Article

Virtual Care, Telemedicine Visits, and Real Connection in the Era of COVID-19: Unforeseen Opportunity in the Face of Adversity

February 2021
JAMA The Journal of the American Medical Association 325(5):437-438

DOI:10.1001/jama.2020.27304

Authors:

Donna Zulman

Stanford University

Understanding Therapeutic Experience: A Qualitative Evaluation of Virtual and In-Person Treatment

Article

Full-text available

Dec 2024

Introduction Following the COVID-19 pandemic, there was adoption of virtual psychotherapy. There are a number of benefits and drawbacks to telehealth video conferencing that are experienced by both clients and clinicians. The current qualitative study sought to outline the advantages and disadvantages that clients and clinicians have personally experienced in virtual versus in-person therapy in an effort to identify the reasons for which one medium may be preferred over another. Methods The research was conducted from March 20, 2023, to April 3, 2023. The interviews with 32 individuals (14 clients and 18 clinicians) took place via Zoom video conferencing. Thematic analysis of the empirical material was conducted until fit and significance were met. Application of empirical principles of qualitative research was complete when categories were saturated, and no new themes had emerged. Results Results indicated that virtual care is appreciated for its convenience and ease, which allows clients to attend sessions even when physical barriers limit them (i.e., sickness, vacation, and between meetings or classes). In terms of maximizing the therapeutic process, this study found that in-person care has a number of benefits that are weakened or diminished when one switches to a virtual setting. Being in-person was reported to have a significant therapeutic impact in terms of attendance, engagement, participation, understanding nonverbal communications, and developing rapport with one’s clinician and fellow clients. Conclusion The results of this study present an overview of client and clinician perceptions of the therapeutic impact of modes of therapy (virtual, in-person). While there is no strong evidence to suggest that one mode of care is clinically indicated over the other, the data outlines the benefits and drawbacks of both.

Therapy Mode Preference Scale: Preliminary Validation Methodological Design

Article

Full-text available

Nov 2024

Background The use of tele–mental health care increased rapidly in 2020 as a critical response to the COVID-19 pandemic, serving as an effective contact-free alternative to treatment. Today, tele–mental health care remains a viable option for individuals with geographic and physical barriers to treatment. However, there are several potential therapeutic disadvantages to tele–mental health care (ie, missing nonverbal signals, handling crises, confidentiality, weakened social connection in group therapy) that should be evaluated. While published literature has explored client satisfaction within teletherapy and the effect of using technology for tele–mental health care demands, there is a need for published surveys that evaluate the therapeutic experience in teletherapy and in-person mediums of care. Objective The authors of this study sought to develop and validate a survey that could evaluate the comparative impact of teletherapy and in-person care from a therapeutic perspective across key factors (ie, therapeutic alliance, engagement, rapport, and confidentiality). Methods Participants were clients who experienced both tele–mental health care and in-person therapy at an intensive outpatient mental health treatment program for young adults from April 2020 through June 2022. Generated items on the survey were formulated based on input from experts in the field and existing validated scales. All individuals completed the survey on the internet, following informed consent (n=89). An exploratory factor analysis was conducted to understand factor structure, and Cronbach α was used to determine internal consistency. Incremental validity was demonstrated through a hierarchical linear regression. Results The exploratory factor analysis revealed a 14-item, 3-factor structure. All 14 items correlated at a minimum of 0.30 with at least one other item. Kaiser-Meyer-Olkin measure of sampling adequacy was 0.75 and Bartlett’s test of sphericity was significant ( χ ² 91 =528.41, P <.001). In total, 3 factors accounted for 61% of the variance, and the preliminary Cronbach α (α=0.71) indicates a satisfactory level of internal consistency. The Zoom Exhaustion and Fatigue Scale (ZEF) and Client Satisfaction Questionnaire (CSQ; −0.29) were significantly correlated, as well as the ZEF and Therapy Mode Preference Scale (TMPS; −0.31), and CSQ and TMPS (0.50; P <.001). Hierarchical linear regression revealed that the CSQ significantly accounted for additional variance in the TMPS ( P <.001). With the ZEF entered into the model, no further variance was accounted for ( P =.06). Conclusions Continual research is warranted to expand the current findings by validating this standardized tool for assessing the therapeutic impact of teletherapy versus in-person care in a generalizable population.

Quality and Dependability of ChatGPT and DingXiangYuan Forums for Remote Orthopedic Consultations: Comparative Analysis

Article

Full-text available

Mar 2024
J MED INTERNET RES

Background The widespread use of artificial intelligence, such as ChatGPT (OpenAI), is transforming sectors, including health care, while separate advancements of the internet have enabled platforms such as China’s DingXiangYuan to offer remote medical services. Objective This study evaluates ChatGPT-4’s responses against those of professional health care providers in telemedicine, assessing artificial intelligence’s capability to support the surge in remote medical consultations and its impact on health care delivery. Methods We sourced remote orthopedic consultations from “Doctor DingXiang,” with responses from its certified physicians as the control and ChatGPT’s responses as the experimental group. In all, 3 blindfolded, experienced orthopedic surgeons assessed responses against 7 criteria: “logical reasoning,” “internal information,” “external information,” “guiding function,” “therapeutic effect,” “medical knowledge popularization education,” and “overall satisfaction.” We used Fleiss κ to measure agreement among multiple raters. Results Initially, consultation records for a cumulative count of 8 maladies (equivalent to 800 cases) were gathered. We ultimately included 73 consultation records by May 2023, following primary and rescreening, in which no communication records containing private information, images, or voice messages were transmitted. After statistical scoring, we discovered that ChatGPT’s “internal information” score (mean 4.61, SD 0.52 points vs mean 4.66, SD 0.49 points; P=.43) and “therapeutic effect” score (mean 4.43, SD 0.75 points vs mean 4.55, SD 0.62 points; P=.32) were lower than those of the control group, but the differences were not statistically significant. ChatGPT showed better performance with a higher “logical reasoning” score (mean 4.81, SD 0.36 points vs mean 4.75, SD 0.39 points; P=.38), “external information” score (mean 4.06, SD 0.72 points vs mean 3.92, SD 0.77 points; P=.25), and “guiding function” score (mean 4.73, SD 0.51 points vs mean 4.72, SD 0.54 points; P=.96), although the differences were not statistically significant. Meanwhile, the “medical knowledge popularization education” score of ChatGPT was better than that of the control group (mean 4.49, SD 0.67 points vs mean 3.87, SD 1.01 points; P<.001), and the difference was statistically significant. In terms of “overall satisfaction,” the difference was not statistically significant between the groups (mean 8.35, SD 1.38 points vs mean 8.37, SD 1.24 points; P=.92). According to how Fleiss κ values were interpreted, 6 of the control group’s score points were classified as displaying “fair agreement” (P<.001), and 1 was classified as showing “substantial agreement” (P<.001). In the experimental group, 3 points were classified as indicating “fair agreement,” while 4 suggested “moderate agreement” (P<.001). Conclusions ChatGPT-4 matches the expertise found in DingXiangYuan forums’ paid consultations, excelling particularly in scientific education. It presents a promising alternative for remote health advice. For health care professionals, it could act as an aid in patient education, while patients may use it as a convenient tool for health inquiries.

The Use of Telemedicine in the Care of Pregnant Women with Gestational Diabetes

Article

Full-text available

Jul 2023

Dr Katarzyna Cyganek

The Use of Large Language Models in Generating Patient Education Materials: a Scoping Review

Article

Full-text available

Jan 2025
Acta Inform Med

Background Patient Education is a healthcare concept that involves educating the public with evidence-based medical information. This information surges their capabilities to promote a healthier life and better manage their conditions. LLM platforms have recently been introduced as powerful NLPs capable of producing human-sounding text and by extension patient education materials. Objective This study aims to conduct a scoping review to systematically map the existing literature on the use of LLMs for generating patient education materials. Methods The study followed JBI guidelines, searching five databases using set inclusion/exclusion criteria. A RAG-inspired framework was employed to extract the variables followed by a manual check to verify accuracy of extractions. In total, 21 variables were identified and grouped into five themes: Study Demographics, LLM Characteristics, Prompt-Related Variables, PEM Assessment, and Comparative Outcomes. Results Results were reported from 69 studies. The United States contributed the largest number of studies. LLM models such as ChatGPT-4, ChatGPT-3.5, and Bard were the most investigated. Most studies evaluated the accuracy of LLM responses and the readability of LLM responses. Only 3 studies implemented external knowledge bases leveraging a RAG architecture. All studies except 3 conducted prompting in English. ChatGPT-4 was found to provide the most accurate responses in comparison with other models. Conclusion This review examined studies comparing large language models for generating patient education materials. ChatGPT-3.5 and ChatGPT-4 were the most evaluated. Accuracy and readability of responses were the main metrics of evaluation, while few studies used assessment frameworks, retrieval-augmented methods, or explored non-English cases.

