A comparison study between metropolitan and rural hospital-based telehealth activity to inform adoption and expansion

Telehealth-guided provider-to-provider communication to improve rural health: A systematic review

INTRODUCTION

Telehealth may address healthcare disparities for rural populations. This systematic review assesses the use, effectiveness, and implementation of telehealth-supported provider-to-provider collaboration to improve rural healthcare.

METHODS

We searched Ovid MEDLINE®, CINAHL®, EMBASE, and Cochrane CENTRAL from 1 January 2010 to 12 October 2021 for trials and observational studies of rural provider-to-provider telehealth. Abstracts and full text were dual-reviewed. We assessed the risk of bias for individual studies and strength of evidence for studies with similar outcomes.

RESULTS

Seven studies of rural uptake of provider-to-provider telehealth documented increases over time but variability across geographic regions. In 97 effectiveness studies, outcomes were similar with rural provider-to-provider telehealth versus without for inpatient consultations, neonatal care, outpatient depression and diabetes, and emergency care. Better or similar results were reported for changes in rural clinician behavior, knowledge, confidence, and self-efficacy. Evidence was insufficient for other clinical uses and outcomes. Sixty-seven (67) evaluation and qualitative studies identified barriers and facilitators to implementing rural provider-to-provider telehealth. Success was linked to well-functioning technology, sufficient resources, and adequate payment. Barriers included lack of understanding of rural context and resources. Methodologic weaknesses of studies included less rigorous study designs and small samples.

DISCUSSION

Rural provider-to-provider telehealth produces similar or better results versus care without telehealth. Barriers to rural provider-to-provider telehealth implementation are common to practice change but include some specific to rural adaptation and adoption. Evidence gaps are partially due to studies that do not address differences in the groups compared or do not include sufficient sample sizes.

Perspectives on telehealth implementation in Australia: An exploratory qualitative study with practice managers and general practitioners

BACKGROUND

There is a lack of understanding regarding the impact of telehealth on clinical delivery and the feasibility of sustained implementation by health services. The COVID-19 pandemic provided an ideal opportunity to identify factors related to the implementation of telehealth. This study assessed factors that influenced telehealth implementation during COVID-19 in the Western region of Victoria, Australia, from the perspectives of practice managers and general practitioners (GPs).

METHODS

Employing a qualitative approach, we conducted semi-structured interviews with 14 GPs and 11 practice managers across metropolitan and rural settings in the Western region of Victoria, Australia. Interviews were conducted between December 2021 to June 2022, which included periods during and beyond the peak of the COVID-19 pandemic. Themes were synthesised using the Consolidated Framework for Implementation Research, which comprised five domains: innovation, inner setting, outer setting, individuals and implementation process. An additional domain related to billing and finances was added.

RESULTS

The innovation domain revealed that telehealth was identified by both stakeholder groups as a critical tool for improving healthcare access for vulnerable patients. GPs highlighted the role of telehealth in follow-up care and the need for extended telephone consultation services. For the implementation process, both stakeholder groups identified a shift in attitudes among GPs from reluctance to acceptance of telehealth. In terms of outer setting, constant changes in regulations posed challenges to administrative staff. Practice managers faced difficulties in acquiring information on changes, but those with robust professional networks were well supported. Initial loss of incentive funding and government-imposed billing methods posed hurdles for clinics. Both stakeholder groups highlighted the need for education around videoconference and a standardised telehealth platform.

CONCLUSION

Evolving telehealth regulations during the emergence of COVID-19 posed financial, operational and administrative challenges to primary care clinics. To ensure sustainability, policymakers should improve stakeholder communication, set interoperability standards, and ensure sustainable funding for telehealth.

Does it get better? An ongoing exploration of physician experiences with and acceptance of telehealth utilization

INTRODUCTION

COVID-19 forced health systems to rapidly implement telehealth for routine practice, often without sufficient training or standards. We conducted a longitudinal survey of physicians to explore changes in their perceptions of the challenges and benefits of telehealth and identify recommendations for future practice.

METHODS

An anonymous online survey was distributed to a cohort of internal medicine physicians in May to June 2020 and March to June 2021. Changes in responses between 2020 and 2021 and by site (private vs. public) were described. These findings, along with those of a thematic analysis of open-ended responses to questions on telehealth experiences, informed a set of recommendations.

