ArticleLiterature Review

Telehealth interventions for reducing waiting lists and waiting times for specialist outpatient services: A scoping review

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Abstract

We undertook a scoping review of the published literature to identify and summarise key findings on the telehealth interventions that influence waiting times or waiting lists for specialist outpatient services. Searches were conducted to identify relevant articles. Articles were included if the telehealth intervention restructured or made the referral process more efficient. We excluded studies that simply increased capacity. Two categories of interventions were identified – electronic consultations and image-based triage. Electronic consultations are asynchronous, text-based provider-to-provider consultations. Electronic consultations have been reported to obviate the need for face-to-face appointments between the patient and the specialist in between 34–92% of cases. However, it is often reported that electronic consultations are appropriate in less than 10% of referrals for outpatient care. Image-based triage has been used successfully to reduce unnecessary or inappropriate referrals and was used most often in dermatology, ophthalmology and otolaryngology (ENT). Reported reduction rates for face-to-face appointments by specialty were: dermatology 38–88%, ophthalmology 16–48% and ENT 89%. Image–based triage can be twice as effective as non-image based triage in reducing unnecessary appointments. Telehealth interventions can effectively be used to reduce waiting lists and improve the coordination of specialist services, and should be considered in conjunction with clinical requirements.

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... Teleophthalmology has emerged as a viable alternative to delivering eye care that may improve patients' access to timely and appropriate care. [7][8][9] Teleophthalmology is a means to provide ophthalmic care at a distance using information and communication technology. 8 10 A variety of eye care delivery models have been reported to benefit from teleophthalmology. ...
... For example, in one scoping review, teleophthalmology was found to contribute to reducing face-to-face appointments with ophthalmologists by 16%-48% through reducing inappropriate and unnecessary referrals. 7 Similarly, implementing remote retinal imaging-based referrals reduced the waiting time for patients to see an ophthalmologist from 14 weeks to 4 weeks. 7 Teleophthalmology has been found to improve elderly patients' access to specialist eye care and reduce workload on specialist centres and unnecessary visits. ...
... 7 Similarly, implementing remote retinal imaging-based referrals reduced the waiting time for patients to see an ophthalmologist from 14 weeks to 4 weeks. 7 Teleophthalmology has been found to improve elderly patients' access to specialist eye care and reduce workload on specialist centres and unnecessary visits. 10 Patients also reported high levels of satisfaction with teleophthalmology services due to reduced cost and time of travel, as well as increased accessibility to services. ...
Article
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Introduction Novel teleophthalmology technologies have the potential to reduce unnecessary and inaccurate referrals between community optometry practices and hospital eye services and as a result improve patients’ access to appropriate and timely eye care. However, little is known about the acceptability and facilitators and barriers to the implementations of these technologies in real life. Methods and analysis A theoretically informed, qualitative study will explore patients’ and healthcare professionals’ perspectives on teleophthalmology and Artificial Intelligence Decision Support System models of care. A combination of situated observations in community optometry practices and hospital eye services, semistructured qualitative interviews with patients and healthcare professionals and self-audiorecordings of healthcare professionals will be conducted. Participants will be purposively selected from 4 to 5 hospital eye services and 6–8 affiliated community optometry practices. The aim will be to recruit 30–36 patients and 30 healthcare professionals from hospital eye services and community optometry practices. All interviews will be audiorecorded, with participants’ permission, and transcribed verbatim. Data from interviews, observations and self-audiorecordings will be analysed thematically and will be informed by normalisation process theory and an inductive approach. Ethics and dissemination Ethical approval has been received from London-Bromley research ethics committee. Findings will be reported through academic journals and conferences in ophthalmology, health services research, management studies and human-computer interaction.
... We have identified some works that demonstrate telehealth as a technology to improve the patient experience through timeliness of care (Caffery et al, 2016;Gattu et al, 2016;Lum et al, 2020); and better access (Qureshi et al, 2015;Lurie and Carr, 2018;Lavin et al, 2020); leading to an improved quality of life for care seekers (Waibel et al, 2017). Other works connected a decreased hospitalization and resource utilization to the implementation of telehealth solutions (Gattu et al, 2016), lessening the workload on the care staff (Bashir and Bastola, 2018), thus improving the work life of health care providers (Lopo et al, 2020). ...
... Timeliness of Care: Evidence suggests that the adoption of telehealth has improved timely access to care, especially for low acuity conditions or serious, time-sensitive situations; hospitals are adopting telehealth to improve operational efficiencies and provide timelier access to specialty care (Lum et al, 2020). Our review has identified a case, with a significant (75%) reduction in patient wait times for urgent care conditions, through a telehealth triage program (Caffery et al, 2016). In another case, while chronic pain clinic patients waited for an in person consultation, they have received useful advice in 86% of cases, through their telehealth portals, reducing the negative impact of the long wait times on their day to day lives. ...
... In another case, while chronic pain clinic patients waited for an in person consultation, they have received useful advice in 86% of cases, through their telehealth portals, reducing the negative impact of the long wait times on their day to day lives. Using virtual visits for low-acuity patients, reduced the emergency departments wait from 2.5 hours to 40 minutes (Caffery et al, 2016) and timely diagnosis of minor illnesses in children and adolescents has improved school attendance (Gattu et al, 2016). ...
Conference Paper
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Delve into the 21st century to welcome telehealth! It has taken so long coming, only to be accelerated by the COVID -19 pandemic. With the advent of telehealth solutions, healthcare systems are on the edge of the biggest gush in activity in over a century. In this paper, we look for evidence in the literature that treats the disruption introduced by Telehealth diffusion and the resulting, long awaited, contribution to optimizing health system performance. In our paper, we attempt to use the scoping review to detect evidence to answer this question. We performed a search up to April of 2021. Data were extracted on general study characteristics, clinical domain, technology, setting, category of outcome, and results. We then concluded with a synthesis of the information and call to action. We then coded the findings through the lens of the quadruple aim, provided reflections from the scoping review to inform how telehealth can be a dynamic element of system resilience. Though faced with unintended consequences, telehealth promises to be a viable alternative to in-person care, optimizing health system performance especially in times of constrained resources during a pandemic.
... In these conditions, the requirement for the advanced arrangement of medical care benefits, that is, Telehealth, telemedicine and video conference with patients, has become basic now like never before. It is a way to deal with, overcome any barrier between the patients and specialists in two different geographic areas and to empower robust clinical consideration [25]. ...
... There is previous evidence that telehealth strategies, including e-consultations, risk and tele-triage based on risk assessment protocols can reduce waiting lists for referrals to specialized care in countries that do not have universal health systems. In a scoping review on the topic, Caffery et al. concluded that telehealth interventions obviate the need for face-to-face consultations with specialists in 34 to 92 % of cases [30]. However, the model of referral system applied in SUS is probably unique, which hampers direct confrontation of our results with those from studies conducted in other countries. ...
Article
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Background Management of patient flow within a healthcare network, allowing equitable and qualified access to healthcare, is a major challenge for universal health systems. Implementation of telehealth strategies to support referral management has been shown to increase primary care resolution and to promote coordination of care. The objective of this study was to assess the impact of telehealth strategies on waiting lists and waiting times for specialized care in Brazil. Methods Before-and-after study with measures obtained between January 2019 and February 2020. Baseline measurements of waiting lists were obtained immediately before the implementation of a remotely operated referral management system. Post-interventional measurements were obtained monthly, up to six months after the beginning of operation. Data was extracted from the database of the project. General linear models were applied to assess interaction of locality and time over number of cases on waiting lists and waiting times. Results At baseline, the median number of cases on waiting lists ranged from 2961 to 12,305 cases. Reductions of the number of cases on waiting lists after six months of operation were observed in all localities. The magnitude of the reduction ranged from 54.67 to 88.97 %. Interaction of time measurements was statistically significant from the second month onward. Median waiting times ranged from 159 to 241 days at baseline. After six months, there was a decrease of 100 and 114 waiting days in two localities, respectively, with reduction of waiting times only for high-risk cases in the third locality. Conclusions Adoption of telehealth strategies resulted in the reduction of number of cases on waiting lists. Results were consistent across localities, suggesting that telehealth interventions are viable in diverse settings.
... Estudios observacionales sugieren un potencial en este tipo de consultas para reducir no solo los tiempos de espera para la atención especializada, sino también la necesidad de consultas presenciales, según el entorno y la especialidad [4][5][6] . Si bien los estudios de programas individuales han demostrado beneficios relacionados con la mejora del acceso a la atención especializada, una mejor coordinación de la atención, una alta satisfacción entre los proveedores de atención primaria y hospitalaria, y una experiencia positiva del paciente 7 , los programas de telemedicina entre proveedores no han logrado un uso generalizado. ...
Article
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Resumen Las consultas de telemedicina asíncronas entre proveedores son un modo emergente de comunicación entre la atención hospitalaria y la atención primaria. El territorio de la Catalunya Central se ha caracterizado por la implantación de programas de telemedicina asíncronas desde el 2007, siempre garantizando la autonomía del paciente, el secreto profesional y la protección de los datos. Estos programas de telemedicina asíncrona (teledermatología, teleaudiometrías, teleúlceras, telepárpados, entre otros) no se han entendido como un reemplazo a las visitas presenciales, sino como un complemento, mejorando la accesibilidad (especialmente, en las zonas rurales) y favoreciendo la longitudinalidad tan característica de la atención primaria. En los últimos 15 años, en la Catalunya Central se ha creado una «cultura de telemedicina», que hace que sea mucho más fácil adaptarse a los cambios tecnológicos que se van a producir inexorablemente en un futuro no muy lejano.
... Telehealth programs have the potential to improve patient outcomes and satisfaction, enable operational efficiency, reduce the brick and mortar costs of in-person care, and expand the reach of specialized care. [16][17][18][19][20] Furthermore, the flexibility to offer services remotely may provide a better work-life balance for clinicians. It may also decrease clinician burnout, as telemedicine visits tend to be shorter in duration than in-person visits, giving clinicians more time to complete their visit notes. ...
Article
Background: COVID-19 spurred rapid adoption and expansion of telemedicine. We investigated the factors driving visit modality (telemedicine vs. in-person) for outpatient visits at a large cardiovascular center. Methods: We used electronic health record data from March 2020 to February 2021 from four cardiology subspecialties (general cardiology, electrophysiology, heart failure, and interventional cardiology) at a large academic health system in Northern California. There were 21,912 new and return visits with 69% delivered by telemedicine. We used hierarchical logistic regression and cross-validation methods to estimate the variation in visit modality explained by patient, clinician, and visit factors as measured by the mean area under the curve. Results: Across all subspecialties, the clinician seen was the strongest predictor of telemedicine usage, while primary visit diagnosis was the next most predictive. In general cardiology, the model based on clinician seen had a mean area under the curve of 0.83, the model based on the primary diagnosis had a mean area under the curve of 0.69, and the model based on all patient characteristics combined had a mean area under the curve of 0.56. There was significant variation in telemedicine use across clinicians within each subspecialty, even for visits with the same primary visit diagnosis. Conclusion: Individual clinician practice patterns had the largest influence on visit modality across subspecialties in a large cardiovascular medicine practice, while primary diagnosis was less predictive, and patient characteristics even less so. Cardiovascular clinics should reduce variability in visit modality selection through standardized processes that integrate clinical factors and patient preference.
... Even though due to COVID-19 the shift towards the use of telemedicine was a necessary step, the use of telemedicine in general has many advantages for patients and practitioners. For instance due to decreased costs by saving time and nullifying mileage (Hayward et al., 2019), reducing waiting time for referrals (Caffery et al., 2016) and even higher patient satisfaction and better patient care (Planchard et al., 2020;Dellifraine and Dansky, 2008). Other observations were a positive effect on decision-making (Hayward et al., 2019), increased accessibility and participation to meeting, conferences, multidisciplinary patient discussions and educational sessions (Deora et al., 2020;Meyer et al., 2008;Planchard et al., 2020). ...
Article
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Introduction Due to COVID-19 related restriction, the use of telemedicine has increased tremendously. With this increase, an evaluation in the neurosurgical field seems appropriate. Research question To what extent has telemedicine made its way in neurosurgical practice during the COVID-19 pandemic? Material and Methods A 29-question survey was distributed among members of the congress of neurological surgeons regarding (Barsom et al., 2020) the respondents demographics, (Zu et al., 2020) the current level of COVID-19 restrictions, (Greven et al., 2020) the current use of telemedicine and (LoPresti et al., 2020) potential difficulties and consequences of telemedicine for patient care. Results The average number of weekly outpatient visits decreased with 31 visits to a mean of 15 visits per week, while the average number of surgeries performed decreased with 5 to a mean of 2 procedures per week. On average 60% of the normal consultations have been converted to telehealth consults. Telemedicine was expected to increase the ability to quickly meet patients for urgent appointments (70%) but was also expected to decrease the quality of the relationship (56%) between practitioners and patients. The biggest difficulties due to use of telemedicine were the inability to perform physical examination (42%) followed by the inability of patients to use technology (24%) and working with elderly patients (20%). Discussion and Conclusion Telemedicine, however, comes with concerns regarding the quality of the relationship between patients and practitioners and regarding accessibility among certain patient groups. With these concerns, areas of improvement and further research are indicated. Due to the COVID-19 pandemic, telemedicine has become an integral part of the neurosurgical healthcare.
... Telehealth can assist (or manage the burden) with remote screening and the facilities of care during such pandemic situations (Lurie & Carr, 2018). Evidence has shown that in the healthcare system, digital health can improve the quality of access to healthcare, decrease the expenses, resulting in a better health provision for the users (Caffery, et al., 2016), and also it can contribute to decreasing the patients overload to the health care professionals in the institutions like hospitals, clinics. At the same time, positioning technologies, satellite monitoring, health sensors and apps, drones (drones were applied in carrying medicine and spraying disinfectants in agricultural farms) and 3D Printing which was deployed to mitigate the impact to the supply chain and export bans on personal protective equipment (Restás, et al., 2021) Other technologies as video conference platforms, big data and facial recognition, artificial intelligence, autonomous vehicles, mobile tracking/mass surveillance, were used also to mitigate the epidemic effects not only in the health system but also in the day to day life (Restás, et al, 2021). ...