Telemedicine Disparities in Ambulatory Cardiology Visits in a Large Academic Health System

Article

Full-text available

Sep 2024

Background The COVID-19 pandemic prompted rapid expansion of telemedicine to access subspecialty care. However, potential disparities in access to telemedicine in cardiology remain to be fully characterized. Objectives The authors aimed to study whether telemedicine visit modality (video or audio only) differed by sociodemographic characteristics in the outpatient cardiology population of a large academic health center. Methods We conducted a retrospective cross-sectional study of telemedicine encounter data from all outpatient cardiology telemedicine visits from January 1, 2020, to December 31, 2021. We examined unique patients’ first telemedicine encounter during the study period. The primary outcome was visit modality, video versus audio-only visit. Predictors of audio-only visit modality were assessed using adjusted logistic regression analyses. Results There were 47,961 total adult cardiology telemedicine encounters among 39,381 unique patients. Of all encounters, 20.4% were audio only. Odds of audio-only visit modality increased with age, with the highest odds of audio-only visits in patients aged >75 years (OR: 3.4; 95% CI: 2.8-4.2). Non-White race (OR: 1.2; 95% CI: 1.1-1.3), lack of private insurance (Medicaid OR: 2.8; 95% CI: 2.5-3.1 and Medicare OR: 1.7; 95% CI: 1.5-1.8), and higher social deprivation index quintile (social deprivation index 5, most deprived, OR: 2.0; 95% CI: 1.9-2.2) were also associated with increased odds of audio-only modality. Conclusions We identified sociodemographic disparities in telemedicine visit modality in a large outpatient cardiology population. These findings highlight the important role of audio-only visits in accessing telemedicine, and opportunities to narrow the digital health divide.

Patient Perspectives on Coordinated Care: Preliminary Results from the Implementation Stage Using Patient-Reported Experience Measures (PREMs)

Article

Full-text available

Apr 2025

Background and Objectives: Integrated health services are health services that are managed and delivered in a way that ensures patients receive a continuum of health promotion, disease prevention, diagnosis, treatment, disease management, rehabilitation, and palliative care services at different levels and sites of care within the health system, and according to their needs, throughout their life course. Assessing the effectiveness of their implementation, the perspective of the process participant—the patient—is examined. There are three main types of patient-reported measures: PROM, PREM and HLS. PREM (patient-reported experience measure) is a tool that allows the objective measurement of the patient’s experience related to healthcare services, for instance, the timeliness of visits or receiving recommendations. The aim of this study was to evaluate the coordinated care experienced by patients (PREMs) before and after the introduction of coordinated care, using the JOP-POP tool as a key measure. Materials and Methods: This longitudinal study was conducted in two stages. The first stage concerned the joining of the coordinated care program by the entity in which the study was conducted; the study was repeated six months after joining coordinated care (CC). At each stage of the study, the study group included 40 patients. The Shapiro–Wilk test was used to verify the normality of the distribution of quantitative variables. For statistical analysis, the Wilcoxon test for paired samples was used to compare two ordinal dependent variables. For independent variables, the Mann–Whitney and the Kruskal–Wallis ANOVA by ranks tests were used, with a post hoc test of multiple comparisons of mean ranks. Results: A statistically significant relationship (p = 0.00157) was observed between the number of chronic diseases and health status assessment before inclusion in coordinated care. The patients’ responses showed statistically significant improvement 6 months after the introduction of coordinated care (CC). The improvement in assessment was related to the time physicians spent with patients. The greatest improvement over 6 months was achieved in coordination of care and the smallest improvement was noted in the approach to the patient. Conclusions: The JOP-POP tool may be useful in future studies to assess patients’ experiences with implementing coordinated care.

Exploring Contactless Vital Signs Collection in Video Telehealth Visits Among Veterans Affairs Providers and Patients: Pilot Usability Study

Article

Full-text available

Oct 2024

Background To expand veterans’ access to health care, the Veterans Affairs (VA) Office of Connected Care explored a novel software feature called “Vitals” on its VA Video Connect telehealth platform. Vitals uses contactless, video-based, remote photoplethysmography (rPPG) through the infrared camera on veterans’ smartphones (and other devices) to automatically scan their faces to provide real-time vital statistics on screen to both the provider and patient. Objective This study aimed to assess VA clinical provider and veteran patient attitudes regarding the usability of Vitals. Methods We conducted a mixed methods evaluation of Vitals among VA providers and patients, collecting data in July and August 2023 at the VA Boston Healthcare System and VA San Diego Healthcare System. We conducted analyses in October 2023. In-person usability testing sessions consisted of a think-aloud procedure while using the software, a semistructured interview, and a 26-item web-based survey. Results Usability test sessions with 20 VA providers and 13 patients demonstrated that both groups found Vitals “useful” and “easy to use,” and they rated its usability highly (86 and 82 points, respectively, on a 100-point scale). Regarding acceptability or willingness/intent to use, providers and patients generally expressed confidence and trust in Vitals readings, with high ratings of 90 and 85 points, respectively. Providers and patients rated Vitals highly for its feasibility and appropriateness for context (90 and 90 points, respectively). Finally, providers noted that Vitals’ flexibility makes it appropriate and advantageous for implementation in a wide range of clinical contexts, particularly in specialty care. Providers believed that most clinical teams would readily integrate Vitals into their routine workflow because it saves time; delivers accurate, consistently collected vitals; and may reduce reporting errors. Providers and veterans suggested training and support materials that could improve Vitals adoption and implementation. Conclusions While remote collection of vital readings has been described in the literature, this is one of the first accounts of testing a contactless vital signs measurement tool among providers and patients. If ongoing initiatives demonstrate accuracy in its readings, Vitals could enhance telemedicine by providing accurate and automatic reporting and recording of vitals; sending patients’ vital readings (pending provider approval) directly to their electronic medical record; saving provider and patient time; and potentially reducing necessity of some home-based biometric devices. Understanding usability issues before US Food and Drug Administration approval of Vitals and its implementation could contribute to a seamless introduction of Vitals to VA providers and patients.

Classification of Internal and External Distractions in an Educational VR Environment Using Multimodal Features

Article

Sep 2024
IEEE T VIS COMPUT GR

Virtual reality (VR) can potentially enhance student engagement and memory retention in the classroom. However, distraction among participants in a VR-based classroom is a significant concern. Several factors, including mind wandering, external noise, stress, etc., can cause students to become internally and/or externally distracted while learning. To detect distractions, single or multi-modal features can be used. A single modality is found to be insufficient to detect both internal and external distractions, mainly because of individual variability. In this work, we investigated multi-modal features: eye tracking and EEG data, to classify the internal and external distractions in an educational VR environment. We set up our educational VR environment and equipped it for multi-modal data collection. We implemented different machine learning (ML) methods, including k-nearest-neighbors (kNN), Random Forest (RF), one-dimensional convolutional neural network - long short-term memory (1D-CNN-LSTM), and two-dimensional convolutional neural networks (2D-CNN) to classify participants' internal and external distraction states using the multi-modal features. We performed cross-subject, cross-session, and gender-based grouping tests to evaluate our models. We found that the RF classifier achieves the highest accuracy over 83% in the cross-subject test, around 68% to 78% in the cross-session test, and around 90% in the gender-based grouping test compared to other models. SHAP analysis of the extracted features illustrated greater contributions from the occipital and prefrontal regions of the brain, as well as gaze angle, gaze origin, and head rotation features from the eye tracking data.

