles, telehealth is here to stay and can be successfully incorporated in any total joint arthroplasty practice with the appropriate adjustments.

Telehealth and Palliative Care for Patients With Cancer: Implications of the COVID-19 Pandemic

It has been reported that the incidence of SARS-CoV-2 infection is higher in patients with cancer than in the general population and that patients with cancer are at an increased risk of developing severe life-threatening complications from COVID-19. Increased transmission and poor outcomes noted in emerging data on patients with cancer and COVID-19 call for aggressive isolation and minimization of nosocomial exposure. Palliative care and oncology providers are posed with unique challenges due to the ongoing COVID-19 pandemic. Telepalliative care is the use of telehealth services for remotely delivering palliative care to patients through videoconferencing, telephonic communication, or remote symptom monitoring. It offers great promise in addressing the palliative and supportive care needs of patients with advanced cancer during the ongoing pandemic. We discuss the case of a 75-year-old woman who was initiated on second-line chemotherapy, to highlight how innovations in technology and telehealth-based interventions can be used to address patients’ palliative and supportive care needs in the ongoing epidemic.

Implementation of Telehealth in Radiation Oncology: Rapid Integration During COVID-19 and Its Future Role in Our Practice

Purpose

The widespread coronavirus disease 2019 (COVID-19) pandemic has resulted in significant changes in care delivery among radiation oncology practices and has demanded the rapid incorporation of telehealth. However, the impact of a large-scale transition to telehealth in radiation oncology on patient access to care and the viability of care delivery are largely unknown. In this manuscript, we review our implementation and report data on patient access to care and billing implications. Because telehealth is likely to continue after COVID-19, we propose a radiation oncology–specific algorithm for telehealth.

Methods and Materials

In March 2020, our department began to use telehealth for all new consults, posttreatment encounters, and follow-up appointments. Billable encounters from January to April 2020 were reviewed and categorized into 1 of the following visit types: in-person, telephonic, or 2-way audio-video. Logistic regression models tested whether visit type differed by patient age, income, or provider.

Results

There was a 35% decrease in billable activity from January to April. In-person visits decreased from 100% to 21%. Sixty percent of telehealth appointments in April were performed with 2-way audio-video and 40% by telephone only. In-person consultation visits were associated with higher billing codes compared with 2-way audio-video telehealth visits (P < .01). No difference was seen for follow-up visits. Univariate and multivariable analysis identified that older patient age was associated with reduced likelihood of 2-way audio-video encounters (P < .01). The physician conducting the telehealth appointment was also associated with the type of visit (P < .01). Patient income was not associated with the type of telehealth visit.

Conclusions

Since the onset of the COVID-19 pandemic, we have been able to move the majority of patient visits to telehealth but have observed inconsistent utilization of the audio-video telehealth platform. We present guidelines and quality metrics for incorporating telehealth into radiation oncology practice, based on type of encounter and disease subsite.

Patient's Perspectives of Telepsychiatry: The Past, Present and Future

Access to mental health care has significant disparities due to treatment gap, more so particularly for the remotely residing, physically vulnerable, aging populations. Adoption of technology will enable more people to receive specialty care addressing distance, transportation and cost-related barriers to treatment engagement from the comfort of home. Telemedicine has been regarded as "electronic personal protective equipment" by reducing the number of physical contacts and risk contamination for patients during COVID-19 crisis. This review aimed to give a broad view of patients' perception of the use of telepsychiatry in terms of clinical outcome, cost-effectiveness, and solutions to address patients' challenges with the adoption of technology. Over the years, telepsychiatry, both in synchronous and asynchronous modalities, had shown to improve patients' adherence to treatment, follow-up rates, and clinical symptoms, overcome stigma and discrimination, and save cost expenses accessing health care with better satisfaction and usability outcomes. Its utility is widespread such as in delivering care emergency evaluation, crisis intervention, conducting neuropsychological assessments, psychotherapy, promoting lifestyle modification, enhancing self-efficacy, and overcoming patients' linguistic and cultural barriers to care. However, patients' privacy and confidentiality and psychiatrists' legal liability remain as matter of major concern in digital platform. To keep up with the pace of technology and patients' expectations, a more agile approach is essential to develop, improve, and evaluate telepsychiatric interventions.