Article
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COVID-19 has created enormous challenges for health systems around the world. An immense range of digital health technologies has been considered as strategies. The aim of this article is to describe the implementation of digital technologies during the COVID-19 pandemic in prevention, diagnosis and treatment globally. Relevant articles published electronically in English using the following terms "COVID-19", "2019-nCov", "coronavirus", terminologies, "severe acute respiratory syndrome 2", SARS-CoV-2", "access to digital health, telemedicine and e-health, challenges and opportunities, in different data sources were researched. A total of 455 articles were found, and 46 published articles about prevention, treatment, and diagnosis approaches were selected. Digital technologies were useful in holistic control, care management and prevention, digital information, data collection, transfer and storage, frontline protection, risk reduction, analysis and adequate system of monitoring information during the pandemic situation, applying teleservice, consultations to specialists via online/offline, intelligent health system, which decreased the burden of patients to health professionals in institutions. In addition, it helped provide safe, rapidly and adequate patient data; and to avoid contamination for healthcare providers, the general population and patients. Still, the use of digital technologies in health is insufficient in many countries. It is essential to expand alternative ways of adapting digital technologies in health practices, but also to implement other studies on the use of digital health technologies beyond the focus on COVID-19.
... This is a known fact where many patients critically spend almost half-a-day at the hospital just for their monthly appointments. Caffery, Farjian, and Smith's (2016) advocated that electronic consultations, and image-based triage of referrals are often effective in reducing waiting lists and waiting times. Finally, they shared that they were afraid of getting other contagious diseases while waiting for their appointment (M=4.05, ...
... [1] Telehealth has been implemented in the past to improve access to subspecialty care in neuromuscular and musculoskeletal disorders. [2][3][4][5][6][7][8][9] Multiple studies, including randomized controlled trials, support that orthopaedic telehealth consultation is safe and effective, results in similar plans of care and patient-reported outcomes, and creates significant cost reduction with noninferior patient satisfaction. [10][11][12][13][14][15][16][17][18][19] In orthopaedic trauma, the institution of virtual fracture clinics has been shown to improve rates of follow-up within 72 hours, to decrease mean wait times and noshow rates, to decrease rates of discharges after a single visit (a marker of unnecessary referrals), and to limit increases in spending. ...
Article
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Objectives: Despite clinical and economic advantages, routine utilization of telemedicine remains uncommon. The purpose of this study was to examine potential disparities in access and utilization of telehealth services during the rapid transition to virtual clinic during the coronavirus pandemic. Design: Retrospective chart review. Setting: Outpatient visits (in-person, telephone, virtual-Doxy.me) over a 7-week period at a Level I Trauma Center orthopaedic clinic. Intervention: Virtual visits utilizing the Doxy.me platform. Main outcome measures: Accessing at least 1 virtual visit ("Virtual") or having telephone or in-person visits only ("No virtual"). Methods: All outpatient visits (in-person, telephone, virtual) during a 7-week period were tracked. At the end of the 7-week period, the electronic medical record was queried for each of the 641 patients who had a visit during this period for the following variables: gender, ethnicity, race, age, payer source, home zip code. Data were analyzed for both the total number of visits (n = 785) and the total number of unique patients (n = 641). Patients were identified as accessing at least 1 virtual visit ("Virtual") or having telephone or in-person visits only ("No virtual"). Results: Weekly totals demonstrated a rapid increase from 0 to greater than 50% virtual visits by the third week of quarantine with sustained high rates of virtual visits throughout the study period. Hispanic and Black/African American patients were able to access virtual care at similar rates to White/Caucasian patients. Patients of ages 65 to 74 and 75+ accessed virtual care at lower rates than patients ≤64 (P = .003). No difference was found in rates of virtual care between payer sources. A statistically significant difference was found between patients from different zip codes (P = .028). Conclusion: A rapid transition to virtual clinic can be performed at a level 1 trauma center, and high rates of virtual visits can be maintained. However, disparities in access exist and need to be addressed.
... Others report that patients are open to telehealth consultations, but retain a preference for face-to-face services (Eikelboom et al. 2014;Eikelboom and Atlas 2005;Tao et al. 2020). There was a strong recognition amongst audiologists that telehealth services can lead to better efficiency: less travel for clients or clinicians, more timely attention, and better overall access, as evidenced in the audiology (Saunders and Roughley 2020;Reginato and Ferrari 2014) and broader literature (Kokesh, Ferguson, and Patricoski et al. 2011;Caffery, Farjian, and Smith 2016;Taylor et al. 2018). ...
Article
Objective To determine the attitudes of audiologists towards telehealth and use of telehealth for the delivery of ear and hearing services pre-, during- and post- the COVID-19 pandemic, and to identify the perceived effects of telehealth on services and barriers to telehealth. Design An online survey distributed through the International Society of Audiology and member societies. Study sample A total of 337 audiologists completing the survey between 23 June and 13 August 2020. Results There was a significant increase in the perceived importance of telehealth from before (44.3%) to during COVID-19 (87.1%), and the use of telehealth previous (41.3%), current (61.9%) and expected use of telehealth (80.4%). Telehealth was considered adequate for many audiology services, although hearing assessment and device fitting by telehealth received least support. Matters related to timeliness of services and reduction of travel were reported as the main advantages, but relationships between practitioners and clients may suffer with telehealth. Important barriers were technologies related to the client or remote site; clinic-related items were moderate barriers, although more clinician training was a common theme provided through open-ended responses. Conclusion The COVID-19 pandemic has resulted in audiologists having a more positive attitude towards and greater use of telehealth, but with some reservations.
... Based on studies conducted on these topics, both patients and providers are satisfied with the consultation options provided by telemedicine [29]. Options available have been shown to positively influence the pa- tients' sense of security, health awareness, and adherence to medications in a time-saving and cost-saving manner [30]. ...
Article
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Background Asthma and chronic obstructive pulmonary diseases are conditions characterized by a variable progression. Some individuals experience longer asymptomatic periods while others acute worsening periods and/or exacerbations triggered by symptom multiplication factors. Medications are adjusted to the patients’ respiratory function, self-assessment of health and emerging certain physical changes. A more effective treatment may be applied by real-time data registered during the patient’s everyday life. Aim and methods Introducing new modern digital technology in pulmonary rehabilitation (PR) to help tracking the patients’ medication, thus we systematically reviewed the latest publications on telemedicine and pulmonary telerehabilitation. Conclusion The use of the latest digital technologies in PR is very exciting and offers great opportunities while treating patients affected by specific conditions. On the one hand, adherence to medication can be improved in patients with chronic respiratory diseases by using these new state of the art devices; on the other hand, digital devices will also be able to monitor various physiological parameters of patients during their usual everyday activities. Data can be stored on a smartphone and shared with the provider. Relying on this information, physicians will be able to tailor medications and dosage to the specific needs of individual patients. Telerehabilitation may be a sustainable solution to the growing burden of chronic respiratory disease worldwide. However, PR must keep its cornerstones, such as education and motivations, which are most successful when conducted in person. Many issues remain to be resolved in the future, e.g. cybersecurity while using smart devices since they offer unique opportunities for PR.
... For clinicians, the benefits in terms of reduced time and travel are especially noticeable when care is normally provided through outreach services (Snoswell et al., 2019b;Tousignant et al., 2015). Additional benefits are increased service efficiencies (Azarmina and Wallace, 2005;Bauer et al., 2019), possible waitlist reduction and avoidance of unnecessary referrals (Caffery et al., 2016;Snoswell et al., 2016). The use of telehealth may also contribute to more culturally appropriate care (Snoswell et al., 2019b;Caffery et al., 2018) with improved social and emotional well-being for patients (Caffery et al., 2017). ...
Purpose This study aims to determine elements of telehealth that have the potential to increase costs for the health system in the short to medium term. Design/methodology/approach A search of PubMed, EMBASE and Scopus databases was performed in May 2018 using broad terms for telehealth and economics. Articles were included if they identified and explained reasons for an increase in cost for telehealth services. Studies were categorised by economic analysis type for data extraction and descriptive synthesis. Findings Fourteen studies met inclusion criteria and were included in the review. These studies identified that increased health system costs were due to implementation costs (e.g. for equipment, software or staff training), increased use of other healthcare services (e.g. pharmaceutical services) and ongoing service costs (including staff salaries) resulting from telehealth being additive to traditional service (e.g. increased frequency of contact). Originality/value Telehealth is often assumed to be a cost-effective method of delivering healthcare, even to the point where direct cost savings are expected by decision makers as a result of implementation. However, this investigation suggests it does not routinely reduce costs for the health system and can actually increase costs at both implementation and ongoing service delivery stages. Health services considering implementing telehealth should be motivated by benefits other than cost reduction such as improved accessibility, greater patient centricity and societal cost–benefit.
... A specific reference search for articles contained within relevant systematic reviews was also conducted to augment search inclusiveness, resulting in 117 additional articles, including 2 articles from 1994 that are the earliest explicit use of teleotolaryngology. [7][8][9][10][11] Exclusion criteria included inability to locate or access full-length text, a lack of specific reference to clinical otolaryngology practice, a primary objective or focus not related to telehealth and telemedicine, nonprimary or review-based literature, oral presentations or poster sessions, and journal correspondence or editorial pieces without extractable material. ...
Article
Objective The COVID-19 pandemic has spurred widespread adoption and advancement in telehealth activities, representing a marked change in otolaryngology practice patterns. The present study undertakes a scoping review of research focused on telehealth in otolaryngology (teleotolaryngology) to identify key themes and commonly utilized outcome measures that will assist future development in this growing field. Data Sources PubMed, Embase, and Cochrane databases and reference review. Review Methods Per guidelines of the PRISMA Extension for Scoping Reviews, we performed database queries using a comprehensive search strategy developed in collaboration with research librarians at the Columbia University Irving Medical Center. We identified 596 unique references to undergo title and abstract review by 2 independent reviewers, leaving 439 studies for full-text review. Results We included 285 studies for extraction of notable findings, leaving 262 unique studies after accounting for content overlap. We identified core outcome measures, including patient and provider satisfaction, costs and benefits, quality of care, feasibility, and access to care. Publication volume increased markedly over time, though only 4% of studies incorporated randomized study group assignment. Using an iterative approach to thematic development, we organized article content across 5 main themes: (1) exploration of teleotolaryngology evolution, (2) role in virtual clinical encounters, (3) applications in interdisciplinary care and educational initiatives, (4) emerging and innovative technologies, and (5) barriers to implementation. Conclusion This scoping review of teleotolaryngology documents its evolution and identifies current use cases, limitations, and emerging applications, providing a foundation from which to build future studies, inform policy decision making, and facilitate implementation where appropriate.
... 7 Before the pandemic, investigators have found a varying degree of success in telehealth initiatives, including substantial differences in the effective uptake between alternate clinical specialities. 8 Empirical evidence during the pandemic provides a generally positive assessment of their use, with examples from ophthalmology 9 and orthopaedics. 10 However, few studies so far have utilised data from multiple sources, and this may limit the depth of any resulting insight. ...
Article
In response to societal restrictions due to the COVID‐19 pandemic, a significant proportion of physical outpatient consultations were replaced with virtual appointments within the Bristol, North Somerset and South Gloucestershire healthcare system. The objective of this study was to assess the impact of this change in informing the potential viability of a longer‐term shift to telehealth in the outpatient setting. A retrospective analysis was performed using data from the first COVID‐19 wave, comprising 2998 telehealth patient surveys and 143,321 distinct outpatient contacts through both the physical and virtual medium. Four in five specialities showed no significant change in the overall number of consultations per patient during the first wave of the pandemic when telehealth services were widely implemented. Of those surveyed following virtual consultation, more respondents ‘preferred’ virtual (36.4%) than physical appointments (26.9%) with seven times as many finding them ‘less stressful’ than ‘more stressful’. In combining both patient survey and routine activity data, this study demonstrates the importance of using data from multiple sources to derive useful insight. The results support the potential for telehealth to be rapidly employed across a range of outpatient specialities without negatively affecting patient experience.
... We recently reported more than 90% cure rates in CHC using ECHO [7]. Feasibility and efficacy of telemedicine have also been demonstrated in patients with cirrhosis [8], monitoring of liver transplant recipients [9], and other systemic diseases [10][11][12][13][14][15][16]. ...
Article
Full-text available
Coronavirus disease 2019 (COVID‐19) has hampered health care delivery globally. We evaluated the feasibility, outcomes, and safety of telehepatology in delivering quality care amid the pandemic. A telemedicine setup using smartphones by hepatologists was organized at our tertiary‐care center after pilot testing. Consecutive patients availing telehepatology services were recruited between March and July 2020. An adapted model for assessment of telemedicine was used after validity and reliability testing, to evaluate services 7‐21 days after index teleconsultation. Of the 1,419 registrations, 1,281 (90.3%) consultations were completed. From 245 randomly surveyed patients, 210 (85.7%) responded (age [years, interquartile range]: 46 [35‐56]; 32.3% females). Seventy percent of patients belonged to the middle or lower socio‐economic class, whereas 61% were from rural areas. Modes of teleconsultation were audio (54.3%) or hybrid video call (45.7%). Teleconsultation alone was deemed suitable in 88.6% of patients. Diagnosis and compliance rates were 94% and 82.4%, respectively. Patients’ convenience rate, satisfaction rate, improvement rate, success rate, and net promoter scores were 99.0%, 85.2%, 49.5%, 46.2% and 70, respectively. Physical and mental quality of life improved in 67.1% and 82.8% of patients, respectively, following index teleconsultation. Person‐hours and money spent by patients were significantly lower with teleconsultation (P
... Several studies have been performed on the effectiveness of digital clinics. A review of the effect of telehealth interventions on waiting times for various specialties in Australia showed a 38-88% reduction for dermatology, 16-48% for ophthalmology and 89% for otorhinolaryngology [10]. Additionally, a Canadian study comparing in-person vs. telemedicine consultations for chronic pain treatment showed lower average direct patient costs and higher satisfaction levels [11]. ...