Comprehensiveness of Large Language Models in Patient Queries on Gingival and Endodontic Health

Article

Full-text available

Aug 2024
INT DENT J

Aim Given the increasing interest in using large language models (LLMs) for self-diagnosis, this study aimed to evaluate the comprehensiveness of two prominent LLMs, ChatGPT-3.5 and ChatGPT-4, in addressing common queries related to gingival and endodontic health across different language contexts and query types. Methods We assembled a set of 33 common real-life questions related to gingival and endodontic healthcare, including 17 common-sense questions and 16 expert questions. Each question was presented to the LLMs in both English and Chinese. Three specialists were invited to evaluate the comprehensiveness of the responses on a five-point Likert scale, where a higher score indicated greater quality responses. Results LLMs performed significantly better in English, with an average score of 4.53, compared to 3.95 in Chinese (Mann–Whitney U test, P < .05). Responses to common sense questions received higher scores than those to expert questions, with averages of 4.46 and 4.02 (Mann–Whitney U test, P < .05). Among the LLMs, ChatGPT-4 consistently outperformed ChatGPT-3.5, achieving average scores of 4.45 and 4.03 (Mann–Whitney U test, P < .05). Conclusions ChatGPT-4 provides more comprehensive responses than ChatGPT-3.5 for queries related to gingival and endodontic health. Both LLMs perform better in English and on common sense questions. However, the performance discrepancies across different language contexts and the presence of inaccurate responses suggest that further evaluation and understanding of their limitations are crucial to avoid potential misunderstandings. Clinical Relevance This study revealed the performance differences of ChatGPT-3.5 and ChatGPT-4 in handling gingival and endodontic health issues across different language contexts, providing insights into the comprehensiveness and limitations of LLMs in addressing common oral healthcare queries.

When “virtual” works and when it doesn’t: A survey of physician and patient experiences with virtual care during the COVID-19 pandemic

Article

Full-text available

Jun 2024

Objective To assess the experience of virtual care among both patients and physicians across a range of clinical scenarios during the COVID-19 pandemic. Methods A web-based survey was disseminated to patients and physicians through a variety of media and healthcare communications from May 2020 to July 2021. Demographic details and attitudes across a range of virtual care domains were collected. Quantitative responses were analyzed descriptively. Open-text responses were gathered to contrast when a virtual visit was superior or inferior to an in-person one, and a thematic content analysis was used. Results There were 197 patients and 93 physician respondents, representing a range of demographic and practice characteristics. Patients noted several benefits of virtual care and felt it should continue to be available. Physicians felt they could do a lot of their care virtually. Common themes related to the superiority of virtual care were for “quick” visits, reviewing test results, chronic disease monitoring, and medication needs. Virtual care was less ideal when a physical exam was needed, and was not perceived as a good fit for an individual's cultural, language, or emotional needs. Certain conditions were identified as both ideal and non-ideal for the virtual format (e.g. mental healthcare). Discussion Certain situations are more amenable to virtual care with personal preferences among both patients and physicians. Future priorities should ensure that virtual care is effective across the range of clinical situations in which it may be used and that both virtual and in-person options are equally available to those who want them.

Life and disease status of patients with Parkinson's disease during and after zero-COVID in China: an online survey

Article

Full-text available

Feb 2024

Background Little is known about the impact of the COVID-19 pandemic on patients with Parkinson’s disease (PD) at different stages of the pandemic. This study aims to assess the lives and disease status of PD patients during the zero-COVID policy period and after ending the zero-COVID policy. Methods This multicenter cross-sectional study included two online surveys among PD patients in China, from May 30 to June 30 in 2022 and from January 1 to February 28 in 2023, respectively. The survey questionnaires contained four sections: (1) status of COVID-19 infection; (2) impact on motor and non-motor symptoms; (3) impact on daily and social lives; and (4) impact on PD disease management. Results A total of 1764 PD patients participated in the first online survey, with 200 patients having lockdown experience and 3 being COVID-19-positive (0.17%). In addition, 537 patients participated in the second online survey, with 467 patients having COVID-19 infection (86.96%). (1) During zero-COVID, all of the COVID-19-positive patients had mild symptoms of COVID-19 and no death was reported. After zero-COVID, 83.51% of the COVID-19-positive patients had mild symptoms. The overall death rate and inpatient mortality rate of COVID-19-positive PD patients were 3.21% and 30.00%, respectively. (2) During zero-COVID, 49.43% of PD patients reported worsening of PD-related symptoms (lockdown vs. unlockdown, 60.50% vs. 48.02%, P = 0.0009). After zero-COVID, 54.93% of PD patients reported worsening of PD-related symptoms (COVID-19 positive vs. COVID-19 negative, 59.31% vs. 25.71%, P < 0.0001). (3) During zero-COVID, 62.36% of patients felt worried, and ‘limited outdoor activities’ (55.39%) was the top reason for mental health problems. After zero-COVID, 59.03% of patients felt worried, with ‘poor health’ (58.10%) being the top reason. The PD patients tended to change their daily activities from offline to online, and their economic and caregiver burdens increased both during and after zero-COVID. (4) Most PD patients would like to choose online rehabilitation during (69.56%) and after zero-COVID (69.27%). The demand for online medication purchasing also increased during (47.00%) and after zero-COVID (26.63%). Conclusions The COVID-19 pandemic aggravated the motor and non-motor symptoms of PD patients either during or after the zero-COVID policy period. The PD patients also experienced prominent mental health problems, changes in daily activities, and increases in economic and caregiver burdens. The COVID-19 pandemic has changed ways of PD management with increasing demands for online medication purchasing and rehabilitation.

Fighting the Same Battles on a New Battleground: Embedding Technologies in a Virtual Care Environment

Article

Full-text available

Jan 2024

The pandemic necessitated the rapid design, development and implementation of technologies to allow remote monitoring of COVID-19 patients at home. This study aimed to explore the environmental barriers and facilitators to the successful development and implementation of virtual care technologies in this fast-paced context. We interviewed eight staff at a virtual hospital in Australia. We found key facilitators to be a learning organizational culture and strong leadership support. Barriers included interoperability issues, legislative constraints and unrealistic clinician expectations. Also, we found that a combination of hot-desking and the lack of single sign on in the virtual care environment, was reported to create additional work for staff. Overall, despite this unique context, our findings are consistent with prior work examining design and implementation of healthcare technologies. The fast pace and high-pressure environment appeared to magnify previously reported barriers, but also cultivate and foster a learning culture.

Assessing the utility of ChatGPT as an artificial intelligence‐based large language model for information to answer questions on myopia

Article

Full-text available

Aug 2023

Assessing the utility of ChatGPT as an artificial intelligence-based large language model for information to answer questions on myopia

Article

Full-text available

Jul 2023
OPHTHAL PHYSL OPT

Purpose: ChatGPT is an artificial intelligence language model, which uses natural language processing to simulate human conversation. It has seen a wide range of applications including healthcare education, research and clinical practice. This study evaluated the accuracy of ChatGPT in providing accurate and quality information to answer questions on myopia. Methods: A series of 11 questions (nine categories of general summary, cause, symptom, onset, prevention, complication, natural history, treatment and prognosis) were generated for this cross-sectional study. Each question was entered five times into fresh ChatGPT sessions (free from influence of prior questions). The responses were evaluated by a five-member team of optometry teaching and research staff. The evaluators individually rated the accuracy and quality of responses on a Likert scale, where a higher score indicated greater quality of information (1: very poor; 2: poor; 3: acceptable; 4: good; 5: very good). Median scores for each question were estimated and compared between evaluators. Agreement between the five evaluators and the reliability statistics of the questions were estimated. Results: Of the 11 questions on myopia, ChatGPT provided good quality information (median scores: 4.0) for 10 questions and acceptable responses (median scores: 3.0) for one question. Out of 275 responses in total, 66 (24%) were rated very good, 134 (49%) were rated good, whereas 60 (22%) were rated acceptable, 10 (3.6%) were rated poor and 5 (1.8%) were rated very poor. Cronbach's α of 0.807 indicated good level of agreement between test items. Evaluators' ratings demonstrated 'slight agreement' (Fleiss's κ, 0.005) with a significant difference in scoring among the evaluators (Kruskal-Wallis test, p < 0.001). Conclusion: Overall, ChatGPT generated good quality information to answer questions on myopia. Although ChatGPT shows great potential in rapidly providing information on myopia, the presence of inaccurate responses demonstrates that further evaluation and awareness concerning its limitations are crucial to avoid potential misinterpretation.