Telemedicine, the current COVID-19 pandemic and the future: a narrative review and perspectives moving forward in the USA

A narrative review was conducted to examine the current state of the utilisation of telemedicine amid the current COVID-19 pandemic and to evaluate the benefits of continuing telemedicine usage in the future. A literature review was performed for articles related to telemedicine. Databases including PubMed, Google Scholar, Cochrane Library and Ovid MEDLINE were searched. Three reviewers independently performed article selection based on relevance to our topic. We included all articles between 1990 and 2020 related to telemedicine using the following keywords: ‘telemedicine’, ‘telehealth’, ‘policy’, ‘COVID-19’, ‘regulation’, ‘rural’, ‘physical examination’, ‘future’. A total of 60 articles were identified, and through careful selection we narrowed the final number of articles to 42 based on relevance to our topic. Telemedicine has been rapidly evolving over the past several decades. Issues with regulation and reimbursement have prevented its full immersion into the healthcare system. During the current pandemic, Centers for Medicare and Medicaid services have expanded access to telemedicine services. The advantages of telemedicine moving forward include its cost-effectiveness, ability to extend access to specialty services and its potential to help mitigate the looming physician shortage. Disadvantages include lack of available technological resources in certain parts of the country, issues with security of patient data, and challenges in performing the traditional patient examination. It is critically important that changes are made to fully immerse telemedicine services into the healthcare landscape in order to be prepared for future pandemics as well as to reap the benefits of this service in the future.

Rapid Deployment of Chiropractic Telehealth at 2 Worksite Health Centers in Response to the COVID-19 Pandemic: Observations from the Field

OBJECTIVE

The purpose of this paper is to describe the rapid deployment of telehealth, particularly real time video conference, for chiropractic services as a response to COVID-19.

METHODS

Two health centers at 2 campuses of a large California corporation have chiropractic care integrated into physical medicine services. Care was suspended beginning on March 17, 2020 to prevent spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) among patients and staff. On March 19, the Governor of California issued a stay at home order. With musculoskeletal problems being common in the employee patient population, telehealth services were quickly developed to continue chiropractic care for patients. Using existing infrastructure, several members of the health center team developed chiropractic telehealth operations within 2 days.

RESULTS

Musculoskeletal telehealth services included examinations, risk assessment, advice, and rehabilitative exercises. These telehealth visits facilitated care that would have otherwise been unavailable to employees. Patients reported that the appointments were helpful, addressed their concerns, and provided a safe method to see their doctor. Regular interprofessional teamwork and relations between the clinic operator and client company were key contributors to operationalizing this service in our integrated healthcare environment.

CONCLUSION

We were able to quickly implement real time video conferencing and other forms of telehealth for chiropractic services at 2 worksite health centers. This paper includes information and insights to providers about setting up similar telehealth systems so they may also provide this benefit for patients in their communities during pandemics or disasters.

The Virtual Neurologic Exam: Instructional Videos and Guidance for the COVID-19 Era

Objective:

To outline features of the neurologic examination that can be performed virtually through telemedicine platforms (the virtual neurological examination [VNE]), and provide guidance for rapidly pivoting in-person clinical assessments to virtual visits during the COVID-19 pandemic and beyond.

Methods:

The full neurologic examination is described with attention to components that can be performed virtually.

Results:

A screening VNE is outlined that can be performed on a wide variety of patients, along with detailed descriptions of virtual examination maneuvers for specific scenarios (cognitive testing, neuromuscular and movement disorder examinations).

Conclusions:

During the COVID-19 pandemic, rapid adoption of virtual medicine will be critical to provide ongoing and timely neurological care. Familiarity and mastery of a VNE will be critical for neurologists, and this article outlines a practical approach to implementation.