... Nankavil et al. have demonstrated remote operation of a slit lamp while acquiring high-resolution live video to and from America, Canada and the Netherlands [56]. A review of telehealth interventions found that imagebased triage was twice as effective in reducing the need for appointments when compared with non-image-based [57]. This could have a profound impact on the efficiency of workflow for ophthalmologists and considerably reduce the cost of attending hospital or office-based appointments. ...
Article
Advances in information and communication technology (ICT) are having an increasing impact on the practice of ophthalmology. Successive generations of 4G networks have provided continued improvements in bandwidth and download speeds. Fibre-optic networks were promised as the next step in the development of a faster and more reliable network. However, due to considerable delays in their widespread implementation, original expectations have not been met. Currently, the new 5G network is on the verge of widespread release and aims to offer previously unparalleled bandwidth, speed, reliability and access. This review aims to highlight the potential profound impact near instantaneous communication (the 5G network) may have on ophthalmology and the delivery of eyecare to the global population. Conversely, if the new network fails to deliver as intended, the wireless network itself may become yet another obstacle to adopting next-generation technologies in eyecare.
... The need to enhance the quality of health care services and meet patient needs has prompted the development of applications that will improve patient flow and experience and cut back the cycle time during hospital visits. A review of telehealth interventions reported that such interventions can render the coordination of specialist services including surgery more efficient [1]. The extent to which the apps used in health care can be effective is dictated by the experiences of care users, who inevitably must be involved in the testing of these apps. ...
... Több nemzetközi kutatás szerint az infokommunikációs eszközök nyújtotta lehetőségek hasonló orvos-beteg kommunikációt tesznek lehetővé, mint az interperszonális, közvetlen kapcsolattartás (Seuren et al., 2020). Pozitív visszajelzésekről számolnak be a kutatások e téren mind a betegek, mind pedig az orvosok részéről (Vimalalanda et al., 2015;Caffery -Farjian -Smith, 2016). ...
Article
A Covid19 járvány az orvosi és egészségügyi kommunikációban a személyes interakciók számának drasztikus csökkenését eredményezte. Bizonyossá vált, hogy hosszútávon számolni kell az online egészségügyi tevékenységek, az online konzultációk előtérbe kerülésével, a telemedicina nagymértékű térhódításával. A sikeres orvos–beteg kommunikáció rendkívül fontos a gyógyítás folyamatában, erre fel kell készíteni a leendő orvostanhallgatókat. Ennek hatékony módja a szimulációs kommunikációoktatás színész-páciensekkel, amelyhez a szimulációs laborok biztosítanak autentikus helyszínt. A Covid19 járvány hatására az orvosi és egészségügyi kommunikáció számos formájának online térbe kerülése és az online oktatás bevezetése új megvilágításba helyezi a feldolgozandó interakciókat és a szimulációs kommunikáció módszerét. A PTE ÁOK-n 2016 óta működik sikeresen a szimulációs orvosi kommunikációs képzés hivatásos színészek segítségével. A járvány megfékezését célzó korlátozó intézkedések következtében az oktatás 2020. márciusától elektronikus távoktatás formájában folytatódott. A szimulációs orvosi kommunikációs képzés platformja a Microsoft Teams lett, így a képzés tematikájának és módszerének online átalakítására került sor. A tanulmány célja a nemzetközi tapasztalatok és a szerzők saját tapasztalatának bemutatása a személyes jelenléten alapuló és az online szimulációs gyakorlatok összehasonlításával. A hallgatók visszajelzései és a felvételek értékelése alapján elmondható, hogy a szimulációs gyakorlatok online formában is sikeresek voltak és biztosítani tudták az orvostanhallgatók kommunikatív kompetenciáinak a fejlesztését a telemedicina nyújtotta lehetőségekkel.
... These methods have been highly effective in high-income countries [4][5][6] and their use and effectiveness in LMIC has been seen across diverse settings and MH conditions [7][8][9][10][11][12]. There are numerous advantages to tele-MH solutions, including reduced travel, wait times and costs, and improved access to services [13][14][15][16], especially in understaffed, remote, or insecure areas. In some cases, they are considered an enabling and empowering form of service delivery and have increased patient and caregiver satisfaction rates [17,18]. ...
Article
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Background ‘Tele-Mental Health (MH) services,’ are an increasingly important way to expand care to underserved groups in low-resource settings. In order to continue providing psychiatric, psychotherapeutic and counselling care during COVID-19-related movement restrictions, Médecins Sans Frontières (MSF), a humanitarian medical organization, abruptly transitioned part of its MH activities across humanitarian and resource-constrained settings to remote format. Methods From June–July of 2020, investigators used a mixed method, sequential explanatory study design to assess MSF staff perceptions of tele-MH services. Preliminary quantitative results influenced qualitative question guide design. Eighty-one quantitative online questionnaires were collected and a subset of 13 qualitative follow-up in-depth interviews occurred. Results Respondents in 44 countries (6 geographic regions), mostly from Sub-Saharan Africa (39.5%), the Middle East and North Africa (18.5%) and Asia (13.6%) participated. Most tele-MH interventions depended on audio-only platforms (80%). 30% of respondents reported that more than half of their patients were unreachable using these interventions, usually because of poor network coverage (73.8%), a lack of communication devices (72.1%), or a lack of a private space at home (67.2%). Nearly half (47.5%) of respondents felt their staff had a decreased ability to provide comprehensive MH care using telecommunication platforms. Most respondents thought MH staff had a negative (46%) or mixed (42%) impression of remote care. Nevertheless, almost all respondents (96.7%) thought tele-MH services had some degree of usefulness, notably improved access to care (37.7%) and time efficiency (32.8%). Qualitative results outlined a myriad of challenges, notably in establishing therapeutic alliance, providing care for vulnerable populations and those inherent to the communications infrastructure. Conclusion Tele-MH services were perceived to be a feasible alternative solution to in-person therapeutic interventions in humanitarian settings during the COVID-19 pandemic. However, they were not considered suitable for all patients in the contexts studied, especially survivors of sexual or interpersonal violence, pediatric and geriatric cases, and patients with severe MH conditions. Audio-only technologies that lacked non-verbal cues were particularly challenging and made risk assessment and emergency care more difficult. Prior to considering tele-MH services, communications infrastructure should be assessed, and comprehensive, context-specific protocols should be developed.
... The relative effectiveness of telemedicine, as compared to in-person consultations, remains a subject of study. A scoping review of the use of telemedicine was inconclusive about the relative effectiveness of electronic and face-to-face consultations (Caffery et al., 2016;Roine et al., 2001). On the one hand, replacing traditional face-to-face patient care can potentially result in a breakdown of the traditional relationship between the health professional and the patient, leading to the potential for depersonalization of the service (Hjelm, 2005). ...
Article
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Telemedicine can expand access to health care at relatively low cost. Historically, however, demand for telemedicine has remained low. Using administrative records and a difference‐in‐differences methodology, we estimate the change in demand for telemedicine experienced after the onset of the COVID‐19 epidemic and the imposition of mobility restrictions. We find that the number of telemedicine calls made during the pandemic increased by 230 percent compared to the pre‐pandemic period. The effects were mostly driven by older individuals with preexisting conditions who used the service for internal medicine consultations. The demand for telemedicine remained relatively high even after mobility restrictions were relaxed, which is consistent with telemedicine being an “experience good.” These results are a proof of concept for policy makers to use such relatively low‐cost medical consultations, made possible by new technologies, to provide needed expansion of access to health care.
... Expanded use of telehealth can address these issues. Telehealth is reported to significantly reduce wait times for appointments in different medical specialties (4)(5)(6)(7). Published economic analyses of telehealth demonstrate cost saving from healthcare system perspective by reducing travel costs, staff wages due to shorter appointments, and reducing hospitalizations (8)(9)(10). ...
Article
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Background With the COVID-19 pandemic, the demand and availability of telehealth in outpatient care has had exponential growth. Although use of telehealth has been studied and validated for various medical specialties, relatively few studies have looked at its role in gastroenterology. Aim To assess effectiveness of telehealth medicine in gastroenterology by comparing medication adherence rate for patients seen with telehealth and traditional in-person appointment for various gastrointestinal conditions. Methods Retrospective chart review of patients seen in outpatient gastroenterology clinic was performed to identify patients who were given prescription to fill either through telehealth or in-person appointment. By using provincial pharmacy database, we determined the prescription fill rate. Results A total of 206 patients were identified who were provided new prescriptions or prescription renewal at their gastroenterology clinic visit. One hundred and three patients were seen through in-person visit during pre-pandemic period, and 103 patients were seen through telehealth appointment during COVID-19 pandemic. The mean age of patients was 49.2 years (55% female). On average, patients had 4.7 previous visits with their gastroenterologists before their visit. IBD management was the most common reason for visits (37.9% and 46.6% in telehealth and in-person groups, respectively). Prescription fill rate for patients seen through telehealth was 92.2% compared to 81.6% for the in-person group (OR: 2.69, 95% CI: 1.12–6.45; P = 0.023). Conclusions Medication adherence rate for telehealth visits was higher than for in-patient visits. These findings suggest that telehealth can be an effective method of care delivery, especially for patients with chronic gastrointestinal conditions like IBD.
... Telemedicine is defined as "the delivery of health care and the exchange of health-care information across distances" (5). Previous research supports the claim that telehealth interventions can effectively shorten waiting lists and improve the coordination of specialist services (6). ...
Article
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Background Although telemedicine care has grown in recent years, telepsychiatry is growing at a slower pace than expected, because service providers often hamper the assimilation and expansion of telepsychiatry due their attitudes and perceptions. The unified theory of acceptance and use of technology (UTAUT) is a model that was developed to assess the factors influencing the assimilation of a new technology. We used the UTAUT model to examine the associations between the attitudes and perceptions of psychiatrists in Israel toward telepsychiatry and their intention to use it. Methods An online, close-ended questionnaire based on a modified UTAUT model was distributed among psychiatrists in Israel. Seventy-six questionnaires were completed and statistically analyzed. Results The behavioral intention of Israeli psychiatrists to use telepsychiatry was relatively low, despite their perceptions of themselves as capable of high performance with low effort. Nonetheless, they were interested in using telepsychiatry voluntarily. Experience in telepsychiatry, and to a lesser extent, facilitating conditions, were found to be positively correlated with the intention to use telepsychiatry. Psychiatrists have a positive attitude toward treating patients by telepsychiatry and perceive its risk as moderate. Discussion Despite high performance expectancy, low effort expectancy, low perceived risk, largely positive attitudes, high voluntariness, and the expectancy for facilitating conditions, the intention to use telepsychiatry was rather low. This result is explained by the low level of experience, which plays a pivotal role. We recommend promoting the facilitating conditions that affect the continued use of telepsychiatry when initiating its implementation, and conclude that it is critical to create a sense of success during the initial stages of experience.
... There is mounting evidence that the individual, societal, and healthcare pressures imposed by the COVID-19 pandemic have exacerbated the burden of chronic pain and created more difficulty for individuals to manage their pain [9]. Furthermore, the pandemic has heavily played into the biopsychosocial model's influence on pain [10]. ...
Article
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Purpose of Review Chronic pain in the USA has presented with higher prevalence rates among women, older adults, those unemployed, living in poverty, living in rural environments, and adults with public health insurance. The COVID-19 pandemic has heavily played into the biopsychosocial model of pain. Consequently, greater impacts have affected patients with mood disorders, opioid abuse, and chronic pain. Concurrently, telemedicine has become a popular vehicle during the COVID-19 pandemic in continuing to provide quality patient care. The purpose of this article is to review the benefits and challenges related to the delivery of telemedicine for patients with chronic pain. Recent Findings The benefits of telemedicine have been examined from patient psychosocial and convenience factors as well in relation to medical practice efficiency. Within chronic pain management, one of telemedicine’s most effective utilization is seen via post-injection follow-up and assessment of further necessary interventions. Challenges also exist in this framework, from lack of physical examination and convenient close therapeutic monitoring and drug screening, to technological and resource cost capabilities of older and disadvantaged chronic pain patients, to barriers in establishing patient-provider rapport. During the COVID-19 pandemic, telehealth services were covered at rates comparable to in-person visits. Health insurance coverage and payment were major barriers for implementation of telemedicine prior to the pandemic. It is difficult to predict ongoing coverage and payment of telehealth services, although the benefits in terms of access and patient satisfaction have clearly been demonstrated. Summary While telemedicine has proven to be a very useful tool with a wealth of advantages, the delivery of virtual healthcare for chronic pain poses a set of challenges that will need to be met to ensure the quality and standard of care continue to be upheld.
... Telehealth use has increased within the last two decades, specifically during the COVID-19 pandemic [24]. While it was initially designed to facilitate access to the healthcare system in medical deserts, telehealth has reduced waiting times and travel times [25]. Medical student programs still lack training for telehealth practices [26], and eOSCEs might be a suitable tool to help them train for their future practice that might include telehealth. ...
Article
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The COVID-19 pandemic has led health schools to cancel many on-site training and exams. Teachers were looking for the best option to carry out online OSCEs, and Zoom was the obvious choice since many schools have used it to pursue education purposes. Methods: We conducted a feasibility study during the 2020-2021 college year divided into six pilot phases and the large-scale eOSCEs on Zoom on June 30th, 2021. We developed a specific application allowing us to mass create Zoom meetings and built an entire organization, including a technical support system (an SOS room and catching-up rooms) and teachers' training sessions. We assessed satisfaction via an online survey. Results: On June 30th, 531/794 fifth-year medical students (67%) participated in a large-scale mock exam distributed in 135 Zoom meeting rooms with the mobilization of 298 teachers who either participated in the Zoom meetings as standardized patients (N =135, 45%) or examiners (N =135, 45%) or as supervisors in the catching-up rooms (N =16, 6%) or the SOS room (N =12, 4%). In addition, 32/270 teachers (12%) experienced difficulties connecting to their Zoom meetings and sought the help of an SOS room member. Furthermore, 40/531 students (7%) were either late to their station or had technical difficulties and declared those issues online and were welcomed in one of the catching-up rooms to perform their eOSCE stations. Additionally, 518/531 students (98%) completed the entire circuit of three stations, and 225/531 students (42%) answered the online survey. Among them, 194/225 (86%) found eOSCES helpful for training and expressed their satisfaction with this experience. Conclusion: Organizing large-scale eOSCEs on Zoom is feasible with the appropriate tools. In addition, eOCSEs should be considered complementary to on-site OSCEs and to train medical students in telemedicine.