Teleconsultation as a Modern Form of Health Care Service in the Case of Poland: Assessment of Its Potential Use from the Perspective of Health Care Providers and Patients

Article

Full-text available

Jul 2023
TELEMED J E-HEALTH

Introduction: The coronavirus disease 2019 (COVID-19) pandemic has facilitated access to health care services through telemedicine in Poland, where it has not been a common approach so far. Therefore, the aim of this study was to evaluate telemedicine as a form of health care provision in the Polish health care system. Methods: An online questionnaire was distributed to 2,318 patients and health care workers. Questions included telemedical services usage, attitude toward telemedical consultations, who should decide about the nature of the consultation, advantages and disadvantages of telemedicine, the possibility of teleconsultations remaining available after the pandemic, and the subjective perception of overuse of remote consultations by doctors. Results: In general, respondents approved of teleconsultations (3.62 on 1-5 scale) but specific clinical situations gained higher and lower scores-among the highest ranking were prescription renewal (4.68), interpretation of examination results (4.15), and treatment continuation/follow-up (3.81). Among least ranking were consulting children 2-6 years old (1.93) and children younger than 2 years old (1.55) as well as consulting acute symptoms (1.47). Health care workers rated their general attitude significantly higher than nonhealth care workers toward telemedicine consults (3.91 vs. 3.34, p < 0.001) and toward 12 out of 13 specific clinical situations and settings (p < 0.001). The only exception was "consulting acute symptoms," which received exactly the same rating within both groups (1.47, p = 0.99). Most respondents agreed that teleconsultations should remain an option for contacting a physician regardless of the epidemic situation. Each group declared that they should be the one to decide about the consultation form. Conclusions: Results of this study could help optimize and facilitate telemedical consultation usage after the COVID-19 pandemic.

How does work environment relate to diagnostic quality? A prospective, mixed methods study in primary care

Article

Full-text available

May 2023

Objectives The quest to measure and improve diagnosis has proven challenging; new approaches are needed to better understand and measure key elements of the diagnostic process in clinical encounters. The aim of this study was to develop a tool assessing key elements of the diagnostic assessment process and apply it to a series of diagnostic encounters examining clinical notes and encounters’ recorded transcripts. Additionally, we aimed to correlate and contextualise these findings with measures of encounter time and physician burnout. Design We audio-recorded encounters, reviewed their transcripts and associated them with their clinical notes and findings were correlated with concurrent Mini Z Worklife measures and physician burnout. Setting Three primary urgent-care settings. Participants We conducted in-depth evaluations of 28 clinical encounters delivered by seven physicians. Results Comparing encounter transcripts with clinical notes, in 24 of 28 (86%) there was high note/transcript concordance for the diagnostic elements on our tool. Reliably included elements were red flags (92% of notes/encounters), aetiologies (88%), likelihood/uncertainties (71%) and follow-up contingencies (71%), whereas psychosocial/contextual information (35%) and mentioning common pitfalls (7%) were often missing. In 22% of encounters, follow-up contingencies were in the note, but absent from the recorded encounter. There was a trend for higher burnout scores being associated with physicians less likely to address key diagnosis items, such as psychosocial history/context. Conclusions A new tool shows promise as a means of assessing key elements of diagnostic quality in clinical encounters. Work conditions and physician reactions appear to correlate with diagnostic behaviours. Future research should continue to assess relationships between time pressure and diagnostic quality.

“Can you hear me now?”: a qualitative exploration of communication quality in virtual primary care encounters for patients with intellectual and developmental disabilities

Article

Full-text available

Apr 2023

Background High quality communication is central to effective primary care. The COVID-19 pandemic led to a dramatic increase in virtual care but little is known about how this may affect communication quality. Adults with intellectual and developmental disabilities (IDD) can experience challenges communicating or communicate in non-traditional ways. This study explored how the use of virtual modalities, including telephone and video, affects communication in primary care interactions for patients with IDD. Methods This qualitative descriptive study included semi-structured interviews with a multi-stakeholder sample of 38 participants, including 11 adults with IDD, 13 family caregivers, 5 IDD support staff and 9 primary care physicians. Interviews were conducted in Ontario, Canada between March and November 2021 by video-conference or telephone. A mixed inductive and deductive thematic analysis approach was used to code the data and identify themes. Themes were reviewed and refined with members of each stakeholder group. Results Four elements of communication were identified that were affected by virtual care: (1) patient engagement in the virtual appointment; (2) the ability to hear other participants and have the time and space to be heard; (3) the ability to use nonverbal communication strategies; and (4) the ability to form trusting relationships. In some cases, the virtual platform hindered these elements of communication. Video offered some advantages over telephone to support nonverbal communication, and stimulate engagement; though this could be limited by technical challenges. For adults with IDD who find it difficult to attend in-person appointments, virtual care improved communication quality by allowing them to participate from a space where they were comfortable. Conclusion Though there are circumstances in which virtual delivery can improve communication for patients with IDD, there are also challenges to achieving high quality patient-provider communication over telephone and video. Improved infrastructure and training for providers, patients and caregivers can help improve communication quality, though in some cases it may never be appropriate. A flexible patient-centred approach is needed that includes in-person, telephone and video options for care.

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

Article

Full-text available

May 2022

Background: Though telemedicine is a promising approach for removing barriers to care and improving access for patients, telemedicine use for many medical specialties has decreased from its peak during the acute COVID-19 public health crisis. Understanding the barriers and facilitators to the maintenance of web-based visits-one key component of telemedicine-is critical for ensuring the continuous availability of this service for patients. Objective: The purpose of this study is to describe medical providers' perceived barriers and facilitators to the continued use of web-based visits to inform quality improvement efforts and promote sustainability. Methods: We performed a qualitative content analysis of free-text responses from a survey of medical providers administered from February 5-14, 2021, at a large, midwestern academic institution, including all providers from medical professions that offered telemedicine (eg, physicians, residents or fellows, nurse practitioners, physicians assistants, or nurses) who completed at least 1 web-based visit from March 20, 2020, to February 14, 2021. The primary outcome was the experience of providing web-based visits, including barriers and facilitators to continued usage of web-based visits. Survey questions included 3 major domains: quality of care, technology, and satisfaction. Responses were coded using qualitative content analysis and further analyzed through a matrix analysis to understand the providers' perspectives and elucidate key barriers and facilitators of web-based visit usage. Results: Of 2692 eligible providers, 1040 (38.6%) completed the survey, of whom 702 were providers from medical professions that offered telemedicine. These providers spanned 7 health care professions and 47 clinical departments. The most common professions represented were physicians (486/702, 46.7%), residents or fellows (85/702, 8.2%), and nurse practitioners (81/702, 7.8%), while the most common clinical departments were internal medicine (69/702, 6.6%), psychiatry (69/702, 6.6%), and physical medicine and rehabilitation (67/702, 6.4%). The following 4 overarching categories of provider experience with web-based visits emerged: quality of care, patient rapport, visit flow, and equity. Though many providers saw web-based visits as a tool for improving care access, quality, and equity, others shared how appropriate selection of web-based visits, support (eg, patient training, home devices, and broadband access), and institutional and nationwide optimization (eg, relaxation of licensing requirements across state borders and reimbursement for phone-only modalities) were needed to sustain web-based visits. Conclusions: Our findings demonstrate key barriers to the maintenance of telemedicine services following the acute public health crisis. These findings can help prioritize the most impactful methods of sustaining and expanding telemedicine availability for patients who prefer this method of care delivery.

Associations With Virtual Visit Use Among Patients Receiving Radiation Therapy

Article

Full-text available

Mar 2023

Purpose: The objective of this study was to test for patient characteristics associated with virtual versus office visits among radiation oncology patients. Methods and materials: Using the electronic health record, we extracted encounter data and corresponding patient information for the 6 months before and 6 months of COVID-19-enabled virtual visits (October 1, 2019, to March 22, 2020 vs March 23, 2020, to September 1, 2020) at a National Cancer Institute-Designated Cancer Center. Encounters during COVID-19 were categorized as in-person or virtual visits. We compared patient demographic variables including race, age, sex, marital status, preferred language, insurance status, and tumor type during the pre-COVID-19 period as a baseline versus during the COVID-19 period. Multivariable analyses examined associations between these variables and virtual visit use. Results: We analyzed 4974 total encounters (2287 before COVID-19 and 2687 during COVID-19) for 3960 unique patients. All (100%) pre-COVID-19 encounters were in-person. During COVID-19, 21% of encounters were via virtual visits. There were no differences identified in pre- versus during-COVID-19 patient characteristics. However, we found significant differences in patient characteristics for in-person versus virtual encounters during COVID-19. On multivariable analysis, virtual visit use was less common among patients who were Black versus White (odds ratio [OR], 0.75; 95% CI, 0.57-0.99; P = .044) and not married versus married (OR, 0.76; 95% CI, 0.59-0.98; P = .037). Patients with head and neck (OR, 0.63; 95% CI, 0.41-0.97; P = .034), breast (OR, 0.36; 95% CI, 0.21-0.62; P ≤ .001), gastrointestinal/abdominal (OR, 0.31; 95% CI, 0.15-0.63; P = .001), or hematologic malignancy (OR, 0.20; 95% CI, 0.04-0.95; P = .043) diagnoses were less likely to be scheduled for virtual visits relative to patients with genitourinary malignancy. No Spanish-speaking patients engaged in a virtual visit. We did not identify differences in the insurance status or sex of patients scheduled for virtual visits. Conclusions: We found significant differences in virtual visit use by patient sociodemographic and clinical characteristics. Further investigation into implications of differential virtual visit use including social and structural determinants and subsequent clinical outcomes is indicated.

