Will the United States pass on telemedicine progress?

Background

During the COVID-19 pandemic, federal and state health policies allowed temporary flexibilities for Medicare and Medicaid beneficiaries, leading to a sharp increase in telemedicine use. However, many of the flexibilities that enabled innovation and growth in telemedicine continue temporarily since the federal emergency declaration ended in May 2023, and the United States has not made permanent decisions about telemedicine policy. Analysts have raised concerns about increased spending, program integrity, safety, and equity, and recommend strengthening oversight.

Methods

Here, we argue that we must continue the flexibilities to better understand telemedicine's quality, safety, and outcomes, and until the United States can develop an evidence-based digital health strategy. A premature regression to pre-pandemic telemedicine policies risks unintended consequences.

Conclusion

We must continue the current policy flexibilities, safeguard against fraud and abuse, and immediately prioritize research and evaluation of telemedicine's quality, safety, and outcomes, to avoid unintended consequences and support more permanent policy decision-making.

Telemedicine from Home or the Office: Perceptions of Mental Health Providers

Introduction: The COVID-19 pandemic led to a rapid transition to telemedicine for mental health care and redefined many providers' work environments and practices. The purpose of the study was to investigate the impact of work location on telemental health (TMH) benefits, disruptions, and concerns to further understand the rapid implementation of telemedicine for mental health treatment. Methods: A sample of 175 practicing TMH providers completed an online survey between July and August 2020. Providers answered questions about personal demographics and practice characteristics. Next, they answered questions about benefits, disruptions, and concerns regarding the use of telemedicine in their practice. Chi-square and independent samples t-test were conducted to identify work location differences for personal demographics and clinical practice characteristics. Three multivariate analyses of covariance were conducted to examine overall differences in perceptions of telemedicine benefits, concerns, and disruptions based on work location while covarying for provider race, ethnicity, percentage of caseload seen through telemedicine, practice type, specialty, and primary method of reimbursement. Results: TMH providers who primarily work from an office reported more benefit of reduced costs/overhead (ηp2 = 0.039), less benefit of limiting the spread of the virus (ηp2 = 0.028), and more concern about reimbursement (ηp2 = 0.046) than those who primarily work from home. We observed no difference in disruptions, patient access to care, quality of care, and work-life balance. Discussion: Exploration into work location of TMH providers aids in understanding of clinical workflows and provider wellbeing. Our findings suggest that telemedicine may be easily integrated into different types of clinical workflows and work locations.

Exploring telemental health practice before, during, and after the COVID-19 pandemic

INTRODUCTION

This study investigated how mental health providers' use of telemedicine has changed since the coronavirus disease (COVID) 2019 pandemic and their expectations for continuing to use it once the pandemic ends.

METHODS

A 15-min online survey was completed by 175 practicing and licensed telemental health providers who use telemedicine. In addition to personal and professional demographic items, the survey included items about the frequency of telemedicine use, proportion of caseload served by telemedicine, comfort using telemedicine before and during the COVID-19 pandemic, and expectations to use telemedicine after the pandemic ends. A series of χ2 analyses, an independent samples t-test, and analyses of variance were conducted.

RESULTS

The pandemic resulted in a greater proportion of telemental health providers using telemedicine on a daily basis (17% before and 40% during the pandemic; p < 0.01) and serving more than half of their caseload remotely (9.1% before and 57.7% during the pandemic; p < 0.05). Also, there was a statistically significant increase in their comfort using telemedicine before and during the pandemic (p < 0.001). Providers reported expecting to use telemedicine more often after the pandemic ends (M = 3.35; SD = 0.99). Expectations to provide telemental health services after the pandemic were greater for mental health counselors, providers who practiced in rural regions, and providers who served patients through out-of-pocket payments.

DISCUSSION

Telemental health providers use telemedicine daily as a result of the COVID-19 pandemic, with expectations of continuing to use telemedicine in practice after the pandemic. This expectation is more prominent in certain segments of providers and warrants further investigation.

Communicating about online health information with patients: Exploring determinants among telemental health providers

Objective

To investigate determinants of telemental health (TMH) providers' openness to discuss and confidence to use online mental health information with patients, focusing on providers' eHealth literacy and perceived usefulness of online MH information.

Methods

TMH providers (N = 472) completed a web-based survey with questions about discussing and using online health information with patients, perceived usefulness of the Internet as a source of patient information, and eHealth literacy.