... [39][40][41][42] Similarly, telemedicine can ease referrals 39 and improve the referral process, 43 having knock-on effects that decrease congestion at referral centres. 44 In addition, telemedicine can improve local clinical care and skill levels through consultation and formal (online elearning programmes) and informal (experiential learning) education, enhancing diagnostic and case management skills. 45,46 The issue of medication shortages often has more to do with maldistribution and poor supply chain management leading to wastage, 47 and ehealth solutions may crossover between health informatics and telemedicine through national and facility focused software programs to monitor the process. ...
Article
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Objective Global efforts to implement national ehealth strategies have occurred, yet specific telemedicine implementations have fallen behind. A weakness inherent within many, perhaps most, national ehealth strategies, including Botswana's – is a lack of telemedicine focus. This is despite its potential to address many current healthcare system needs. The development of a telemedicine-specific strategy, to complement the existing ehealth strategy, has been proposed. This paper reports on an emulated process to determine prioritised health needs, identify broad solutions, consider ehealth and then telemedicine solutions, and prioritise these as insight for telemedicine-specific strategy development. Methods The eHealth Strategy Development Framework (eHSDF) was adopted and steps 5–7 were emulated. Key informants participated in telephone-based semi-structured interviews in November 2020, using a key informant interview guide. Participants were asked specific questions related to national health needs, proposed solutions, and prioritisation. The interviews were recorded and transcribed for analysis. Results Eleven key informants identified the top five perceived health issues as human resource shortages, congestion and overcrowding, prevalence of diseases, poor referral system, and lack of diagnostic and case management skills. Solutions were proposed, some of which included: Telehealth (including telemedicine), health informatics, and elearning. Telemedicine solutions included: a health professional help desk, teleconsultations, and apps for specialist referral. eLearning solutions were training, mentoring, and continuing professional development. Conclusion A telemedicine-specific strategy, addressing the identified health issues and aligned to the existing national ehealth strategy, would provide the required focus to enable the development and deployment of telemedicine activities in the country.
... Research suggests that many outpatient appointments are for inappropriate cases that could have been managed in primary care. 118 Although teledermatology has been utilised for many years, its application in reducing demand for secondary care outpatient services and diversions to established GPwSI services has not been formally explored. 119 ...
Article
Background Oral surgery referrals from dentists are rising and putting increased pressure on finite hospital resources. It has been suggested that primary care specialist services can provide care for selected patients at reduced costs and similar levels of quality and patient satisfaction. Research questions Can an electronic referral system with consultant- or peer-led triage effectively divert patients requiring oral surgery into primary care specialist settings safely, and at a reduced cost, without destabilising existing services? Design A mixed-methods, interrupted time study (ITS) with adjunct diagnostic test accuracy assessment and health economic evaluation. Setting The ITS was conducted in a geographically defined health economy with appropriate hospital services and no pre-existing referral management or primary care oral surgery service. Hospital services included a district general, a foundation trust and a dental hospital. Participants Patients, carers, general and specialist dentists, consultants (both surgical and Dental Public Health), hospital managers, commissioners and dental educators contributed to the qualitative component of the work. Referrals from primary care dental practices for oral surgery procedures over a 3-year period were utilised for the quantitative and health economic evaluation. Interventions A consultant- then practitioner-led triage system for oral surgery referrals embedded within an electronic referral system for oral surgery with an adjunct primary care service. Main outcome measures Diagnostic test accuracy metrics for sensitivity and specificity were calculated. Total referrals, numbers of referrals sent to primary care and the cost per referral are reported for the main intervention. Qualitative findings in relation to patient experience and whole-system impact are described. Results In the diagnostic test accuracy study, remote triage was found to be highly specific (mean 88.4, confidence intervals 82.6 and 92.8) but with lower values for sensitivity. The implementation of the referral system and primary care service was uneventful. During consultant triage in the active phases of the study, 45% of referrals were diverted to primary care, and when general practitioner triage was used this dropped to 43%. Only 4% of referrals were sent from specialist primary care to hospital, suggesting highly efficient triage of referrals. A significant per-referral saving of £108.23 [standard error (SE) £11.59] was seen with consultant triage, and £84.13 (SE £11.56) with practitioner triage. Cost savings varied according the differing methods of applying the national tariff. Patients reported similar levels of satisfaction for both settings, and speed of treatment was their over-riding concern. Conclusions Implementation of electronic referral management in primary care can lead, when combined with triage, to diversions of appropriate cases to primary care. Cost savings can be realised but are dependent on tariff application by hospitals, with a risk of overestimating where hospitals are using day case tariffs extensively. Study limitations The geographical footprint of the study was relatively small and, hence, the impact on services was minimal and could not be fully assessed across all three hospitals. Future work The findings suggest that the intervention should be tested in other localities and disciplines, especially those, such as dermatology, that present the opportunity to use imaging to triage. Funding The National Institute for Health Research Health Services and Delivery Research programme.
... Additionally, combining referral data across practices/regions could lead to better local, regional and provincial specialist access information for human resource planning purposes. This could complement other initiatives that may contribute to shortening specialist wait times including telehealth consults [22] (electronic asynchronous consultations obviating the need for face to face appointments between patient and specialist) and e-referral systems (i.e. province wide electronic health referral system where wait times could be viewed and referral status could be tracked), pre-assessment in specialized clinics [23] (a model of triage and appointment allocation to reduce wait times), and central intake [24] (instead of having multiple-queues and multiple-servers to manage referrals, specific specialists in a given jurisdiction would have a single queue allowing each patient to see the first available specialist) [25,26]. ...
Article
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Background More than 50% of Canadian adult patients wait longer than four weeks to see a specialist after referral from primary care. Access to accurate wait time information may help primary care physicians choose the timeliest specialist to address a patient’s specific needs. We conducted a mixed-methods study to assess if primary to specialist care wait times can be extracted from electronic medical records (EMR), analyzed the wait time information, and used focus groups and interviews to assess the potential clinical utility of the wait time information. Methods Two family practices were recruited to examine primary care physician to specialist wait times between January 2016 and December 2017, using EMR data. The primary outcome was the median wait time from physician referral to specialist appointment for each specialty service. Secondary outcomes included the physician and patient characteristics associated with wait times as well as qualitative analyses of physician interviews about the resulting wait time reports. Results Wait time data can be extracted from the primary care EMR and converted to a report format for family physicians and specialists to review. After data cleaning, there were 7141 referrals included from 4967 unique patients. The 5 most common specialties referred to were Dermatology, Gastroenterology, Ear Nose and Throat, Obstetrics and Gynecology and Urology. Half of the patients were seen by a specialist within 42 days, 75% seen within 80 days and all patients within 760 days. There were significant differences in wait times by specialty, for younger patients, and those with urgently labelled medical situations. Overall, wait time reports were perceived by clinicians to be important since they could help family physicians decide how to triage referrals and might lead to system improvements. Conclusions Wait time information from primary to specialist care can aid in decision-making around specialist referrals, identify bottlenecks, and help with system planning. This mixed method study is a starting point to review the importance of providing wait time data for both family physicians, specialists and local health systems. Future work can be directed towards developing wait time reporting functionality and evaluating if wait time information will help increase system efficiency and/or improve provider and patient satisfaction.
... (1) It had been shown to be effective, efficient and cost-effective in various specialities. (2)(3)(4)(5)(6)(7) Due to the global COVID-19 pandemic, the use of telemedicine consultations had become an integral part of practice for various medical and surgical specialties, including otolaryngology, head and neck surgery (OHNS). (8) Otolaryngologists had been particularly at risk of contracting COVID-19 due to the higher viral load in the upper aerodigestive tract, (9) therefore the use of telemedicine had been especially important to enable ongoing safe patient care while minimising risk to clinicians. ...
Preprint
Background The use of telehealth during the COVID-19 pandemic has emerged as both a necessary and significant tool in the provision of safe and timely healthcare in the field of otolaryngology. Increased access to specialist care in a regional setting is an additional benefit. Variation in diagnostic accuracy of telehealth consultations may affect diagnosis and management. Therefore, our aim is to determine the diagnostic accuracy of telemedicine for otolaryngology in an Australian regional setting. Methods Retrospective review was conducted for all patients who received an initial telemedicine appointment over a 7 month period during the COVID-19 pandemic in regional Victoria, Australia. Data was collected regarding initial diagnosis and management from telemedicine consultations, subsequent physical appointment findings and management and intraoperative findings. Statistical analysis was performed using Prism (version 8.0, GraphPad). Results Two hundred and fifty-nine patients were included. The most common conditions referred were for consideration of tonsillectomy with or without adenoidectomy (44.0%). Overall diagnostic accuracy of the initial referrer was 63.3% and for telephone appointments it was 81.9%. Concordance of recommended treatment plans between telephone and physical appointments was 96.9%. Conclusion There are significant benefits of phone only telemedicine within the context of a global pandemic which were compounded by a regional setting. Paediatric patients were found to be of highest benefit for telemedicine with high diagnostic accuracy and concordance of treatment plans.
... [7][8][9] Different class councils of healthcare professional categories have already adopted initiatives for the use of Although still controversial, 11 there is evidence that the use of telemarketing can bring benefits, such as a reduction in travel costs for patients and health professionals, as well as improvements in the quality of care, by expediting access to health professionals. [12][13][14][15][16] The science and practice of physical therapy have grown rapidly in recent years and there has never been a better time than now to provide a quick solution, with adequate, accessible, patient-friendly, and innovative technolog. 17,18 The available technology provides physical therapists new ways of delivering efficacious treatments and ensuring continuity of care for patients as well as business continuity for professionals during this period. ...
Article
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Introduction: On March 11, 2020, Covid-19 was characterized by the World Health Organization as a pandemic. In this context, different health professional councils have adopted initiatives to use communication technologies to provide services at a distance. Specifically, for physiotherapy, the Federal Council of Physiotherapy and Occupational Therapy (COFFITO) made possible the modalities of teleconsultation, teleconsulting, and telemonitoring. Objective: This study aimed to develop guidelines for physiotherapists who provide teleservices, which will help ensure the safety and quality of their professional practice during the COVID-19 pandemic. Methods: An integrative literature review was conducted through PubMed (National Library of Medicine), Cochrane Library, Higher Education Personnel Improvement Coordination Portal - CAPES, Virtual Health Library, Google Scholar, and personal experience within the team to develop guidelines for remote physical therapy during the COVID-19 pandemic. Results: Initially, 3,298 articles were selected from all cited search bases, scaled to 2,031 after exclusion due to repetition, 78 were in compliance with the proposed study, 73 of which were excluded for not answering the guiding question; therefore, 5 articles were accepted for the final analysis and used for the elaboration of the guidelines. Conclusion: The results provide an overview of the literature and guidelines for physiotherapists to implement physiotherapy teleconsultation, as well as some of the challenges that need to be considered.
Article
With unprecedented access to the internet and media devices, a cultural shift in healthcare practice and research is already underway. Social media has transformed the way we communicate and has found applications in healthcare research from data sharing to study recruitment. Wearables and personal health monitoring platforms have become increasingly widespread in the past decade allowing for novel studies with remote clinical monitoring and data collection. Furthermore, artificial intelligence has evolved with the advent of machine learning to exponentially improve prediction algorithms and become a powerful tool for clinical decision making and research. These technologies offer unprecedented opportunities to advance clinical research, while empowering patients to be active participants. As these digital tools evolve, our understanding of their advantages and pitfalls will help us optimize their use while ensuring ethical practices and most importantly, patient safety.
Article
Hospital congestion, delayed discharge, and bypassing primary care facilities are challenges facing the Iranian health‐care sector. We conducted a case study at the Sheikh al‐Rais Specialty Clinic, Tabriz, Iran, to find plausible, practical policy options for designing and implementing a referral system to reduce and regulate referral volumes to this clinic. We first reviewed the evidence on existing options of hospital congestion and unnecessary referral reduction by conducting a scoping literature review and then supplemented the findings with 18 semistructured interviews. We examined the perspectives of service users and experts in the field. Six practical policy options were identified: institutionalization of the referral system and family physician program, reinforcing gatekeeping system, use of telemedicine, utilization of educational algorithms, implementation of electronic health records, and establishing specialized clinics in different city areas. Local context adaptation, ensuring the availability of resources, political support, and feasibility are critical factors for successful policy implementation. 伊朗医疗部门面临的挑战包括医院拥挤、出院延迟和绕过初级保健设施。我们在伊朗大不里士的Sheikh al‐Rais专科诊所进行了一项案例研究,以寻找合理且实用的政策选项,用于设计和实施转诊系统,进而减少和调节该诊所的转诊量。我们首先使用范围综述,审视了关于医院拥挤和减少不必要转诊的现有选项,随后通过18次半结构化访谈补充了研究结果。我们分析了该领域的服务用户和专家的观点。确定了六个实用的政策选项:转诊系统和家庭医生计划的制度化、加强把关系统、使用远程医疗、使用教育算法、实施电子医疗记录、以及在不同城市地区建立专科诊所。适应地方情境、确保资源的可用性、政治支持、以及可行性是政策实施取得成功的关键因素。 La congestión hospitalaria, el retraso en el alta y eludir los centros de atención primaria son desafíos que enfrenta el sector de la atención médica iraní. Realizamos un estudio de caso en la Clínica de Especialidades Sheikh al‐Rais, Tabriz, Irán, para encontrar opciones de políticas prácticas y plausibles sobre el diseño e implementación de un sistema de derivación para reducir y regular los volúmenes de derivación a esta clínica. Primero revisamos la evidencia sobre las opciones existentes de congestión hospitalaria y reducción de referencias innecesarias mediante la realización de una revisión de la literatura de alcance y luego complementamos los hallazgos con 18 entrevistas semiestructuradas. Examinamos las perspectivas de los usuarios del servicio y los expertos en el campo. Se identificaron seis opciones prácticas de política: institucionalización del sistema de referencia y el programa de médicos de familia, refuerzo del sistema de vigilancia, uso de telemedicina, utilización de algoritmos educativos, implementación de registros de salud electrónicos y establecimiento de clínicas especializadas en diferentes áreas de la ciudad. La adaptación al contexto local, asegurando la disponibilidad de recursos, el apoyo político y la viabilidad son factores críticos para la implementación exitosa de políticas. Improving documentation using electronic health records, integrating electronic ‎health records with referral systems, controlling and reducing the demand for unnecessary ‎referrals through screening mechanisms, and the ability to refer patients to the most appropriate ‎level of referral are crucial. The workload in (sub‐) specialized university clinics can be reduced by ‎implementing the proposed policy options. Establishing an electronic health record system is pivotal in providing advanced and qualified health‐care services. Improving documentation using electronic health records, integrating electronic ‎health records with referral systems, controlling and reducing the demand for unnecessary ‎referrals through screening mechanisms, and the ability to refer patients to the most appropriate ‎level of referral are crucial. The workload in (sub‐) specialized university clinics can be reduced by ‎implementing the proposed policy options. Establishing an electronic health record system is pivotal in providing advanced and qualified health‐care services.