Solving the Explainable AI Conundrum: How to Bridge the Gap Between Clinicians Needs and Developers Goals

Article

Full-text available

Dec 2022

Explainable AI (XAI) is considered the number one solution for overcoming implementation hurdles of AI/ML in clinical practice. However, it is still unclear how clinicians and developers interpret XAI (differently) and whether building such systems is achievable or even desirable. This longitudinal multi-method study queries (n=112) clinicians and developers as they co-developed the DCIP – an ML-based prediction system for Delayed Cerebral Ischemia. The resulting framework reveals that ambidexterity between exploration and exploitation can help bridge opposing goals and requirements to improve the design and implementation of AI/ML in healthcare.

The impact of COVID-19 on kidney transplant care

Article

Full-text available

Jan 2023

The SARS-CoV-2 virus precipitated the coronavirus 2019 (COVID-19) pandemic, which placed considerable strain on healthcare systems and necessitated immediate and rapid alterations in the delivery of healthcare. In the transplant population, COVID-19 directly impacts an inherently vulnerable population in the setting of immunosuppression and co-morbidities, but also further complicates the clinical evaluation and management of kidney transplant candidates and recipients in a strained healthcare environment being challenged by the pandemic. Many transplant centers around the world saw mortality rate spikes in organ recipients related to COVID-19, and changes in care delivery abound. This review evaluates the care of the kidney transplant patient through all phases of the process including pre-operative evaluations, perioperative care, post-transplantation considerations, and how the global pandemic has changed the way we care for our patients.

Solving the Explainable AI Conundrum: How to Bridge the Gap Between Clinicians Needs and Developers Goals

Preprint

Full-text available

Nov 2022

Future-proofing the Profession: Physiotherapists’ perceptions of their current and emerging role

Article

Full-text available

Dec 2022
PHYSIOTHERAPY

Objectives As healthcare systems continue to modernise, physiotherapists are required to transform their practice to remain contemporary and meet future population needs. The study aims to gain an insight into physiotherapists’ perceptions of their current and emerging future role. The intention is to develop an understanding of the physiotherapist’s role and how it can continue to evolve to support populations’ needs in more sustainable and innovative ways. Design A qualitative design using semi-structured interviews was undertaken informed by Gadamerian hermeneutic philosophy. Participants Participants were gained from a postgraduate physiotherapy programme in Northwest England that recruits physiotherapists from across the UK; via the research teams’ professional networks and using snowball sampling. Interviews were digitally recorded and transcribed verbatim. Thematic analysis was undertaken. Ethical approval and informed consent was obtained. Results 23 participants (15 female). 4 themes were identified: ‘An underpinning philosophy of practice’ that promotes holistic care and supports patient wellbeing. An ‘evolving role broadening the scope of practice’ with many ‘agents of change shaping the profession’. When ‘preparing the future workforce and their transition into practice’, graduates were seen as more adaptable and resilient. However, more affiliation between the university and placement providers to enhance learning environments is needed. Conclusions Physiotherapists need to re-evaluate their role so a clear vision for the future can be co-created to ensure they remain contemporary and continue to optimise their potential. An emerging role that re-envisages a holistic approach that incorporates health promotion as fundamental to this role could support physiotherapists’ transformation in practice.

The impact of Covid-19 on animal-assisted interventions: perceptions of UK animal-assisted intervention providers

Article

Full-text available

Nov 2022
J Publ Health

Background Animal-assisted interventions (AAIs) are increasingly common in UK health settings. The Covid-19 pandemic has impacted on their delivery, with many organizations offering AAIs virtually during lockdown periods. This small-scale survey aims to explore the impact of Covid-19 on the delivery of AAIs, and associated challenges and opportunities. Methods A cross-sectional, retrospective questionnaire survey was conducted with UK AAI providers. The anonymized survey was distributed via academic and third sector networks and social media. Descriptive statistics and free-text responses are presented. Results Thirty-six AAI providers completed the survey. Of these, 83.3% continued to deliver AAIs during the pandemic. Twenty-eight delivered AAIs remotely and highlighted associated challenges, such as clients being unable to touch the animal, and clients having restricted access to the required technology. Over half reported their animal missed face-to-face interaction. However, they also reported advantages to remote delivery, such as for those who are allergic or fearful of animals. The most commonly reported challenges of in situ delivery included difficulty maintaining distance from the client and the use of face masks, which were perceived to hinder communication. Conclusion The transition to remote delivery has highlighted challenges and opportunities. Further research could explore these in greater depth and compare the impact of different delivery modes.

Functional Disorders as a Common Motor Manifestation of COVID‐19 Infection or Vaccination

Article

Full-text available

Nov 2022

Background and purpose: There have been over 500 million confirmed cases of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), also known as coronavirus disease 2019 (COVID-19), across the globe. To date, a broad spectrum of neurological manifestations following acute infections as well as COVID-19 vaccines have been reported. The aim of this study was to describe the spectrum of neurological manifestations seen in the 'COVID-19 clinic' established in a tertiary Movement Disorders clinic. Methods: In this consecutive case-series study over the period March 2020-January 2022, clinical information regarding demographic data, clinical history and examination findings, investigation results and video recordings of outpatients with motor manifestations associated with COVID-19 infection or vaccination were reviewed. Results: Twenty-one adult patients were reviewed in this ad hoc clinic at Toronto Western Hospital. The majority of the patients were female (76%) and the mean (range) age was 50.7 ± 17.2 (21-80) years. Nine patients (43%) presented with motor manifestations following COVID-19 infection. Twelve patients (57%) developed neurological symptoms following at least one dose of the mRNA or viral vector-based COVID-19 vaccine. The most common manifestation observed was a functional movement disorder (43%). The vaccine group demonstrated a higher number of functional disorders compared to the infection group (58% vs. 22%; p = 0.08). Conclusion: Functional motor manifestations can be associated with COVID-19 and are likely to be under-reported. In view of the co-existence of functional symptoms, movement disorders and mental health conditions observed in this study, we would advocate the use of dedicated COVID-19 Neurology clinics with full access to an experienced multidisciplinary team.

Paving the road for more ethical and equitable policies and practices in telerehabilitation in psychology and neuropsychology: a research protocol for a rapid review (Preprint)

Article

Sep 2024

Background Virtual rehabilitation, or telerehabilitation (TR), has exponentially evolved in the last few years, gaining particular momentum since the COVID-19 pandemic. In response to a new reality of strict restrictions of physical contact necessitating the shift from in-person health services to tele-health visits, TR has seen widespread adoption. In this context, ensuring ethical and equitable TR services is crucial for establishing sustainable TR models for psychology and neuropsychology into health care systems. This requires complete and consistent guidance for clinicians and patients involved. Objective The objective of this study is to synthesize existing evidence to provide timely insights on potential ethical and equitable benefits and pitfalls associated with the use of TR in a psychological and neuropsychological framework. Methods A rapid review of TR practices will be conducted specifically within the context of neuropsychology and psychology rehabilitation. We will include review articles published between 2010 and 2020 as well as original articles published between 2020 and 2023, all addressing TR issues with a main focus on neuropsychological and/or psychological rehabilitation activities. This research protocol describes the methodology, including search strategy, screening process, data extraction, and analysis methods. Results Guided by an experienced librarian, the search strategy was designed and performed in 3 relevant databases. Articles were screened in accordance with the inclusion and exclusion criteria, and data were collected by 2 independent reviewers. Data extraction is underway, and we expect to complete the rapid review in January 2025. Conclusions This study is part of a broader cross-Canadian initiative aimed at informing policy development and clinical practices in TR. By evaluating the ethical and equitable considerations specific to psychology and neuropsychology, this review aims to contribute to help shape future TR practices to ensure access to high-quality, accessible TR services supporting diverse patient needs in psychology and neuropsychology. International Registered Report Identifier (IRRID) DERR1-10.2196/66639