Results

Providers were open to discussing online health information with patients if they were not treating substance abuse disorders (b = -0.83), felt the Internet was a useful resource (b = 0.18), and felt confident in their skills to evaluate the online information (b = 0.21). Providers were confident using online health information if they worked in a small clinic (b = 0.37), felt the Internet was a useful resource (b = 0.31), knew where to access relevant online health information (b = 0.13), and had skills to help their patients find (b = 0.17) and evaluate (b = 0.54) online information.

Conclusion

TMH providers are likely to use online health information resources if they know where and how to find them and perceive the Internet as a useful resource.

Innovation

To effectively discuss online health information with patients, providers require skills to evaluate the information with patients.

Consensus Guidelines for Teledermatology: Scoping Review

BACKGROUND

Consensus guidelines and recommendations play an important role in fostering quality, safety, and best practices, as they represent an expert interpretation of the biomedical literature and its application to practice. However, it is unclear whether the recent collective experience of implementing telemedicine and the concurrent growth in the evidence base for teledermatology have resulted in more robust guidance.

OBJECTIVE

The objective of this review was to describe the extent and nature of currently available guidance, defined as consensus guidelines and recommendations available for telemedicine in dermatology, with guidance defined as consensus or evidence-based guidelines, protocols, or recommendations.

METHODS

We conducted a single-reviewer scoping review of the literature to assess the extent and nature of available guidance, consensus guidelines, or recommendations related to teledermatology. We limited the review to published material in English since 2013, reflecting approximately the past 10 years. We conducted the review in November and December of the year 2022.

RESULTS

We identified 839 potentially eligible publications, with 9 additional records identified through organizational websites. A total of 15 publications met the inclusion and exclusion criteria. The guidelines focused on varied topics and populations about dermatology and skin diseases. However, the most frequent focus was general dermatology (8/15, 53%). Approximately half of the telemedicine guidance described in the publications was specific to dermatology practice in the context of the COVID-19 pandemic. The publications were largely published in or after the year 2020 (13/15, 87%). Geographical origin spanned several different nations, including Australia, the United States, European countries, and India.

CONCLUSIONS

We found an increase in COVID-19-specific teledermatology guidance during 2020, in addition to general teledermatology guidance during the period of the study. Primary sources of general teledermatology guidance reported in the biomedical literature are the University of Queensland's Centre for Online Health and Australasian College of Dermatologists E-Health Committee, and the American Telemedicine Association. There is strong evidence of international engagement and interest. Despite the recent increase in research reports related to telemedicine, there is a relative lack of new guidance based on COVID-19 lessons and innovations. There is a need to review recent evidence and update existing recommendations. Additionally, there is a need for guidance that addresses emerging technologies.

Older adults' experience with virtual conversational agents for health data collection

Introduction

Virtual conversational agents (i.e., chatbots) are an intuitive form of data collection. Understanding older adults' experiences with chatbots could help identify their usability needs. This quality improvement study evaluated older adults' experiences with a chatbot for health data collection. A secondary goal was to understand how perceptions differed based on length of chatbot forms.

Methods

After a demographic survey, participants (≥60 years) completed either a short (21 questions), moderate (30 questions), or long (66 questions) chatbot form. Perceived ease-of-use, usefulness, usability, likelihood to recommend, and cognitive load were measured post-test. Qualitative and quantitative analyses were used.

Results

A total of 260 participants reported on usability and satisfaction metrics including perceived ease-of-use (5.8/7), usefulness (4.7/7), usability (5.4/7), and likelihood to recommend (Net Promoter Score = 0). Cognitive load (12.3/100) was low. There was a statistically significant difference in perceived usefulness between groups, with a significantly higher mean perceived usefulness for Group 1 than Group 3. No other group differences were observed. The chatbot was perceived as quick, easy, and pleasant with concerns about technical issues, privacy, and security. Participants provided suggestions to enhance progress tracking, edit responses, improve readability, and have options to ask questions.

Discussion

Older adults found the chatbot to be easy, useful, and usable. The chatbot required low cognitive load demonstrating it could be an enjoyable health data collection tool for older adults. These results will inform the development of a health data collection chatbot technology.

Clinical and Information Services Needed by Telemental Health Providers

Purpose: To identify clinical and informational services that telemental health (TMH) providers need to be more successful in their practice. Methods: In February-March 2021, 472 TMH providers completed a cross-sectional survey. Providers indicated the degree to which they need clinical (e.g., build therapeutic alliances) and informational (e.g., learn about regulatory changes) services. Independent samples t-tests were conducted to examine differences in needs according to when telemedicine was adopted. Results: TMH providers neutrally-to-somewhat agreed they could benefit from clinical (M = 3.24; standard deviation [SD] = 0.78) and informational (M = 3.66; SD = 0.82) services. Prepandemic TMH providers reported a greater need for services that help them cultivate relationships with patients, monitor health conditions, and to remain updated about reimbursement processes. Conclusion: All TMH providers could benefit from information about the latest trends and best practices in telemedicine. Prepandemic providers could benefit most from policy-related updates and patient-engagement services.