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The purpose of the paper is to systematically review the literature of enablers and challenges for implementation and adoption e-health service. The review aims to identify the most critical success factors and barriers related with the development and growth of the e-health services under different circumstances. A total 68 relevant publications related to enablers and challenges of e-health services were selected from a total 694 research papers. These publications were thoroughly reviewed to find out the critical factors influencing the e-health services. The findings indicate that there are five broad factors viz. technological, environmental, organizational, social and economical along with four major stakeholders’ viz. citizens, patients, caregivers and service providers which influence the e-health services. These factors act as enablers as well as challenges for proper implementation and adoption of e-health services in different situations. On the basis of the findings of the review, a conceptual diamond model of e-health services adoption has been proposed.
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Resumen Introducción La pandemia COVID-19 ha provocado un inusitado impulso a la telemedicina (TM). Analizamos el impacto de la pandemia en la TM aplicada en las consultas de cefaleas españolas, revisamos la literatura y lanzamos unas recomendaciones para implantar la TM en las consultas. Método Tres fases: 1) Revisión de la base Medline desde el año 1958 (primera experiencia de TM); 2) Formulario Google Forms enviado a todos los neurólogos del Grupo de Estudio de Cefaleas de la Sociedad Española de Neurología (GECSEN), y 3) Consenso on-line de expertos GECSEN para emitir recomendaciones para implantar la TM en España. Resultados La pandemia por COVID-19 ha empeorado los tiempos de espera presenciales, incrementando el uso de todas las modalidades de TM antes y después de abril de 2020: teléfono fijo (del 75% al 97%), teléfono móvil (del 9% al 27%), correo electrónico (del 30% al 36%) y videoconsulta (del 3% al 21%). Los neurólogos son conscientes de la necesidad de ampliar la oferta con videoconsultas, claramente in crescendo, y otras herramientas de e-health y m-health. Conclusiones Desde el GECSEN recomendamos y animamos a todos los neurólogos que asisten a pacientes con cefaleas a implantar recursos de TM, teniendo como objetivo óptimo la videoconsulta en menores de 60-65 años y la llamada telefónica en mayores, si bien cada caso debe individualizarse. Se deberá contar previamente con la aprobación y asesoramiento de los servicios jurídicos e informáticos y de la dirección del centro. La mayoría de los pacientes con cefalea y/o neuralgia estable son candidatos a seguimiento mediante TM, tras una primera visita que tiene que ser siempre presencial.
Article
Background: The COVID-19 pandemic has necessitated alterations in provision of health care and how patients access it. Telehealth has replaced traditional face-to-face outpatient clinics in an unprecedented manner. This study aimed to assess overall patient and clinician satisfaction with telehealth consultations, to establish acceptability of telehealth during pandemic and non-pandemic times, and document feedback. Materials and methods: A prospective observational study involving women presenting to a general gynaecology outpatient department was performed. Women who attended for consultation between 13 July and 4 September 2020 were invited to participate in a questionnaire following their telehealth appointment. Clinicians consulting in the outpatient department were invited to complete a questionnaire at the end of the eight-week study period. Satisfaction, utility and acceptability data were obtained using visual analogue scales (VAS). Results: Twenty-six out of 56 (46.4%) clinicians and 124/870 (14.3%) patients completed the questionnaire. Patients who responded were older and more likely to have been born in Australia than women who did not (P = 0.0355 and P = 0.005, respectively). Overall patient satisfaction with telehealth was high (median VAS (interquartile range), 8.6 (5.6-9.8)). More women found telehealth to be acceptable during a pandemic than afterward (8.9 vs 6.6, P < 0.0001). Clinicians were less satisfied with telehealth than patients (7.1 vs 8.6, P = 0.02); however, most would be happy to continue using telehealth in non-pandemic times (7.0 (6.2-9.8)). Conclusion: Telehealth consultations allow provision of gynaecological care at a time when reducing risk of infection to patients and staff is paramount. Telehealth gynaecology consultations are efficient and convenient without significant detriment to patient or clinician satisfaction.
Article
Background: The use of telehealth during the COVID-19 pandemic has emerged as both a necessary and significant tool in the provision of safe and timely healthcare in the field of otolaryngology. Increased access to specialist care in a regional setting is an additional benefit. Variation in diagnostic accuracy of telehealth consultations may affect diagnosis and management. Therefore, our aim is to determine the diagnostic concordance of telemedicine for otolaryngology in an Australian regional setting with physical consultations. Methods: Retrospective review was conducted for all patients who received an initial telemedicine appointment over a 7-month period during the COVID-19 pandemic in regional Victoria, Australia. Data were collected regarding initial diagnosis and management from telemedicine consultations, subsequent physical appointment findings and management and intraoperative findings. Statistical analysis was performed using Prism (version 8.0, GraphPad). Results: Two hundred and fifty-nine patients were included. The most common conditions referred were for consideration of tonsillectomy with or without adenoidectomy (44.0%). Overall diagnostic concordance of the initial referrer was 63.3% and for telephone appointments, it was 81.9%. Concordance of recommended treatment plans between telephone and physical appointments was 96.9%. Conclusion: Although physical appointments are an essential aspect of practice in OHNS, there are significant benefits of phone only telemedicine within the context of a global pandemic which were compounded by a regional setting. Paediatric patients were found to have the highest concordance of diagnosis and treatment plans.
Article
Background Waiting time can considerably increase the cost to both the clinic and the patient and be a major predictor of the satisfaction of eye care users. Efficient management of waiting time remains as a challenge in hospitals. Waiting time management will become even more crucial in the postpandemic era. A key consideration when improving waiting time is the involvement of eye care users. This study aimed at improving patient waiting time and satisfaction through the use of Plan-Do-Study-Act (PDSA) quality improvement cycles. Objective The objectives of this study were to determine the waiting time and patient satisfaction, measure the association between waiting time and patient satisfaction, and determine the effectiveness of the PDSA model in improving waiting time and satisfaction. Methods This was a pre-post quality improvement study among patients aged 19 to 80 years, who are consulting with the Magrabi International Council of Ophthalmology Cameroon Eye Institute. We used PDSA cycles to conduct improvement audits of waiting time and satisfaction over 6 weeks. A data collection app known as Open Data Kit (Get ODK Inc) was used for real-time tracking of waiting, service, and idling times at each service point. Participants were also asked whether they were satisfied with the waiting time at the point of exit. Data from 51% (25/49) preintervention participants and 49% (24/49) postintervention participants were analyzed using Stata 14 at .05 significance level. An unpaired 2-tailed t test was used to assess the statistical significance of the observed differences in times before and after the intervention. Logistic regression was used to examine the association between satisfaction and waiting time. Results In total, 49 participants were recruited with mean age of 49 (SD 15.7) years. The preintervention mean waiting, service, and idling times were 450 (SD 96.6), 112 (SD 47), and 338 (SD 98.1) minutes, respectively. There was no significant association between patient waiting time and satisfaction (odds ratio 1, 95% CI 0.99-1; P=.37; χ23=0.4). The use of PDSA led to 15% (66 minutes/450 minutes) improvement in waiting time (t47=2; P=.05) and nonsignificant increase in patient satisfaction from 32% (8/25) to 33% (8/24; z=0.1; P=.92). Conclusions Use of PDSA led to a borderline statistically significant reduction of 66 minutes in waiting time over 6 weeks and an insignificant improvement in satisfaction, suggesting that quality improvement efforts at the clinic have to be made over a considerable period to be able to produce significant changes. The study provides a good basis for standardizing the cycle (consultation) time at the clinic. We recommend shortening the patient pathway and implementing other measures including a phasic appointment system, automated patient time monitoring, robust ticketing, patient pathway supervision, standard triaging, task shifting, physician consultation planning, patient education, and additional registration staff.
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“Continuity of Care” is the main prerequisite for the unhindered movement of people across borders within the European Union (EU). The COntinuity of care in MEtabolic diseases through modern TECHnology (COMETECH) project aims to address the problem of inadequate access to health system services to people who live in isolated communities in Greece and North Macedonia cross-border areas. As the project is almost completed, 4 e-health units—2 in each country—have been established in isolated and deprived communities, aiming at introducing “Continuity of Care” for patients with diabetes in the border region between those countries. The establishment of the e-health units allows affordable access to medical services within Greece-North Macedonia cross-border area. These units (equipped with state-of-the-art medical devices, supported by an advanced software application and medical staff) record data of local people and offer valuable and high-quality medical care services. The records of the EU citizens using the COMETECH services are safely and easily accessible by their physicians. This paper presents the user requirements of e-health units and the medical devices that are set up for the COMETECH Project for helping people with diabetes in the targeted countries.
Article
Introduction/objectivesThis study aims to assess the patients’ ability and willingness to utilize telemedicine (TM) along with identifying some of the barriers to a more widespread adoption of TM in rheumatology.Methods An observational, cross-sectional study of patients visiting a rheumatology clinic was conducted in 2018. We used a survey to assess patients’ attitude on the perceived effectiveness when comparing TM versus in-person visits, as well as patients’ access to technology, distance traveled by the patient to attend the clinic visit, and demographic parameters.ResultsA total of 214 patients were included. Negative correlations were found between the increase in age and access to technologies (front-facing camera (mean age difference − 12.8), telephone (mean age difference − 14.4), and stable internet connection (mean age difference − 15.1)), as well as believing that their needs could be met through TM (r − .224, p < 0.001) and thinking that TM could be an appropriate alternative method of healthcare (r − .298, p < 0.001). Younger patients reported more conflict between appointments and work hours (mean age difference − 11.73). Follow-up patients were more likely to feel that their visit could have been possible over the phone (mean difference − 1.13) or video conferencing (mean difference − 1.13) compared to new patients. Older patients were less likely to think that the purpose of their rheumatology visits could be achieved over the phone (r − .207, p = 0.003) or video conferencing (r − .331, p = 0.001). The further the distance traveled, the more the patients were willing to utilize TM compared to in-person visits (r 0.167, p = 0.019).Conclusion Out of necessity due to the COVID-19 pandemic, rheumatology clinics are increasingly turning to TM. The results of this study suggest that access and familiarity with technology may still be limited in certain demographics, particularly the elderly. Furthermore, this study helps to understand some of the additional barriers to more widespread adoption and patients’ perceived limitations of TM. Key Points • This study aimed to assess rheumatology patients’ willingness to utilize telemedicine (TM) while determining the factors and barriers that may exist for a more widespread adoption of TM, using a cross-sectional survey in the setting of a rheumatologic clinic. • The age of the patient was the most significant contributing factor in a patient’s perception of TM, with older patients being less likely to think that the purpose of their rheumatology visits could be achieved over the phone or via videoconferencing. • The social trend of limited access to technology among the elderly population was reinforced by the results in this study. • Patients who had a greater commute to the clinic were more likely to willing to utilize TM consultations. • The results of this study highlight the elevated difficulty elderly patient populations have in utilizing TM. • With the current outbreak of COVID-19, the importance of utilizing TM specifically among the elderly population could prove vital. Future studies to focus on the elderly population and methods for helping these patients become familiar with TM would be beneficial. • Studies such as this can help to orchestrate future guidelines for TM in the field of rheumatology. Based on our study results, the new-patient encounter should be an in-person face-to-face encounter whenever possible, followed by TM visits for established patients who are able and open to using it, depending on the diagnosis and symptoms of the individual patients.
Article
Introduction This study aimed to determine whether teleretinal screening for hydroxychloroquine retinopathy (HCQR) improves clinical efficiency and adherence to recommended screening guidelines compared to face-to-face screening among patients in a large safety net medical system. Methods In this retrospective cohort study of a consecutive sample of 590 adult patients with active HCQ prescriptions seen in the outpatient ophthalmology clinic at Los Angeles County + University of Southern California Medical Center from 1 September 2018 to 25 November 2019, 203 patients underwent technician-only tele-HCQR screening (THRS), and 387 patients underwent screening with traditional face-to-face visits (F2FV) with an eye-care provider. Data on clinic efficiency measures (appointment wait time and encounter duration) and adherence to recommended screening guidelines were collected and compared between the two cohorts. Results Compared to F2FV, the THRS cohort experienced significantly shorter median (interquartile range) time to appointment (2.5 (1.5–4.6) vs. 5.1 (2.9–8.4) months; p < 0.0001), shorter median encounter duration (1 (0.8–1.4) vs. 3.7 (2.5–5.2) hours; p < 0.0001) and higher proportion of complete baseline screening (102/104 (98.1%) vs. 68/141 (48.2%); p < 0.001) and complete chronic screening (98/99 (99%) vs. 144/246 (58.5%); p < 0.001). Discussion A pilot THRS protocol was successfully implemented at a major safety net eye clinic in Los Angeles County, resulting in a 50.9% reduction in wait times for screening, 72.9% reduction in encounter duration and 49.9% and 40.5% increases in proportions of complete baseline and chronic screening, respectively. Tele-HCQ retinal screening protocols may improve timeliness to care and screening adherence for HCQR in the safety net setting.