Telehomecare Monitoring for Patients Receiving Anticancer Oral Therapy: Protocol for a Mixed Methods Evaluability Study

Article

Jan 2025

Background Telehomecare monitoring (TM) in patients with cancer is a complex intervention. Research shows variations in the benefits and challenges TM brings to equitable access to care, the therapeutic relationship, self-management, and practice transformation. Further investigation into these variations factors will improve implementation processes and produce effective outcomes. Objective This study aims to concurrently analyze implementation and evaluate the effectiveness of TM for patients receiving anticancer oral therapy. The objectives are to (1) contextualize how and why TM is implemented according to (a) site characteristics, (b) team characteristics, and (c) characteristics of patients receiving anticancer oral therapy; (2) assess TM effectiveness for recording electronic patient-reported outcome measures (ePROMs) and patient-reported experience measures (ePREMs) according to the site, implementation process, and patient characteristics; (3) describe the acceptability and feasibility of TM from the perspectives of the people directly or indirectly involved and provide evidence-based actionable guidance in anticipation of provincewide implementation. Methods This type II hybrid effectiveness-implementation study uses a concurrent mixed methods design. Evaluability assessment is integrated into an emerging practice in 3 participating sites to enable the evaluation of implementation strategies on TM clinical outcomes. Quantitative data for ePROMs and ePREMs will be collected using validated oncology questionnaire. Descriptive statistics and repeated measures using multiple linear mixed models and generalized estimating equations analyses will be undertaken alongside interpretive descriptive coding of qualitative data. Qualitative data will be gathered from key informants guided by the RE-AIM (reach, efficacy, adoption, implementation, maintenance) framework and its extension, PRISM (practical robust implementation and sustainability model). The concurrent approach allows results at multiple stages of this study to be integrated iteratively. The methodological choice aims to provide real-world data that are rigorous, rapidly usable in practice, and transferable to other settings. Results Questionnaires were pretested and the technological platform was codeveloped with members of the cancer care team and patients. Preparatory work was carried out to configure the TM platform and activate coordinating mechanisms between members of the cancer care team, patients, information technology experts, and the research team. A steering committee with 3 working groups was established to oversee the technological, clinical, and evaluation aspects of this study. Recruitment of patients for ePROMs started in February 2024, and data collection is expected to continue until March 2025. Interviews with members of the cancer care team began in November 2024. Full analysis should be completed by September 2025. Conclusions This study will clarify how, why, for whom, and under what conditions TM can complement current care models. Our evaluability assessment will help to address implementation complexities and better understand intervention-to-practice operationalization so that implementation might be adapted to contextual factors without potentially harmful or inequitable impacts on patients. International Registered Report Identifier (IRRID) DERR1-10.2196/63099

AI to Mitigate Healthcare Shortages: A Qualitative Analysis of Current and Future Work Conditions to Enhance Job Satisfaction and Wellbeing in Critical Care Nurses and Physicians (Preprint)

Article

Jul 2023
J MED INTERNET RES

Background The escalating global scarcity of skilled health care professionals is a critical concern, further exacerbated by rising stress levels and clinician burnout rates. Artificial intelligence (AI) has surfaced as a potential resource to alleviate these challenges. Nevertheless, it is not taken for granted that AI will inevitably augment human performance, as ill-designed systems may inadvertently impose new burdens on health care workers, and implementation may be challenging. An in-depth understanding of how AI can effectively enhance rather than impair work conditions is therefore needed. Objective This research investigates the efficacy of AI in alleviating stress and enriching work conditions, using intensive care units (ICUs) as a case study. Through a sociotechnical system lens, we delineate how AI systems, tasks, and responsibilities of ICU nurses and physicians can be co-designed to foster motivating, resilient, and health-promoting work. Methods We use the sociotechnical system framework COMPASS (Complementary Analysis of Sociotechnical Systems) to assess 5 job characteristics: autonomy, skill diversity, flexibility, problem-solving opportunities, and task variety. The qualitative analysis is underpinned by extensive workplace observation in 6 ICUs (approximately 559 nurses and physicians), structured interviews with work unit leaders (n=12), and a comparative analysis of data science experts’ and clinicians’ evaluation of the optimal levels of human-AI teaming. Results The results indicate that AI holds the potential to positively impact work conditions for ICU nurses and physicians in four key areas. First, autonomy is vital for stress reduction, motivation, and performance improvement. AI systems that ensure transparency, predictability, and human control can reinforce or amplify autonomy. Second, AI can encourage skill diversity and competence development, thus empowering clinicians to broaden their skills, increase the polyvalence of tasks across professional boundaries, and improve interprofessional cooperation. However, careful consideration is required to avoid the deskilling of experienced professionals. Third, AI automation can expand flexibility by relieving clinicians from administrative duties, thereby concentrating their efforts on patient care. Remote monitoring and improved scheduling can help integrate work with other life domains. Fourth, while AI may reduce problem-solving opportunities in certain areas, it can open new pathways, particularly for nurses. Finally, task identity and variety are essential job characteristics for intrinsic motivation and worker engagement but could be compromised depending on how AI tools are designed and implemented. Conclusions This study demonstrates AI’s capacity to mitigate stress and improve work conditions for ICU nurses and physicians, thereby contributing to resolving health care staffing shortages. AI solutions that are thoughtfully designed in line with the principles for good work design can enhance intrinsic motivation, learning, and worker well-being, thus providing strategic value for hospital management, policy makers, and health care professionals alike.

Telerehabilitation Methods in Neurologic Rehabilitation

Chapter

Oct 2024

Applications involving technological methods are increasingly being used in every aspect of the healthcare system. The use of technological methods in rehabilitation is referred to as telerehabilitation. In this section, we have listed information from current literature regarding telerehabilitation methods in neurological conditions and their mechanisms of action. Telerehabilitation methods in neurological diseases are based on neuroplasticity and motor learning principles. The most used telerehabilitation methods in neurological conditions are videoconferences, mobile applications, virtual reality, and serious games. Telerehabilitation methods increase individuals’ adherence rates in rehabilitation sessions by overcoming barriers in the clinical setting and showing results similar to face-to-face clinical rehabilitation in various parameters for many neurological conditions. Consequently, although there are no definitive results when compared to rehabilitation conducted in a clinical setting in the literature, in Parkinson’s disease, multiple sclerosis (MS), spinal cord injuries (SCIs), intracranial tumors, pediatric neurological patients, and stroke telerehabilitation shows promising results involving motor and non-motor functions through enhancing motor control, increasing neuroplasticity and providing more frequent sessions.

Coronavirus Disease 2019 in Kidney Transplantation – A 2024 Update

Article

Sep 2024

Telemedicine impact on patient disparities and physician practice patterns in cancer rehabilitation: A multicenter retrospective study

Article

Jun 2024

Objective To examine the impact of telemedicine on demographic and practice patterns between outpatients receiving virtual versus in‐person cancer rehabilitation physiatry care. Design Multicenter retrospective study. Setting Outpatient cancer rehabilitation physiatry clinics at four academic medical centers in the United States. Patients Patients with cancer diagnoses or history of cancer diagnosis. Interventions Cancer rehabilitation physiatry encounters. Main Outcome Measures Visit mode (in‐person, telemedicine); disparities variables (age, race, and gender) by visit mode, and practice interventions (imaging, medications, procedures, other orders, and orders of any type) by visit mode. Results Among a total of 7004 encounters, 2687 unique patients were found. In‐person participants were significantly older than the average telemedicine participant (mean 62.9 vs. 60.7 years; p < .001). A race effect was seen ( p = .037) with individuals reporting as Asian or other being more likely to have telemedicine encounters. No gender disparities were seen. Using a random visit analysis model to compare populations receiving in‐person versus telemedicine care, a slight majority (53%) of follow‐up visits were via telemedicine, versus 40% of new patient visits ( p < .001). No significant differences were seen in medication prescribing frequency (38.9% telemedicine vs. 36.7% in‐person, adjusted relative risk [RR]: 0.988, confidence interval [CI]: 0.73–1.34; p = .988) or imaging frequency (2.4% telemedicine vs. 7.6%; adjusted RR: 0.784, CI: 0.44–1.39; p = .408) between telemedicine versus in‐person visit types. Other orders were significantly less likely to be placed during telemedicine than in‐person visits (19.9% telemedicine vs. 28.6% in‐person; adjusted RR: 0.623, CI: 0.45–0.86, p = .004). Order(s) of any type were placed in 54% of visits (52% telemedicine vs. 56% in‐person; adjusted RR: 0.92 for telemedicine, CI: 0.83–1.01, p = .082). Conclusions Telemedicine has been integrated into cancer rehabilitation physiatry practices and appears to be conducive for placing many types of orders, especially medications. Age was found to be the only major demographic difference between in‐person and telehealth patients.