Provider Perspectives on Telemental Health Usage After COVID-19: A Retrospective Analysis (Preprint)

Background

Mental health care pivoted to telemedicine during the COVID-19 pandemic, and there is uncertainty around the sustainability of this rapid shift.

Objective

This study examined how intentions to continue using telemedicine after the COVID-19 pandemic are influenced by provider perceptions of usefulness, ease of use, and professional social influence, facilitating organizational conditions.

Methods

We conducted a web-based, cross-sectional survey of 369 telemental health providers between February and March 2021. A hierarchical linear regression analysis was conducted to predict intentions to continue using telemedicine after the COVID-19 pandemic.

Results

Most providers began using telemedicine in March 2020 or later (257/369, 69.6%) and attended to ≥50% of their clients via telemedicine (299/369, 81.0%). Intention to continue using telemedicine after the COVID-19 pandemic was predicted by the telemedicine caseload (β=.10; P=.005), perceived usefulness in general (β=.10; P=.008), ease of use (β=.08; P=.04), social influence (β=.68; P<.001), and facilitating conditions (β=.08; P=.047).

Conclusions

Exploration of the predictors of telemedicine usage beyond the COVID-19 pandemic aids in surveillance of telemedicine usage, integration with future clinic workflows, and the shaping of public policy. It is important to consider telemedicine services as not only a response to a crisis but also an effective and useful solution for everyday life. Our results suggest widespread, sustainable telemedicine adoption.

The Symbiosis of Virtual Reality Exposure Therapy and Telemental Health: A Review

Phobias and related anxiety are common and costly mental health disorders. Experts anticipate the prevalence of phobias will increase due to the COVID-19 pandemic. Exposure therapies have been established as effective and reliable treatments for anxiety, including recent innovations in virtual reality-based exposure therapy (VRET). With the recent advent of telemental health (TMH), VRET is poised to become mainstream. The combination of VRET and TMH has the potential to extend provider treatment options and improve patient care experiences. In this narrative review, we describe how recent events have accelerated VRET + TMH, identify barriers to VRET + TMH implementation, and discuss strategies to navigate those barriers.

Perceptions of Telemental Health Care Delivery During COVID-19: A Cross-Sectional Study With Providers, February-March 2021

The COVID-19 pandemic accelerated adoption of telemental health (TMH). Providers with limited TMH experience faced challenges during the rapid switch to remote patient care. We investigated TMH providers' perceptions about remote care one year into the pandemic according to when providers adopted telemedicine (i.e., before vs. after March 2020) and how much of their caseloads were served remotely (i.e., < 50% vs. ≥ 50%). Between February-March 2021, 472 TMH providers completed a cross-sectional, web-based survey that measured perceived benefits and satisfaction with telemedicine, therapeutic alliance, patient-centered communication, eHealth literacy, multicultural counseling self-efficacy, and facilitating factors of using telemedicine. Providers who began using telemedicine before the pandemic reported having better training, task-related therapeutic alliance with patients, and ability to conduct multicultural interventions, assessments, and session management. Providers who served ≥ 50% of their caseload remotely reported greater satisfaction with their practice, stronger beliefs about the benefits of telemedicine, and greater perceived effects of telemedicine on alleviating the impact of COVID-19. There were no differences in reports of patient-centered communication nor eHealth literacy. In conclusion, providers who adopted TMH more recently may require additional training and support to successfully establish a working alliance with their patients, especially with multicultural aspects of care.

Quantifying COVID-19's Impact on Telemedicine Utilization

BACKGROUND

While telemedicine has been expanding over the past decade, the COVID-19 pandemic era restrictions regarding in-person care have led to unprecedented levels of telemedicine utilization. To the authors' knowledge, no studies to date have quantitatively analyzed both national and regional trends in telemedicine utilization during COVID-19, both of which have key implications for informing health policy.

OBJECTIVE

To investigate how trends in telemedicine utilization changed across the course of the COVID-19 pandemic.

METHODS

Using data from doxy.me, the largest free telemedicine platform, and the NIH Clinical Center, the largest U.S. clinical research hospital, we assessed changes in total telemedicine minutes, new provider registrations, monthly sessions, and average session length from March-November 2020. We also conducted state-level analysis of how telemedicine expansion differed by region.