RESULTS

The survey response rate was 111/391 in 2021 compared to 122/378 in 2020. Fewer physicians reported that telehealth was more difficult than in person with regards to taking a history (49% in 2020, 33% in 2021, p= 0.015), maximizing patient adherence (33% in 2020, 19% in 2021, p = 0.028), and maintaining patient relationships (31%, 25%, p = 0.009) in 2021. Similar proportions of physicians reported continued challenges with building new patient relationships (75%, 77%, p = 0.075), educating patients (40%, 32%, p = 0.393), and working collaboratively with their team (38%, 41%, p = 0.794). Physicians reported increased satisfaction with tele-visits over in-person visits (13%, 27%, p = 0.006) and less worry over doing future tele-visits (45%, 31%, p = 0.027). Physicians' open-ended responses identified recommendations for further improving the design and use of telehealth.

DISCUSSION

Results suggest that physician experience with telehealth improved but opportunities for training and improved integration remain. Longitudinal assessment can deepen understanding of the evolution of telehealth care.

Development of a conceptual framework to understand the stakeholder's perspectives on needs and readiness of rural tele-practice for childhood communication disorders

Background

Tele-practice promotes universal and equitable access to quality health services and emerged as an alternative to overcome physical barriers to intervention access in the 90s. There has been a steady increase in adoption since then, and during the COVID-19 pandemic, there was a surge in online modes of healthcare service delivery. Yet, tele-practice adoption and utilization in rural and remote areas are not spontaneous. Therefore, as a first step, prior to the implementation of a comprehensive tele-practice model, a baseline situational analysis was undertaken to assess the needs and readiness of parents of children with disabilities and different cadres of health care providers towards accepting tele-practice services in their settings. This paper describes the process of development of the conceptual framework that guided the baseline needs and readiness assessment (situational analysis).

Methods

The Bowen's feasibility framework served as the primary framework to evaluate the feasibility outcomes of the implementation. Therefore, this framework also guided the baseline situational analysis. For specificity of the framework to tele-practice, several telemedicine planning frameworks relevant for low- and middle-income countries were reviewed to identify and map suitable constructs and attributes to the Bowen's constructs. A description of the framework selection process and a review of each of the selected telemedicine frameworks are provided.

Results

The constructs and attributes from this conceptual framework were used to develop the guides for focus group discussions (FGDs) and semi-structured interviews (SSIs). The guides were prepared separately for each stakeholder group.

Conclusions

The developed framework facilitated the assessment of needs and readiness suited to the context and among various stakeholders involved in the proposed implementation of the comprehensive model of tele-practice for childhood communication disorders in rural communities.

A self-management psychoeducational eHealth program to support and empower people with advanced cancer and their family caregivers: Development using the scrum methodology

Background

eHealth programs could be a flexible and scalable resource to support and empower people with advanced cancer and their family caregivers. A face-to-face intervention that has demonstrated effectiveness is the "FOCUS" program, developed and tested in the USA. Recently the FOCUS program was translated and adapted to the European context as part of an international study in six European countries, resulting in the "FOCUS+" program. FOCUS+ served as the basis for development of the web-based iFOCUS program.

Objective

We aim to (1) describe the development process of the iFOCUS program, (2) outline the challenges we encountered and how they were overcome, and (3) present findings regarding the acceptability and usability of iFOCUS.

Methods

We used the four phased agile Scrum methodology to develop iFOCUS and applied set timeframes of rapid program development and evaluation (sprints). Five teams were involved in the development i.e. a core development group, a web development team, an international consortium, audio-visual experts, and potential end-users.

Results

Development followed seven steps, integrated across the four phases of Scrum: (1) concept design, (2) development of mock-ups, (3) Feedback from the international consortium, (4) technical development of iFOCUS, (5) creating versions for the six participating countries, (6) preliminary testing of iFOCUS and (7) implementing the final version in a randomized controlled trial. User testing included 42 participants (twenty patient-family caregiver dyads and two bereaved family caregivers) who reviewed the iFOCUS program. Users found the iFOCUS program to be acceptable and usable. Feedback mainly focused on text size and fonts. Minor changes to the content, tailoring, and program flow were required. During development we encountered program specific and general challenges. Using the Scrum methodology facilitated iterative development to address these issues. For some challenges, such as tailoring, we had to make pragmatic choices due to time and resource limitations.

Conclusions/discussion

The development of a tailored, self-managed psychoeducational eHealth program for people with advanced cancer and their family caregivers is an intense process and requires pragmatic choices. By keeping the emphasis on the target population during development, no specific remarks pertaining to advanced cancer were identified. Some challenges we encountered are common to eHealth development, others were related to program specific requirements. Using the Scrum methodology allows teams to efficiently collaborate during program development and increases the flexibility of the development process. Interpersonal contact between research staff and potential end-users is recommended during and after the development of eHealth programs.