Rethinking the Abnormal Uterine Bleeding Consult: Creating a Patient-Centered, See-and-Treat Model of Care

Article

May 2024

Historically, the evaluation of abnormal uterine bleeding (AUB) has involved a multi-visit process that uses a multitude of care settings (eg, in-office, imaging, laboratory), with the potential for lengthy delays in care due to the now-commonplace scheduling difficulties many clinics face. Although there is strong evidence for the use of in-office uterine assessment as a best practice, uptake has been limited by the learning curve, technology acquisition costs, and other factors. However, due to the coronavirus disease 2019 (COVID-19) pandemic, clinical practice has faced rapid adaptations that have resulted in the redesigned clinical care model of evaluating this common gynecologic condition in a more patient-centered and streamlined way while maximizing the patient experience, health care efficiency, and physician engagement. This procedure would specifically involve one telehealth or initial visit to assess patient history, perform necessary laboratory testing, review results, and plan outpatient procedures to be conducted in the office or the operating room. Due to the COVID-19 pandemic, clinics have, by necessity, implemented this proposed reimagined pathway in a variety of outpatient settings nationally. We propose that, moving forward, this new procedure be permanently adopted in clinics nationwide as the patient-focused evaluation strategy for AUB.

Integrated Hepatitis C-Opioid Use Disorder Care Through Facilitated Telemedicine: A Randomized Trial

Article

Apr 2024
J Am Med Assoc

Importance Facilitated telemedicine may promote hepatitis C virus elimination by mitigating geographic and temporal barriers. Objective To compare sustained virologic responses for hepatitis C virus among persons with opioid use disorder treated through facilitated telemedicine integrated into opioid treatment programs compared with off-site hepatitis specialist referral. Design, Setting, and Participants Prospective, cluster randomized clinical trial using a stepped wedge design. Twelve programs throughout New York State included hepatitis C–infected participants (n = 602) enrolled between March 1, 2017, and February 29, 2020. Data were analyzed from December 1, 2022, through September 1, 2023. Intervention Hepatitis C treatment with direct-acting antivirals through comanagement with a hepatitis specialist either through facilitated telemedicine integrated into opioid treatment programs (n = 290) or standard-of-care off-site referral (n = 312). Main Outcomes and Measures The primary outcome was hepatitis C virus cure. Twelve programs began with off-site referral, and every 9 months, 4 randomly selected sites transitioned to facilitated telemedicine during 3 steps without participant crossover. Participants completed 2-year follow-up for reinfection assessment. Inclusion criteria required 6-month enrollment in opioid treatment and insurance coverage of hepatitis C medications. Generalized linear mixed-effects models were used to test for the intervention effect, adjusted for time, clustering, and effect modification in individual-based intention-to-treat analysis. Results Among 602 participants, 369 were male (61.3%); 296 (49.2%) were American Indian or Alaska Native, Asian, Black or African American, multiracial, or other (ie, no race category was selected, with race data collected according to the 5 standard National Institutes of Health categories); and 306 (50.8%) were White. The mean (SD) age of the enrolled participants in the telemedicine group was 47.1 (13.1) years; that of the referral group was 48.9 (12.8) years. In telemedicine, 268 of 290 participants (92.4%) initiated treatment compared with 126 of 312 participants (40.4%) in referral. Intention-to-treat cure percentages were 90.3% (262 of 290) in telemedicine and 39.4% (123 of 312) in referral, with an estimated logarithmic odds ratio of the study group effect of 2.9 (95% CI, 2.0-3.5; P < .001) with no effect modification. Observed cure percentages were 246 of 290 participants (84.8%) in telemedicine vs 106 of 312 participants (34.0%) in referral. Subgroup effects were not significant, including fibrosis stage, urban or rural participant residence location, or mental health (anxiety or depression) comorbid conditions. Illicit drug use decreased significantly (referral: 95% CI, 1.2-4.8; P = .001; telemedicine: 95% CI, 0.3-1.0; P < .001) among cured participants. Minimal reinfections (n = 13) occurred, with hepatitis C virus reinfection incidence of 2.5 per 100 person-years. Participants in both groups rated health care delivery satisfaction as high or very high. Conclusions and Relevance Opioid treatment program–integrated facilitated telemedicine resulted in significantly higher hepatitis C virus cure rates compared with off-site referral, with high participant satisfaction. Illicit drug use declined significantly among cured participants with minimal reinfections. Trial Registration ClinicalTrials.gov Identifier: NCT02933970

Harnessing Artificial Intelligence in Bariatric Surgery: Comparative Analysis of ChatGPT-4, Bing, and Bard in Generating Clinician-Level Bariatric Surgery Recommendations

Article

Mar 2024
SURG OBES RELAT DIS

Relationship Education during Pregnancy and Postpartum: In-Person versus Virtual Delivery of MotherWise

Article

Jan 2024

Telemedicine and Cancer Clinical Research: Opportunities for Transformation

Article

Jan 2024
CANCER J

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

Online artificial intelligence platforms and their applicability to gastrointestinal surgical operations

Article

Jan 2024
J GASTROINTEST SURG

Examining and Addressing Telemedicine Disparities Through the Lens of the Social Determinants of Health: A Qualitative Study of Patient and Provider During the COVID-19 Pandemic

Article

Jan 2024

Home-Based Care for Lesbian, Gay, Bisexual, Transgender, Queer or Questioning, or another diverse gender identity Older Adults

Article

Nov 2023

Mariah L. Robertson

ChatGPT: a novel AI assistant for healthcare messaging—a commentary on its potential in addressing patient queries and reducing clinician burnout

Article

Sep 2023

The Moral Difference between Faces & FaceTime

Article

Jul 2023
HASTINGS CENT REP

Kyle E. Karches

Although the technology for telemedicine existed before the Covid-19 pandemic, the need to provide medical services while minimizing the risk of contagion has encouraged its more widespread use. I argue that, although telemedicine can be useful in certain situations, physicians should not consider it an adequate substitute for the office visit. I first provide a narrative account of the experience of telemedicine. I then draw on philosophical critiques of technology to examine how telemedicine has epistemic and ethical effects that make some of the goods of medicine unavailable. Telemedicine rules out an embodied encounter between physician and patient, in which the sense of touch has special importance. The individualized attention facilitated by the in-person visit may better sustain a caring physician-patient relationship. Physicians should criticize attempts by administrators, insurers, or other parties to incentivize the wholesale replacement of traditional office visits with telemedicine.

Telehealth vs In-Person Shared Medical Appointments for an Intensive Therapeutic Lifestyle Change Program for Patients With Type 2 Diabetes and Prediabetes

Article

Jul 2023

In response to Covid-19, the Lifestyle Medicine Clinic at Midland Health elected to utilize telehealth to engage remotely with patients to deliver a 12-week intensive therapeutic lifestyle change (ITLC) program for patients with type 2 diabetes and prediabetes. This program utilized a shared medical appointment (SMA) group visit model. Beginning in May/2020, the program was offered again in-person; however, the telehealth option remained. This study is a retrospective chart review, aimed at comparing pre- and post-program changes in body weight, HbA1c, fasting lipid profile, systolic pressure, and diastolic blood pressure between in-person vs telehealth SMA formats. This study found no statistical difference in ITLC program health outcomes between telehealth vs in-person shared medical groups. At the end of ITLC Programs between both groups, an average weight loss of 9.66 pounds and 1% reduction was noted in ptHbA1C. Total cholesterol reduced by 7.1 mg/dL, and LDL by 15.19 mg/dL. The blood pressure readings showed a reduction in systolic blood pressure of 13.4 mmHg and diastolic blood pressure of 4.14 mmHg. Our results indicated that this novel telehealth delivery model could be equally successful in delivering an intensive therapeutic lifestyle program (ITLC) using an SMA approach to prevent, treat and often put chronic diseases in remission.