RESULTS

National telemedicine utilization peaked in April 2020 at 291 million minutes and stabilized at 200-220 million monthly minutes from May to November 2020. Surges were strongest in New England and weakest in the South and West. Greater telemedicine expansion during COVID-19 was geographically associated with lower COVID-19 cases per capita. The nature of telemedicine visits also changed, as the average monthly visits per provider doubled and average visit length decreased by 60%.

CONCLUSIONS

The COVID-19 pandemic led to an abrupt and subsequently sustained uptick in telemedicine utilization. Regional and institute-level differences in telemedicine utilization should be further investigated to inform policy and procedures for sustaining meaningful telemedicine use in clinical practice.

Assessing the impact of COVID-19 on mental health providers in the southeastern United States

The COVID-19 pandemic has increased the need for mental health care despite novel barriers to services. Little is known about how the pandemic has affected mental health providers and their practice. In July 2020, we conducted a web-based survey of 500 licensed mental health providers to assess their employment and caseloads, logistics of care, quality of care, and patient-provider relationships and communication during the pandemic. Over 90% of providers reported changes to their employment (e.g., furloughs), with 64% no longer practicing. Providers who reported no longer practicing were older in age, racial minorities, served rural communities, worked in small clinics/provider networks, were social workers and marriage and family therapists, and relied on private insurance or out-of-pocket payment. Most practicing providers reported similar-to-increased caseloads (62%), new patients seeking services (67%), and appointment frequency (70%). Approximately 97% of providers used telemedicine, with 54% providing services mostly-to-exclusively via telemedicine. Most providers reported losing contact with patients deemed unstable (76%) or a danger to themselves/others (71%). Most providers reported maintained-to-improved quality of care (83%), patient-provider relationships (80%), and communication (80%). Results highlight concerns relating to mental health services during the pandemic, however practicing providers have demonstrated resilience to coordinate and provide high quality care.

Exploring telemental health practice before, during, and after the COVID-19 pandemic

INTRODUCTION

This study investigated how mental health providers' use of telemedicine has changed since the coronavirus disease (COVID) 2019 pandemic and their expectations for continuing to use it once the pandemic ends.

METHODS

A 15-min online survey was completed by 175 practicing and licensed telemental health providers who use telemedicine. In addition to personal and professional demographic items, the survey included items about the frequency of telemedicine use, proportion of caseload served by telemedicine, comfort using telemedicine before and during the COVID-19 pandemic, and expectations to use telemedicine after the pandemic ends. A series of χ² analyses, an independent samples t-test, and analyses of variance were conducted.

RESULTS

The pandemic resulted in a greater proportion of telemental health providers using telemedicine on a daily basis (17% before and 40% during the pandemic; p < 0.01) and serving more than half of their caseload remotely (9.1% before and 57.7% during the pandemic; p < 0.05). Also, there was a statistically significant increase in their comfort using telemedicine before and during the pandemic (p < 0.001). Providers reported expecting to use telemedicine more often after the pandemic ends (M = 3.35; SD = 0.99). Expectations to provide telemental health services after the pandemic were greater for mental health counselors, providers who practiced in rural regions, and providers who served patients through out-of-pocket payments.

DISCUSSION

Telemental health providers use telemedicine daily as a result of the COVID-19 pandemic, with expectations of continuing to use telemedicine in practice after the pandemic. This expectation is more prominent in certain segments of providers and warrants further investigation.

The singular insemination status of Hypothenemus hampei (Ferrari) (Coleoptera: Curculionidae: Scolytinae) females during the inter-harvest season of a coffee crop

The coffee berry borer, Hypothenemus hampei (Ferrari), can survive in residual coffee berries during the inter-harvest period, while new fructification only appears 2-3 months after the last harvest. The dispersal of colonizing females is an adaptation that enables the life cycle of the species to go ahead whenever his flight aptitude allows. This paper focuses on accurately determining the rate of inseminated females ready to reproduce when emerging from residuals berries to colonize new ones, which constitutes a characteristic of the live cycle far from common in Curculionidae. We dissected females caught in traps baited with a mixture of alcohols during the inter-harvest season, females from infested residual berries collected from branches, and virgin females obtained from pupae reared individually in the laboratory. After microscopic preparation with Giemsa stain, spermathecae were observed to identify the physiological status of each specimen. Out of the females found in the traps, 98.4% displayed recent and abundant insemination and 1.6% sporadic insemination. In contrast, in residual berries, most of females were recently inseminated (84.5%), followed by virgin females (10.5%) and older inseminated females (5%). In addition, the flight tests of the virgin females were negative. These results indicate that all colonizing females were inseminated, ready for flying and oviposition, females inside residual berries showed different physiological status, and virgin females could not migrate since they could not flight. The large number of inseminated females inside the residual berries, and the capacity of migrating females to colonize and reproduce, suggest that it is necessary to control residual berries and use traps to stop the dispersal and reproduction of this pest.