Article
Objectives As telemedicine has become increasingly utilized during the COVID-19 pandemic, portable otoendoscopy offers a method to perform an ear examination at home. The objective of this pilot study was to assess the quality of otoendoscopic images obtained by non-medical individuals and to determine the effect of a simple training protocol on image quality. Methods Non-medical participants were recruited and asked to capture images of the tympanic membrane before and after completion of a training module, as well as complete a survey about their experience using the otoendoscope. Images were de-identified, randomized, and evaluated by 6 otolaryngologists who were blinded as to whether training had been performed prior to the image capture. Images were rated using a 5-point Likert scale. Results Completion of a training module resulted in a significantly higher percentage of tympanic membrane visible on otoendoscopic images, as well as increased physician confidence in identifying middle ear effusion/infection, cholesteatoma, and deferring an in-person otoscopy ( P < .0001). However, even with improved image quality, in most cases, physicians reported that they would not feel comfortable using the images to for diagnosis or to defer an in-person examination. Most participants reported that the otoendoscope was simple to use and that they would feel comfortable paying for the device. Conclusions At-home otoendoscopes can offer a sufficient view of the tympanic membrane in select cases. The use of a simple training tool can significantly improve image quality, though often not enough to replace an in-person otoscopic exam.
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The information technology has made health care providers to offer online/virtual consultation to the users/patients or a follow up about his/her health conditions from their respective homes itself. Online/virtual medical consultation is drawing attention of many and is increasingly becoming very popular as a powerful tool to offer a potential solution to health care services. It enables patients to share, transfer, and communicate data or information in real time with the physician/doctor at a clinical site. With the empowered patients, increased demands on health care and demand by patients for Internet-based services this paper examines the adoption of online/virtual consultation by the patients in the health care context. Further, it makes an attempt to understand the factors responsible to choose online consultation by patients and examines the satisfaction of the users/patients through e-consultation. Finally, this study tries to identify the strategies which can be used by health care providers in order to entice users/patients towards online/virtual consultation. This study tries to provide insights in these related areas.
Article
Objectives Prior to COVID-19, levels of adoption of telehealth were low in the U.S., though they exploded during the pandemic. Following the pandemic, it will be critical to identify the characteristics that were associated with adoption of telehealth prior to the pandemic as key drivers of adoption and outside of a public health emergency. Materials and methods We examined three data sources: The American Telemedicine Association’s 2019 state telehealth analysis, the American Hospital Association’s 2018 annual survey of acute care hospitals and its Information Technology Supplement. Telehealth adoption was measured through five telehealth categories. Independent variables included seven hospital characteristics and five reimbursement policies. After bivariate comparisons, we developed a multivariable model using logistic regression to assess characteristics associated with telehealth adoption. Results Among 2923 US hospitals, 73% had at least one telehealth capability. More than half of these hospitals invested in telehealth consultation services and stroke care. Non-profit hospitals, affiliated hospitals, major teaching hospitals, and hospitals located in micropolitan areas (those with 10-50,000 people) were more likely to adopt telehealth. In contrast, hospitals that lacked electronic clinical documentation, were unaffiliated with a hospital system, or were investor-owned had lower odds of adopting telehealth. None of the statewide policies were associated with adoption of telehealth. Conclusions Telehealth policy requires major revisions soon, and we suggest that these policies should be national rather than at the state level. Further steps as incentivizing rural hospitals for adopting interoperable systems and expanding RPM billing opportunities will help drive adoption, and promote equity.
Article
Introduction As healthcare systems are adapting due to COVID-19, there has been an increased need for telehealth in the outpatient setting. Not all patients have been comfortable with this transition. We sought to determine the relationship between health literacy and technological comfort in our cancer patients. Methods We conducted a survey of patients that presented to the oncology clinics at a single-center over a 2-month period. Patients were given a voluntary, anonymous, survey during their visit containing questions regarding demographics, health literacy and technological comfort. Results 344 surveys were returned (response-rate 64.3%). The median patient age was 61 years, 70% of responders were female and the most common race was White (67.3%). Increasing patient age, male gender, Black and Native-American race, decreased health literacy and lack of home broadband were associated with lower technological comfort score. Conclusion In our cohort, patients with lower health literacy scores, older and male patients, or who have poor internet access showed a lower level of technological comfort. At risk patients can be identified and provided additional support in their use of telehealth services.
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Background ‘Digital Mental Health services,’ or mental health care delivered via internet, computers, mobile phones, tablets, or text messaging services, are an increasingly important way to expand care to underserved groups in low-resource settings. In order to continue providing psychiatric, psychotherapeutic and counselling care during COVID-19-related movement restrictions, Médecins Sans Frontières (MSF), a humanitarian medical organization, abruptly transitioned part of its mental health (MH) activities to digitally supported remote services in 2020 across humanitarian and resource-constrained settings. Methods From June-July of 2020, investigators used a mixed method, sequential explanatory study design to assess MSF staff perceptions of digital MH services provided during the COVID-19 crisis. Preliminary quantitative results influenced qualitative question guide design. Eighty-one quantitative online questionnaires were collected and a subset of 13 qualitative follow-up in-depth interviews (IDI) occurred. Results Respondents in 44 countries (6 world regions), mostly from Sub-Saharan Africa (39.5%), the Middle East (18.5%) and Asia (13.6%) participated. Most digital MH interventions depended on audio-only platforms (80%). 30% of respondents reported that more than half of their patients were unreachable using digital interventions, usually because of poor network coverage (73.8%), a lack of communication devices (72.1%), or a lack of a private space at home (67.2%). Nearly half (47.5%) of respondents felt their staff had a decreased ability to provide comprehensive MH care using digital platforms. Most respondents thought MH staff had a negative (46%) or mixed (42%) impression of remote care. Nevertheless, almost all respondents (96.7%) thought digital MH services had some degree of utility, most commonly citing improved access to care (37.7%) and greater time efficiency (32.8%) as reasons for its continued use. Conclusion Digital MH activities were seen as an acceptable alternative to in-person therapeutic interventions in humanitarian settings during the COVID-19 pandemic. However, they were not considered suitable for all patients in the humanitarian contexts studied, especially survivors of sexual or interpersonal violence, pediatric and geriatric cases, and patients with severe MH conditions. Audio-only technologies that lacked non-verbal cues were particularly challenging and made risk assessment and emergency care more difficult. Prior to considering digital MH services, communications infrastructure should be assessed, and comprehensive, context-specific protocols should be developed.
Article
Objective Practice guidelines advocating for regionalization of endometrial cancer surgery to gynecologic oncologists practicing in designated gynecologic oncology centres were published in Ontario in June 2013. Our objectives were to determine whether this policy affected surgical wait times, and whether longer wait time to surgery is a predictor of survival in high grade endometrial cancer patients. Methods This was a population-based retrospective cohort study, which included patients diagnosed with high-grade non-endometrioid endometrial cancer who had a hysterectomy between 2003 and 2017. Multivariable Cox proportional hazards regression with a spline function was used to model the relationship between surgical wait time and overall survival (OS). Results We identified 3518 patients who underwent hysterectomy for high-grade non-endometrioid endometrial cancer. Patients who had surgery with a gynecologic oncologist had a median surgical wait time from diagnosis to hysterectomy of 53 days compared to 57 days pre-regionalization (p = 0.0007), and from first gynecologic oncology consultation to hysterectomy of 29 days compared to 32 days pre-regionalization (p = 0.0006). Survival was inferior for patients who had surgery within 14 days of diagnosis (HR death 2.7 for 1–7 days, 95% CI 1.61–4.51, and HR death 1.96 for 8–14 days, 95% CI 1.50–2.57), reflective of disease severity. Decreased survival occurred with surgical wait times of more than 45 days from the patient's first gynecologic oncology appointment (HR death 1.19 for 46–60 days, 95% CI 1.04–1.36, and HR death 1.42 for 61–75 days, 95% CI 1.11–1.83). Conclusions Regionalization of surgery for high-grade endometrial cancer has not had an impact on surgical wait times. Patients who have surgery more than 45 days after surgical consultation have reduced survival.
Article
The article presents the results of a SWOT analysis of the asynchronous telerehabilitation (TR) for stroke patients. The strengths, weaknesses, opportunities and threats of asynchronous TR from the perspective of a medical organization are identified. The priorities of SWOT criteria were determined and ranked in accordance with the weight of the criterion in pairwised comparision matrices. The paper may be useful to healthcare professionals, managers of medical organizations at various levels, physicians and medical staff for medical institutions strategies development, designing and implementing stroke prevention healthcare programs and telerehabilitation of post-stroke patients.
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Purpose: Communication between specialists and primary care clinicians is suboptimal, and access to referrals is often limited, which can lead to lower quality, inefficiency, and errors. An electronic consultation (e-consultation) is an asynchronous, non-face-to-face consultation between a primary care clinician and a specialist using a secure electronic communication platform. The purpose of this study was to conduct a randomized controlled trial of e-consultations to test its efficacy and effectiveness in reducing wait times and improving access to specialty care. Methods: Primary care clinicians were randomized into a control (9 traditional) or an intervention (17 e-consultation) arm for referrals to cardiologists. Primary care clinicians were recruited from 12 practice sites in a community health center in Connecticut with mainly medically underserved patients. Two end points were analyzed with a Cox proportional hazards model where the hazard of either a visit or an e-consultation was linked to study arm, sex, race, and age. Results: Thirty-six primary care clinicians participated in the study, referring 590 patients. In total, 69% of e-consultations were resolved without a visit to a cardiologist. After adjusting for covariates, median days to a review for an electronic consultation vs a visit for control patients were 5 and 24, respectively. A review of 6-month follow-up data found fewer cardiac-related emergency department visits for the intervention group. Conclusion: E-consultation referrals improved access to and timeliness of care for an underserved population, reduced overall specialty utilization, and streamlined specialty referrals without any increase in adverse cardiovascular outcomes. e-consultations are a potential solution for improving access to specialty care.
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Background Access to specialty care remains a challenge for primary care providers and patients. Implementation of electronic referral and/or consultation (eCR) systems provides an opportunity for innovations in the delivery of specialty care. We conducted key informant interviews to identify drivers, facilitators, barriers and evaluation metrics of diverse eCR systems to inform widespread implementation of this model of specialty care delivery. Methods Interviews were conducted with leaders of 16 diverse health care delivery organizations between January 2013 and April 2014. A limited snowball sampling approach was used for recruitment. Content analysis was used to examine key informant interview transcripts. Results Electronic referral systems, which provide referral management and triage by specialists, were developed to enhance tracking and operational efficiency. Electronic consultation systems, which encourage bi-directional communication between primary care and specialist providers facilitating longitudinal virtual co-management, were developed to improve access to specialty expertise. Integrated eCR systems leverage both functionalities to enhance the delivery of coordinated, specialty care at the population level. Elements of successful eCR system implementation included executive and clinician leadership, established funding models for specialist clinician reimbursement, and a commitment to optimizing clinician workflows. Conclusions eCR systems have great potential to streamline access to and enhance the coordination of specialty care delivery. While different eCR models help solve different organizational challenges, all require institutional investments for successful implementation, such as funding for program management, leadership and clinician incentives. Electronic supplementary material The online version of this article (doi:10.1186/s12913-015-1233-1) contains supplementary material, which is available to authorized users.
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Introduction: This article presents the scientific evidence for the merit of telemedicine interventions in the diagnosis and management of skin disorders (teledermatology) in the published literature. The impetus for this work derives from the high prevalence of skin disorders, the high cost, the limited availability of dermatologists in certain areas, and the promise of teledermatology to address unmet needs in this area. Materials and methods: The findings are based on a targeted review of scientific studies published from January 2005 through April 2015. The initial search yielded some 5,020 articles in Google Scholar and 428 in PubMed. A review of the abstracts yielded 71 publications that met the inclusion criteria for this analysis. Evidence is organized according to the following: feasibility and acceptance; intermediate outcomes (use of service, compliance, and diagnostic and treatment concordance and accuracy); outcomes (health improvement and problem resolution); and cost savings. A special section is devoted to studies conducted at the Veterans Health Administration. Results: Definitions of teledermatology varied across a wide spectrum of skin disorders, technologies, diagnostic tools, provider types, settings, and patient populations. Outcome measures included diagnostic concordance, treatment plans, and health. Conclusions: Despite these complexities, sufficient evidence was observed consistently supporting the effectiveness of teledermatology in improving accessibility to specialty care, diagnostic and treatment concordance, and skin care provided by primary care physicians, while also reducing cost. One study reported suboptimal clinical results from teledermatology for patients with pigmented skin lesions. On the other hand, confocal microscopy and advanced dermoscopy improved diagnostic accuracy, especially when rendered by experienced teledermatologists.
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Management of chronic disease often requires multidisciplinary clinical efforts and specialist care. With the emergence of Accountable Care Organizations (ACOs), health care systems are incentivized to evaluate methods of information exchange between generalists and specialists in order to provide value while preserving quality. Our objective was to evaluate patient and referring provider satisfaction and outcomes of asynchronous electronic consultations in vascular care in a large tertiary academic medical center. Referring providers were offered a vascular 'e-consult' option through an electronic referral management system. We conducted chart review to understand the downstream effects and surveyed patients and referring providers to assess satisfaction. From 24 March 2014 to 1 March 2015, 54 e-consults were completed. Additional testing and recommendations were made in 49/54 (90.7%) e-consults, including lower-extremity venous duplex ultrasonography with reflux testing, duplex ultrasonography of the carotid artery, computed tomography, magnetic resonance imaging, non-invasive physiology arterial studies, laboratory tests, medications, compression stockings, and sequential lymphedema compression therapy. Referring providers were compliant with recommendations in 40/49 (81.6%) of e-consults. A total of 17/54 (31.5%) patients were surveyed with a median patient satisfaction score of 13.7/15 (91.3%) (SD ± 6.4). The program was associated with high referring provider satisfaction, with 87.0% finding the e-consult very helpful and 80.0% stating it averted the need for a traditional visit. Our experience suggests that e-consults are an effective way to provide vascular care in some patients and are associated with high patient and provider satisfaction. E-consults may therefore be an efficient method of care delivery for vascular patients within an ACO.