Health workforce perceptions on telehealth augmentation opportunities

BACKGROUND

The availability and use of telehealth to support health care access from a distance has expanded in response to the COVID-19 pandemic. Telehealth services have supported regional and remote health care access for many years and could be augmented to improve health care accessibility, acceptability and overall experiences for both consumers and clinicians. This study aimed to explore health workforce representatives' needs and expectations to move beyond existing telehealth models and plan for the future of virtual care.

METHODS

To inform recommendations for augmentation, semi-structured focus group discussions were held (November-December 2021). Health workforce representatives with experience in health care delivery via telehealth across country Western Australia were approached and invited to join a discussion.

RESULTS

Focus group participants included 53 health workforce representatives, with between two and eight participants per discussion. In total, 12 focus groups were conducted: seven were specific to regions, three with staff in centralised roles, and two with a mixture of participants from regional and central roles. Findings identified four key areas for telehealth augmentation: improvements required to existing service practice and processes; equity and access considerations; health workforce-focussed opportunities; and consumer-focussed opportunities.

CONCLUSIONS

Following the onset of the COVID-19 pandemic and the rapid increase in health services delivered via telehealth modalities, it is timely to explore opportunities to augment pre-existing models of care. Workforce representatives consulted in this study suggested modifications to existing process and practice that would improve the current models of care, and recommendations on ways to improve clinician and consumer experiences with telehealth. Improving experiences with virtual delivery of health care is likely to support continued use and acceptance of this modality in health care delivery.

Neonatal retrievals from a regional centre: Outcomes, missed opportunities and barriers to back transfer

AIM

High-risk neonates are retrieved from regional centres to tertiary neonatal units when the required care of the baby exceeds the clinical capabilities of the birthing facility. However, there is limited research on the outcomes of neonatal retrievals from regional special care centres and the barriers to back transfer of neonates from a tertiary centre are not well established. This study aimed to review the outcome of neonatal retrievals >32 weeks gestation from a regional referral centre. The study also aimed to determine missed opportunities for providing care at the regional centre and evaluate patient back transfer delays.

METHODS

All neonates transferred to a tertiary neonatal intensive care unit in North Queensland over the 5-year period January 2016 to December 2020 from a regional neonatal centre were retrospectively reviewed from the electronic medical records.

RESULTS

Fifty neonates transferred to a tertiary neonatal intensive care unit over the study period were identified. Between 2016 and 2020, the number of neonatal retrievals increased (P = 0.021). Out of the 50 neonatal retrievals, 86% were for medical reasons. Overall, eight neonates were identified as missed opportunities whose care could have been maintained at the regional centre with support from the tertiary neonatal intensive care unit. In total, 16 neonates were affected by a delay in back transfer.

CONCLUSIONS

This study shows a significant increase in retrievals to tertiary neonatal intensive care unit over the study period. Increasing bed capacity, utilising telehealth and recruiting regional special care nursery staff could improve outcomes and reduce strain on tertiary neonatal resources.

Ensuring equity: Pharmacogenetic implementation in rural and tribal communities

Implementation strategies for pharmacogenetic testing have been largely limited to major academic medical centers and large health systems, threatening to exacerbate healthcare disparities for rural and tribal populations. There exists a need in Montana (United States)-a state where two-thirds of the population live in rural areas and with a large proportion of tribal residents-to develop novel strategies to make pharmacogenetic testing more broadly available. We established partnerships between University of Montana (UM) and three early adopter sites providing patient-centered care to historically neglected populations. We conducted 45 semi-structured interviews with key stakeholders at each site and solicited participant feedback on the utility of a centralized pharmacogenetic service at UM offering consultations to patients and providers statewide via telehealth. For settings serving rural patients-tribal and non-tribal-participants described healthcare facilities without adequate infrastructure, personnel, and funding to implement pharmacogenetic services. Participants serving tribal communities stressed the need for ethical practices for collecting biospecimens and returning genetic results to patients, largely due to historical and contemporary traumas experienced by tribal populations with regard to genetic research. Participants expressed that pharmacogenetic testing could benefit patients by achieving therapeutic benefit sooner, reducing the risk of side effects, and improving adherence outcomes for patients with limited access to follow-up services in remote areas. Others expressed concern that financial barriers to pharmacogenetic testing for patients of lower socioeconomic status would further exacerbate inequities in care. Participants valued the role of telehealth to deliver pharmacogenetic consults from a centralized service at UM, describing the ability to connect providers and patients to resources and expertise as imperative to driving successful pharmacogenetic implementation. Our results support strategies to improve access to pharmacogenetic testing for neglected patient populations and create opportunities to reduce existing healthcare inequities. By exploring critical challenges for pharmacogenetic implementation focused on serving underserved communities, this work can help guide equitable frameworks to serve as a model for other resource-limited settings looking to initiate pharmacogenetic testing.