Short-distance dispersal of Hypothenemus hampei (Ferrari) females (Coleoptera: Curculionidae: Scolytidae) during the coffee tree fruiting period

The coffee berry borer (CBB), Hypothenemus hampei (Ferrari), is a multivoltine species closely associated with coffee crops worldwide, causing severe damage to the bean. In Mexico, as in all tropical regions, CBB survives during the inter-harvest period in residual berries on the ground or in dry berries remaining on the branches, and then disperses in search of the first suitable berries. In this study, we investigated how CBB dispersed from the first infested nodes during the fruiting period of Coffea canephora Pierre, which provides a favourable trophic level for this insect. Forty-five branches equally distributed in 15 coffee trees, with one infested node and four uninfested nodes, were selected. The branches were subjected to three treatments over nine weeks: 1) glue between nodes with full protection, 2) glue between nodes without protection, and 3) no glue and no protection. In addition, 45 CBB-free branches were selected and subjected to the same three treatments. CBB colonization can occur in three ways: 1) from an infested node to an uninfested node on the same branch, 2) from infested berries to uninfested berries within the nodes, 3) from branches to other branches. We also found that CBB dispersal between nodes of the same branches never occurred by walking but by flying. Thus, in this context of coffee berry development and ripening, and unlike the phenological situation of the inter-harvest period, CBB continuously travels very short distances, thus limiting its control.

Farmers' perceptions, knowledge, and management of coffee pests and diseases and their natural enemies in Chiapas, Mexico

Small farmers' perceptions of coffee Coffea arabica L. herbivores and their natural enemies, how those perceptions relate to field infestation levels, and pest management practices being implemented by members from two organic and nonorganic coffee grower organizations in the Soconusco region, southeastern Mexico, were analyzed through an interview survey, diagnostic workshops, and field sampling. The terms pest, disease, and damage were commonly used as synonyms. The major phytophagous species, as perceived by the interviewees, were Hypothenemus hampei (Ferrari), and to a lesser extent the fungi Corticium koleroga Cooke (Höhnel) and Hemileia vastatrix Berkeley & Broome. Among the nonorganic farmers, other nonpest-related constraints were regarded as more important. Awareness of the existence of natural enemies was low, despite more organic farmers have used the ectoparasitoid bethylid Cephalonomia stephanoderis Betrem against H. hampei. Labor supplied by household members was most frequent for pest control; only organic farmers exchanged labor for this purpose. The levels of infestation by H. hampei, Leucoptera coffeella Guérin-Méneville, and C. koleroga were lower within the organic coffee stands. However, a low effectiveness for pest control was commonly perceived, probably due to a feeling, among the organic farmers, of a low impact of their pest management extension service, whereas a lack of motivation was prevalent among the nonorganic farmers, shown by a concern with their low coffee yields and the emigration of youth. The importance of understanding farmers' perceptions and knowledge of pests and their natural enemies and the need for participatory pest management approaches, are discussed.

Effect of Beauveria bassiana and Metarhizium anisopliae (Deuteromycetes) upon the coffee berry borer (Coleoptera: Scolytidae) under field conditions

The effect of three strains of the fungus Beauveria bassiana (Balsamo) Vuillemin and two strains of Metarhizium anisopliae (Metschnikoff) Sorokin upon the coffee berry borer, Hypothenemus hampei (Ferrari), was studied in three coffee farms at different altitudes (450-1,100 m above sea level) in Soconusco, Chiapas, Mexico. The maximum average percentage mycosis varied according to altitude. At 450 m asl (El Rincon) mycosis was 14.3% for B. bassiana and 6.3% for M. anisopliae; at 880 m asl (Santa Anita) mycosis was 40.6% for B. bassiana and 12.6% for M. anisopliae, and at 1,100 m asl (Alpujarras) 33.9% for B. bassiana and 22. 1% for M. anisopliae. The effect of fungal mycosis through time was not significant (P > 0.01) in any of the farms, but there was a significant difference between the strains of the fungus (P < 0.01); the best strains being Bb25 and Ma4 at the lower altitude, Bb26 and Ma4 for the middle altitude and Bb26 and Ma4 at the higher altitude. Environmental factors such as temperature, relative humidity and rain were not correlated with the percentage mycosis caused by B. bassiana and M. anisopliae. However, in the case of B. bassiana there was a significant, positive correlation (P < 0.01) between the infestation levels of the pest and the mycosis response of the entomopathogen.