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Background: We define electronic consultations (‘‘e-consults’’) as asynchronous, consultative, provider-to-provider communications within a shared electronic health record (EHR) or web-based platform. E-consults are intended to improve access to specialty expertise for patients and providers without the need for a face-to-face visit. Our goal was to systematically review and summarize the literature describing the use and effects of e-consults. Methods: We searched PubMed, EMBASE, the Cochrane Library, and CINAHL for studies related to e-consults published between 1990 through December 2014. Three reviewers identified empirical studies and system descriptions, including articles on systems that used a shared EHR or web-based platform, connected providers in the same health system, were used for two-way provider communication, and were text-based. Results: Our final review included 27 articles. Twenty-two were research studies and five were system descriptions. Eighteen originated from one of three sites with well-developed e-consult programs. Most studies reported on workflow impact, timeliness of specialty input, and/or provider perceptions of e-consults. E-consultations are used in a variety of ways within and across medical centers. They provide timely access to specialty care and are well-received by primary care providers. Discussion: E-consults are feasible in a variety of settings, flexible in their application, and facilitate timely specialty advice. More extensive and rigorous studies are needed to inform the e-consult process and describe its effect on access to specialty visits, cost and clinical outcomes.
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Electronic consultation can improve access to specialist care. However, specialists have been identified as less likely to adopt electronic solutions in clinical settings. We conducted an online survey to explore the perspectives of specialists who use the Champlain BASE eConsult service in Eastern Ontario, Canada. Specialists were asked their opinions on experience with the service, their current consult/referral practices, recommendations for change and expansion of the service, and compensation models. We tabulated descriptive statistics from the multiple choice and Likert scale responses and performed a content analysis with an emergent code strategy for open-text responses. Specialists (n=34, 77% response rate) agreed that the Champlain BASE eConsult service is a feasible way to improve access to specialist care (94%), improves communication between specialists and primary care providers (PCPs) (94%), has educational value for PCPs (91%), and is user friendly (82%). A majority of specialists (88%) felt the service should be expanded provincially and 67% felt it should allow specialist-to-specialist consultation. 88% of specialists agreed that the current compensation process is best. This study provides an in-depth look at the perspective of the specialist physicians who use the Champlain BASE eConsult service. Specialists stated specific recommendations for change that will allow us to ensure the service remains sustainable.
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Abstract There is dissatisfaction among primary care physicians, specialists, and patients with respect to the consultation process. Excessive wait times for receiving specialist services and inefficient communication between practitioners result in decreased access to care and jeopardize patient safety. We created and implemented an electronic consultation (e-consultation) system in Eastern Ontario to address these problems and improve the consultation process. The e-consultation system has passed through the proof-of-concept and pilot study stages and has effectively reduced unnecessary referrals while receiving resoundingly positive feedback from physician-users. Using our experience, we have outlined the 10 steps to developing an e-consultation service. We detail the technical, administrative, and strategic considerations with respect to (1) identifying your partners, (2) choosing your platform, (3) starting as a pilot project, (4) designing your product, (5) ensuring patient privacy, (6) thinking through the process, (7) fostering relationships with your participants, (8) being prepared to provide physician payment, (9) providing feedback, and (10) planning the transition from pilot to permanency. In following these 10 steps, we believe that the e-consultation system and its associated improvements on the consultation process can be effectively implemented in other healthcare settings.
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Background: Access to specialist advice remains a barrier for primary care providers (PCPs) and their patients. Virtual consultations have been used to expedite access. There are few studies demonstrating the utilization and impact of such services. We established a regional e-consultation service that was used across a wide range of specialty services and PCPs. Materials and methods: We prospectively collected all e-consultations submitted from April 1, 2011 to June 30, 2012. Utilization data collected included number of e-consultations submitted, specialist response, and time required for the specialist to complete the e-consultation. Perceived benefit to the PCPs and their patients and the impact on care delivery were determined from a close-out survey. Results: Fifty-nine PCPs submitted 406 e-consultations to 16 specialty services. The specialist provided an answer without requesting further information in 89% of cases, with >90% of cases taking <15 min for the specialist to complete. Seventy-five percent of cases were answered in <3 days. The service was perceived as highly beneficial to providers and patients in>90% of cases. In 43% of submitted cases a traditional referral was originally contemplated but was now avoided. Conclusions: We successfully implemented an e-consultation service across diverse PCPs and specialty services that was highly valued. Almost half of referrals submitted would have required a face-to-face consultation if the service had not been available. Thus e-consultation has tremendous potential for improving access to specialist advice in a much more timely manner than the traditional referral-consultation process.
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Limited access to specialist care remains a major barrier to health care in Canada, affecting patients and primary care providers alike, in terms of both long wait times and inequitable availability. We developed an electronic consultation system, based on a secure web-based tool, as an alternative to face-to-face consultations, and ran a pilot study to evaluate its effectiveness and acceptability to practitioners. In a pilot program conducted over 15 months starting in January 2010, the e-consultation system was tested with primary care providers and specialists in a large health region in Eastern Ontario, Canada. We collected utilization data from the electronic system itself (including quantitative data from satisfaction surveys) and qualitative information from focus groups and interviews with providers. Of 18 primary care providers in the pilot program, 13 participated in focus groups and 9 were interviewed; in addition, 10 of the 11 specialists in the program were interviewed. Results of our evaluation showed good uptake, high levels of satisfaction, improvement in the integration of referrals and consultations, and avoidance of unnecessary specialist visits. A total of 77 e-consultation requests were processed from 1 Jan. 2010 to 1 Apr. 2011. Less than 10% of the referrals required face-to-face follow-up. The most frequently noted benefits for patients (as perceived by providers) included improved access to specialist care and reduced wait times. Primary care providers valued the ability to assist with patient assessment and management by having access to a rapid response to clinical questions, clarifying the need for diagnostic tests or treatments, and confirming the need for a formal consultation. Specialists enjoyed the improved interaction with primary care providers, as well as having some control in the decision on which patients should be referred. This low-cost referral system has potential for broader implementation, once payment models for physicians are adapted to cover e-consultation.
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Purpose: A Web-based consultation system (telenephrology) enables family physicians to consult a nephrologist about a patient with chronic kidney disease. Relevant data are exported from the patient's electronic file to a protected digital environment from which advice can be formulated by the nephrologist. The primary purpose of this study was to assess the potential of telenephrology to reduce in-person referrals. Methods: In an observational, prospective study, we analyzed telenephrology consultations by 28 family practices and 5 nephrology departments in the Netherlands between May 2009 and August 2011. The primary outcome was the potential reduction of in-person referrals, measured as the difference between the number of intended referrals as stated by the family physician and the number of referrals requested by the nephrologist. The secondary outcome was the usability of the system, expressed as time invested, the implementation in daily work hours, and the response time. Furthermore, we evaluated the questions asked. Results: One hundred twenty-two new consultations were included in the study. In the absence of telenephrology, 43 patients (35.3%) would have been referred by their family physicians, whereas the nephrologist considered referral necessary in only 17 patients (13.9%) (P <.001). The family physician would have treated 79 patients in primary care. The nephrologist deemed referral necessary for 10 of these patients. Time investment per consultation amounted to less than 10 minutes. Consultations were mainly performed during office hours. Response time was 1.6 days (95% CI, 1.2-1.9 days). Most questions concerned estimated glomerular filtration rate, proteinuria, and blood pressure. Conclusion: A Web-based consultation system might reduce the number of referrals and is usable. Telenephrology may contribute to an effective use of health facilities by allowing patients to be treated in primary care with remote support by a nephrologist.
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Purpose: Demands on publicly funded ophthalmic services worldwide continue to increase with new treatments, waiting time targets, working time limits, and restricted budgets. These highlight the necessity to develop innovative ways of utilising existing capacity more effectively. Method: A new regional, fully electronic ophthalmic-referral service with digital imaging was trialled using existing information-technology (IT) infrastructure. Following successful pilot study, the service was rolled out regionally. Service delivery data was prospectively collated for all the attendances in the year prior to (2006) and the year following (2008) introduction. Results: Comparing 2006 against 2008, median waiting times reduced (14 vs 4 weeks), and fewer new patients were observed (8714 vs 7462 P<0.0001), with 1359 referrals receiving electronic diagnosis (e-diagnosis). New patient did not arrive (635 vs 503 P<0.0001) and emergencies also reduced (2671 v 1984 P<0.0001). Discussion: Novel use of existing IT infrastructure improves communication between primary and secondary care. This promotes more effective use of limited outpatient capacity by retaining patients with non-progressive, asymptomatic pathology in the community, whilst fast-tracking patients with sight-threatening disease. Resultant significant, sustained improvements in regional service delivery point to a simple model that could easily be adopted by other providers of universal healthcare globally.
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Health reforms in high-income countries increasingly aim to redesign primary care to improve the health of the population and the quality of health care services, and to address rising costs. Primary care improvements aim to provide patients with better access to care and develop more-integrated care systems through better communication and teamwork across sites of care, supported by health information technology and feedback to physicians on their performance. Our international survey of primary care doctors in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Switzerland, the United Kingdom, and the United States found progress in the use of health information technology in health care practices, particularly in the United States. Yet a high percentage of primary care physicians in all ten countries reported that they did not routinely receive timely information from specialists or hospitals. Countries also varied notably in the extent to which physicians received information on their own performance. In terms of access, US doctors were the most likely to report that they spent substantial time grappling with insurance restrictions and that their patients often went without care because of costs. Signaling the need for reforms, the vast majority of US doctors surveyed said that the health care system needs fundamental change.
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Background Patients have typically received health care through face-to-face encounters. However, expansion of electronic communication and electronic health records (EHRs) provide alternative means for patient and physicians to interact. Electronic consultations may complement regular healthcare by providing “better, faster, cheaper” processes for diagnosing, treating, and monitoring health conditions. Virtual consultation between physicians may provide a method of streamlining care, potentially saving patients the time and expense of added visits. The purpose of this study was to compare physician usage and patient satisfaction with virtual consultations (VCs) with traditional consultations (TCs) facilitated within an EHR. Methods We conducted an observational case–control survey study within Kaiser Permanente, Colorado. A sample of patients who had VCs requested by physicians (N = 270) were matched with patients who had TCs requested by physicians (N = 270), by patient age, gender, reason for the consult, and specialty department. These patients (VC and TC), were invited to participate in a satisfaction survey. In addition, 205 primary care physicians who submitted a VC or TC were surveyed. Results During the study period, 58,146 VC or TC were requested (TC = 96.3%). Patients who completed a satisfaction survey (267 out of 540 patients, 49.4% response rate) indicated they were satisfied with their care, irrespective of the kind of consult (mean 10-point Likert score of 8.5). 88 of 205 primary care physicians surveyed (42.9%) returned at least one survey; VC and TC survey response rates and consulted departments were comparable (p = 0.13). More TCs than VCs requested transfer of patient care (p = 0.03), assistance with diagnosis (p = 0.04) or initiating treatment (p =0.04). Within 3 weeks of the consultation request, 72.1% of respondents reported receiving information from VCs, compared with 33.9% of the TCs (p < 0.001). Utility of information provided by consultants and satisfaction with consultations did not differ between VCs and TCs. Conclusions Referring physicians received information from consultants more quickly from VCs compared with TCs, but the value and application of information from both types of consultations were similar. VCs may decrease the need for face-to-face specialty encounters without a decrease in the patient’s perception of care.
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A virtual lesion clinic (VLC) using store-and-forward teledermoscopy was introduced to reduce waiting times and improve access for skin lesion assessment by dermatologists. We aimed to review the efficiency and patient acceptance of a new community-based teledermoscopy service by comparing it to hospital-based face-to-face (FTF) skin lesion clinics. A prospective study compared patient flow through a community-based VLC and a tertiary hospital FTF dermatology clinic. Surveys were sent to patients and their referring doctors after attendance. Waiting times, diagnosis, outcomes, financial costs, patient acceptability and convenience were compared. A total of 300 patients were assessed; 200 were seen in the VLC and 100 in the conventional FTF clinic. Of the 200 patients seen in the VLC, 88% did not require a subsequent FTF clinic assessment to establish the diagnosis. Mean waiting times for first assessment were reduced by two thirds (from 114 days to 39 days) in those seen by the VLC compared to FTF. Financial analysis demonstrated cost savings of 14%. Surveyed patients were highly satisfied and confident in the VLC service. A community-based teledermoscopy service may allow improved management of outpatient referrals while providing a better, quicker and more convenient service. It may also provide cost savings, as teledermoscopy assessment can be cheaper than traditional assessment.
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To describe a quality improvement for referral of National Health Service patients with macular disorders from a community optometry setting in an urban area. Service evaluation of teleophthalmology consultation based on spectral domain optical coherence tomography images acquired by the community optometrist and transmitted to hospital eye services. Fifty patients with suspected macular conditions were managed via telemedicine consultation over 1 year. Responses were provided by hospital eye service-based ophthalmologists to the community optometrist or patient within the next day in 48 cases (96%) and in 34 (68%) patients on the same day. In the consensus opinion of the optometrist and ophthalmologist, 33 (66%) patients required further "face-to-face" medical examination and were triaged on clinical urgency. Seventeen cases (34%) were managed in the community and are a potential cost improvement. Specialty trainees were supervised in telemedicine consultations. Innovation and quality improvement were demonstrated in both optometry to ophthalmology referrals and in primary optometric care by use of telemedicine with spectral domain optical coherence tomography images. E-referral of spectral domain optical coherence tomography images assists triage of macular patients and swifter care of urgent cases. Teleophthalmology is also, in the authors' opinion, a tool to improve interdisciplinary professional working with community optometrists. Implications for progress are discussed.
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Our Problem The length of wait lists to access specialist clinics in the public system is problematic for Queensland Health, general practitioners and patients. To address this issue at The Townsville Hospital, the GP Liaison Officer, GPs and hospital staff including specialists, collaborated to develop a process to review patients waiting longer than two years. GPs frequently send referrals to public hospital specialist clinics. Once received, referrals are triaged to Category A, B or C depending on clinical criteria resulting in appointment timeframes of 30, 90 or 365 days for each category, respectively. However, hospitals often fail to meet these targets, creating a long wait list. These wait listed patients are only likely to be seen if their condition deteriorates and an updated referral upgrades them to Category A. Process to Address the Problem A letter sent to long wait patients offered two options 1) take no action if the appointment was no longer required or 2) visit their GP to update their referral on a clinic specific template if they felt the referral was still required. Local GPs were advised of the trial and provided education on the new template and minimum data required for specialist referrals. What Happened In 2008, 872 letters were sent to long wait orthopaedic patients and 101 responded. All respondents were seen at specially arranged clinics. Of these, 16 patients required procedures and the others were discharged. In 2009 the process was conducted in the specialties of orthopaedics, ENT, neurosurgery, urology, and general surgery. Via this new process 6885 patients have been contacted, 633 patients have been seen by public hospital specialists at specially arranged clinics and 197 have required a procedure. Learnings Since the start of this process in 2008, the wait time to access a specialist appointment has reduced from eight to two years. The process described here is achievable across a range of specialties, deliverable within the routine of the referral centre and identifies the small number of people on the long wait list in need of a procedure.
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Scoping studies are an increasingly popular approach to reviewing health research evidence. In 2005, Arksey and O'Malley published the first methodological framework for conducting scoping studies. While this framework provides an excellent foundation for scoping study methodology, further clarifying and enhancing this framework will help support the consistency with which authors undertake and report scoping studies and may encourage researchers and clinicians to engage in this process. We build upon our experiences conducting three scoping studies using the Arksey and O'Malley methodology to propose recommendations that clarify and enhance each stage of the framework. Recommendations include: clarifying and linking the purpose and research question (stage one); balancing feasibility with breadth and comprehensiveness of the scoping process (stage two); using an iterative team approach to selecting studies (stage three) and extracting data (stage four); incorporating a numerical summary and qualitative thematic analysis, reporting results, and considering the implications of study findings to policy, practice, or research (stage five); and incorporating consultation with stakeholders as a required knowledge translation component of scoping study methodology (stage six). Lastly, we propose additional considerations for scoping study methodology in order to support the advancement, application and relevance of scoping studies in health research. Specific recommendations to clarify and enhance this methodology are outlined for each stage of the Arksey and O'Malley framework. Continued debate and development about scoping study methodology will help to maximize the usefulness and rigor of scoping study findings within healthcare research and practice.
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Audiology in rural Alaska has changed dramatically in the past 6 years by integrating store and forward telemedicine into routine practice. The Audiology Department at the Norton Sound Health Corporation in rural Nome Alaska has used store-and-forward telemedicine since 2002. Between 2002 and 2007, over 3,000 direct audiology consultations with the Ear, Nose, and Throat (ENT) Department at the Alaska Native Medical Center in Anchorage were completed. This study is a 16-year retrospective analysis of ENT specialty clinic wait times on all new patient referrals made by the Norton Sound Health Corporation providers before (1992-2001) and after the initiation of telemedicine (2002-2007). Prior to use of telemedicine by audiology and ENT, 47% of new patient referrals would wait 5 months or longer to obtain an in-person ENT appointment; this dropped to 8% of all patients in the first 3 years with telemedicine and then less than 3% of all patients in next 3 years using telemedicine. The average wait time during the first 3 years using telemedicine was 2.9 months, a 31% drop compared with the average wait time of 4.2 months for the preceding years without telemedicine. The wait time then dropped to an average of 2.1 months during the next 3 years of telemedicine, a further drop of 28% compared with the first 3 years of telemedicine usage.
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Chronic kidney disease is increasingly recognised in the UK, leading to a greater demand for specialist services. Traditional means of meeting this demand rely on GP referral of patients to see a nephrologist. Hospital assessment may be inconvenient for patients and inefficient for health services. 17 general practices and a secondary care nephrology service in Bradford, UK. A before and after evaluation comparing nephrology referrals from implementation and non-implementation practices following the introduction of electronic consultations (e-consultations) for chronic kidney disease. The number, appropriateness and quality of new referrals (paper and electronic) from primary care, the timeliness of responses and the satisfaction of patients and health professionals with the new service. Strategies for change Electronic sharing of primary care electronic health records with the nephrology service was introduced to implementation practices. Participating GPs attended education workshops and received paper and e-guidance about the new service. There was a significant reduction in paper referrals from implementation practices. E-consultation provided nephrologists with access to more clinical information. GPs reported that the service was convenient, provided timely and helpful advice, and avoided outpatient referrals. Specialist recommendations were well followed, and GPs felt more confident about managing chronic kidney disease in the community. E-consultation promotes effective management of patients with mild-to-moderate chronic kidney disease in primary care, allowing specialist resources to be directed towards supporting patients with more complex needs. There is a potential role for e-consultation in other chronic disease specialties.
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Teledermatology is a rapidly growing field with studies showing high diagnostic accuracy when compared with face-to-face diagnosis. Teledermoscopy involves the use of epiluminescence microscopy to increase diagnostic accuracy. The utility of teledermoscopy as a triage tool has not been established. To assess teledermoscopy as a triage tool for a hospital skin lesion clinic. Patients referred to a dermatology skin lesion clinic were recruited. Digital and dermoscopic photographs were taken of skin lesions of concern and the patients were then seen independently face-to-face by two out of three dermatologists. The digital images were evaluated 4 weeks later, as a teledermoscopy consultation, by two of these dermatologists. The diagnosis and management from both types of consultation were compared. Two hundred patients with a total of 491 lesions were seen. There was excellent agreement between teledermoscopy and face-to-face diagnosis with only 12.3% of lesions having disparate diagnoses of clinical significance. Twelve of 491 (2.4%) lesions appeared to have been under-reported by teledermoscopy when compared with face-to-face diagnosis. However, when histopathology became available, only one malignant lesion had been missed (a basal cell carcinoma diagnosed as solar keratosis) by teledermoscopy. Teledermoscopy approximated 100% sensitivity and 90% specificity for detecting melanoma and nonmelanoma skin cancers. Importantly, 74% of all lesions were determined to be manageable by the general practitioner without needing to be seen face-to-face by a dermatologist. This use of teledermoscopy as a triage tool offers the potential to shorten waiting lists and thus improve healthcare access and delivery.
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This project increased access to otolaryngology services by having an audiologist travel to remote Alaska and communicate with an otolaryngologist using store-and-forward electronic consultation. The audiologist was instructed to effectively image appropriate parts of the otolaryngology exam and create telemedicine cases that included clinical histories, images, audiograms, tympanograms, otoacoustic emission testing and/or other documents. The otolaryngology consultants reviewed new referrals as well as follow up cases and made treatment and triage recommendations. Over a 57 month period, 54 trips were made to 14 villages providing 197 clinic service days. The 1,458 patient encounters resulted in referral for surgery or special diagnostic testing 26%, referral for monitoring 23%, starting of medications 19%, referral to regional ENT clinic 15%, and referral to another specialty 5%. Approximately 27% patients did not need to see the otolaryngologist and were triaged out of the specialty clinic. The total cost to run this project was $141,114. Travel was prevented for 85% encounters, resulting in travel cost avoidance in airfare of $496,420. These services were provided at a significantly lower cost and with fewer burdens to the patients when compared to the standard referral system. An audiologist that travels to remote locations and uses store-and-forward telemedicine can rapidly deliver otolaryngology services. This model is a proven mechanism of efficient healthcare delivery that may be expanded to other specialties.
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To test the hypotheses that, compared with conventional outpatient consultations, joint teleconsultation (virtual outreach) would incur no increased costs to the NHS, reduce costs to patients, and reduce absences from work by patients and their carers. Cost consequences study alongside randomised controlled trial. Two hospitals in London and Shrewsbury and 29 general practices in inner London and Wales. 3170 patients identified; 2094 eligible for inclusion and willing to participate. 1051 randomised to virtual outreach and 1043 to standard outpatient appointments. NHS costs, patient costs, health status (SF-12), time spent attending index consultation, patient satisfaction. Overall six months costs were greater for the virtual outreach consultations ( pound 724 per patient) than for conventional outpatient appointments ( pound 625): difference in means pound 99 ($162; 138) (95% confidence interval pound 10 to pound 187, P=0.03). If the analysis is restricted to resource items deemed "attributable" to the index consultation, six month costs were still greater for virtual outreach: difference in means pound 108 ( pound 73 to pound 142, P < 0.0001). In both analyses the index consultation accounted for the excess cost. Savings to patients in terms of costs and time occurred in both centres: difference in mean total patient cost pound 8 ( pound 5 to pound 10, P < 0.0001). Loss of productive time was less in the virtual outreach group: difference in mean cost pound 11 ( pound 10 to pound 12, P < 0.0001). The main hypothesis that virtual outreach would be cost neutral is rejected, but the hypotheses that costs to patients and losses in productivity would be lower are supported.
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To determine whether an email triage system between general practitioners and a neurologist for new outpatient referrals is feasible, acceptable, efficient, safe, and effective. This was a prospective single cohort study on the interface between primary care practitioners and the neurology clinic of a district general hospital. Seventy six consecutive patients with neurological symptoms from nine GPs, for whom a specialist opinion was deemed necessary, were entered in the study. The number of participants managed without clinic attendance and the reduction in neurologist's time compared with conventional consultation was measured, as was death, other specialist referral, and change in diagnosis in the 6 months after episode completion. The acceptability for GPs was ascertained by questionnaire. Forty three per cent of participants required a clinic appointment, 45% were managed by email advice alone, and 12% by email plus investigations. GP satisfaction was high. Forty four per cent of the neurologist's time was saved compared with conventional consultation. No deaths or significant changes in diagnosis were recorded during the 6 month follow up period. Email triage is feasible, acceptable to GPs, and safe. It has the potential for making the practice of neurologists more efficient, and this needs to be tested in a larger randomised study.
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To evaluate a store-and-forward teledermatology system aimed at the routine triage of patients with skin cancer. A multicenter, longitudinal, 4-phase, descriptive and evaluation study of a referred sample of patients attended through teleconsultation between March 2004 and July 2005 (n = 2009). Clinical and dermoscopical examination and histopathological study were considered the gold standard. A skin cancer unit of a public university hospital and 12 primary care centers in southern Spain. The study population comprised patients with circumscribed lesions fulfilling at least 1 of the following criteria: changes in ABCD criteria (asymmetry, border irregularity, color variegation, and diameter >6 mm), recent history, multiple melanocytic lesions, symptoms, and/or patient's application for surgical treatment and concern about moles. Diagnosis, diagnostic category (malignant lesions, high-risk lesions, benign lesions, special lesions, and other lesions), diagnostic confidence level on a 3-point scale, and management decision (referral vs nonreferral) were listed after the evaluation of each teleconsultation. A face-to-face evaluation and biopsy of selected patients were performed. The filtering percentage, as the percentage of patients not referred to the face-to-face clinic, as well as waiting intervals and pick-up or skin cancer detection rates were evaluated as effectiveness indicators. Reliability measures (kappa agreement), accuracy, and diagnostic performance indicators (validity) were also evaluated. The filtering percentage was 51.20% (95% confidence interval [CI], 49.00%-53.40%). The waiting interval to attend the clinic was 12.31 days (95% CI, 8.22-16.40 days) through teledermatology and 88.62 days (95% CI, 38.42-138.82 days; P<.001) for the letter referral system. Pick-up rates were 2.02% (95% CI, 1.10%-2.94%) for malignant melanoma and 27.94% (95% CI, 24.98%-30.90%) or 1:3.71 for patients with any malignant or premalignant lesion. Intraobserver agreement was kappa = 0.91 (95% CI, 0.89-0.93) for the management decision and kappa = 0.95 (95% CI, 0.94-0.96) for the diagnosis. Interobserver concordance was kappa = 0.83 (95% CI, 0.78-0.88) for the management decision and kappa = 0.85 (95% CI, 0.79-0.91) for the diagnosis. Accuracy was kappa = 0.81 (95% CI, 0.78-0.84). Sensitivity was 0.99 (95% CI, 0.98-1.00); specificity, 0.62 (95% CI, 0.56-0.69); pretest likelihood, 0.42 (95% CI, 0.37-0.47); positive posttest likelihood, 0.65 (95% CI, 0.61-0.69); and negative posttest likelihood, 0.01 (95% CI, 0.00-0.05). Store-and-forward teledermatology has demonstrated in this series to be an effective, accurate, reliable, and valid approach for the routine management of patient referrals in skin cancer and pigmented lesion clinics.
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A retrospective noncomparative consecutive case series was conducted to evaluate the clinical outcomes of a novel teleophthalmology program linking optometrists to retina specialists in Alberta, Canada. One hundred seventy-one patients, referred by optometrists via teleophthalmology to a group retina practice between June 2004 and May 2006 underwent stereoscopic, mydriatic digital photography. Images were transmitted to a secure Web server and analyzed by a retina specialist. Diagnosis and recommendations were sent back to the optometrist and, if necessary, patients were referred for additional testing and clinical evaluation. A chart review of all clinical encounters was performed and the data was tabulated. Demographic features, diagnosis, testing, treatment, distance and time traveled by patient, durations between telemedicine referral, teleophthalmology consultation, in-person consultation, testing, and treatment were recorded. One hundred seventy patients were assessed via teleophthalmology for a total of 190 consultations. Eighty-nine patients (52.0%) required conventional in-person consultation with a referral completion success of 92.1% (82 patients). Fifty of these patients underwent additional diagnostic testing including fluorescein angiography (41), optical coherence tomography (14), laboratory testing (5), visual fields (2), carotid Doppler ultrasound (2), and ocular ultrasound (2). Twenty-five patients required surgical or medical treatment including focal argon laser (10), photodynamic therapy (8), panretinal photocoagulation (2), vitrectomy (2), scleral buckle (1), and other procedures (8). Average wait time between telemedicine referral and teleophthalmology review of images by the retina specialist was 1.9 days (maximum = 20 days). For those patients requiring office evaluation, the average wait time between teleophthalmology referral and in-person evaluation was 25.1 days. Twenty-one of the 25 patients (84.0%) requiring treatment underwent examination, testing, and treatment in a single day. When compared to conventional consultation methods, teleophthalmology reduced average travel distance and time by 219.1 km and 2.7 hours, respectively. Teleophthalmology reduced office visits to the retina specialist by 48% while improving the efficiency of clinical examination, testing, and treatment. Patients benefited through reduced travel time and distance.