Sociodemographic disparities in the use of cardiovascular ambulatory care and telemedicine during the COVID-19 pandemic

Article

Jun 2023
AM HEART J

Background: The COVID-19 pandemic accelerated adoption of telemedicine in cardiology clinics. Early in the pandemic, there were sociodemographic disparities in telemedicine use. It is unknown if these disparities persisted and whether they were associated with changes in the population of patients accessing care. Methods: We examined all adult cardiology visits at an academic and an affiliated community practice in Northern California from March 2019 to February 2020 (pre-COVID) and March 2020 to February 2021 (COVID). We compared patient sociodemographic characteristics between these periods. We used logistic regression to assess the association of patient/visit characteristics with visit modality (in-person vs telemedicine and video- vs phone-based telemedicine) during the COVID period. Results: There were 54,948 pre-COVID and 58,940 COVID visits. Telemedicine use increased from <1% to 70.7% of visits (49.7% video, 21.0% phone) during the COVID period. Patient sociodemographic characteristics were similar during both periods. In adjusted analyses, visits for patients from some sociodemographic groups were less likely to be delivered by telemedicine, and when delivered by telemedicine, were less likely to be delivered by video versus phone. The observed disparities in the use of video-based telemedicine were greatest for patients aged ≥80 years (vs age <60, OR 0.24, 95% CI 0.21, 0.28), Black patients (vs non-Hispanic White, OR 0.64, 95% CI 0.56, 0.74), patients with limited English proficiency (vs English proficient, OR 0.52, 95% CI 0.46-0.59), and those on Medicaid (vs privately insured, OR 0.47, 95% CI 0.41-0.54). Conclusions: During the first year of the pandemic, the sociodemographic characteristics of patients receiving cardiovascular care remained stable, but the modality of care diverged across groups. There were differences in the use of telemedicine vs in-person care and most notably in the use of video- vs phone-based telemedicine. Future studies should examine barriers and outcomes in digital healthcare access across diverse patient groups.

"Comprehensive Healthcare for America": Using the Insights of Behavioral Economics to Transform the U. S. Healthcare System

Article

Full-text available

May 2023
J LAW MED ETHICS

"Comprehensive Healthcare for America" is a largely single-payer reform proposal that, by applying the insights of behavioral economics, may be able to rally patients and clinicians sufficiently to overcome the opposition of politicians and vested interests to providing all Americans with less complicated and less costly access to needed healthcare.

Comparing Physician and Artificial Intelligence Chatbot Responses to Patient Questions Posted to a Public Social Media Forum

Article

Full-text available

Apr 2023

Importance: The rapid expansion of virtual health care has caused a surge in patient messages concomitant with more work and burnout among health care professionals. Artificial intelligence (AI) assistants could potentially aid in creating answers to patient questions by drafting responses that could be reviewed by clinicians. Objective: To evaluate the ability of an AI chatbot assistant (ChatGPT), released in November 2022, to provide quality and empathetic responses to patient questions. Design, setting, and participants: In this cross-sectional study, a public and nonidentifiable database of questions from a public social media forum (Reddit's r/AskDocs) was used to randomly draw 195 exchanges from October 2022 where a verified physician responded to a public question. Chatbot responses were generated by entering the original question into a fresh session (without prior questions having been asked in the session) on December 22 and 23, 2022. The original question along with anonymized and randomly ordered physician and chatbot responses were evaluated in triplicate by a team of licensed health care professionals. Evaluators chose "which response was better" and judged both "the quality of information provided" (very poor, poor, acceptable, good, or very good) and "the empathy or bedside manner provided" (not empathetic, slightly empathetic, moderately empathetic, empathetic, and very empathetic). Mean outcomes were ordered on a 1 to 5 scale and compared between chatbot and physicians. Results: Of the 195 questions and responses, evaluators preferred chatbot responses to physician responses in 78.6% (95% CI, 75.0%-81.8%) of the 585 evaluations. Mean (IQR) physician responses were significantly shorter than chatbot responses (52 [17-62] words vs 211 [168-245] words; t = 25.4; P < .001). Chatbot responses were rated of significantly higher quality than physician responses (t = 13.3; P < .001). The proportion of responses rated as good or very good quality (≥ 4), for instance, was higher for chatbot than physicians (chatbot: 78.5%, 95% CI, 72.3%-84.1%; physicians: 22.1%, 95% CI, 16.4%-28.2%;). This amounted to 3.6 times higher prevalence of good or very good quality responses for the chatbot. Chatbot responses were also rated significantly more empathetic than physician responses (t = 18.9; P < .001). The proportion of responses rated empathetic or very empathetic (≥4) was higher for chatbot than for physicians (physicians: 4.6%, 95% CI, 2.1%-7.7%; chatbot: 45.1%, 95% CI, 38.5%-51.8%; physicians: 4.6%, 95% CI, 2.1%-7.7%). This amounted to 9.8 times higher prevalence of empathetic or very empathetic responses for the chatbot. Conclusions: In this cross-sectional study, a chatbot generated quality and empathetic responses to patient questions posed in an online forum. Further exploration of this technology is warranted in clinical settings, such as using chatbot to draft responses that physicians could then edit. Randomized trials could assess further if using AI assistants might improve responses, lower clinician burnout, and improve patient outcomes.

Understanding how virtual care has shifted primary care interactions and patient experience: A qualitative analysis

Article

Apr 2023
J TELEMED TELECARE

Introduction: The widespread and rapid implementation of virtual care has introduced evolutionary changes in the context, process, and way primary care is delivered. The objectives of this study were to: (1) understand whether and how virtual care has shifted the therapeutic relationship; (2) describe the core components of compassionate care from the patient perspective and (3) identify how and in what circumstances compassionate care might be amplified. Methods: Participants living in Ontario, Canada were eligible if they had interacted with their primary care clinician following the rapid implementation of virtual care in March 2020, irrespective of virtual care use. One-on-one semi-structured interviews were conducted with all participants and data were analyzed using inductive thematic analysis. Results: Four themes emerged across 36 interviews: (1) Virtual care shifts communication patterns but the impact on the therapeutic relationship is unclear; (2) Rapid implementation of virtual care limited perceived quality and access among those who did not have the option to utilize it; (3) Patients perceive five key elements as central to compassion in a virtual context; and (4) Leveraging technology to fill gaps within and beyond the visit is a step towards improving experiences for all. Discussion: Virtual care has transformed the ways in which patient-clinician communication operates in primary care. Patients with access to virtual care described largely positive experiences, while those whose interactions were limited to phone visits experienced decreased quality and access to care. Attention must shift to identifying effective strategies to support the health workforce in building virtual compassion competencies.

Barriers and Facilitators for Patient-Centered Care for Hospitalized COVID Patients: Lived Experiences from Ex-hospitalized Patients and Health Care Professionals

Article

Dec 2022

The COVID pandemic has challenged patient-centeredness, an increasingly valued approach in the pursuit of high-quality care. This research aimed to explore barriers and facilitators for patient-centered care (PCC) in the context of the COVID pandemic. Semi-structured interviews were conducted with seven ex-hospitalized COVID patients and ten health care professionals (HCPs) who have cared for this patient group. A phenomenological design was used with a photo-elicitation method to capture participants’ lived experiences. Findings indicate that COVID entailed multiple and interrelated barriers across all dimensions of PCC. COVID care practices like intubation and isolation also negatively impacted patients’ physical comfort, ability to communicate, and emotional well-being. Despite HCPs’ motivation to improve patients’ well-being, they were hampered by serious barriers, including a lack of time and challenges in care coordination. Due to these difficulties, the question can be raised whether PCC during a communicable disease pandemic is feasible. Nevertheless, as shown in this study, key facilitators such as digital communication tools and a holistic and personal care approach demonstrate that rendering PCC remains vital and should be aimed for and that this could be informed by the lived experiences of HCPs and patients.

Emergency Medicine Telehealth: A Pandemic Becomes a Gateway for Virtual Care in Missouri

Article

Sep 2022
Mo Med

Telehealth provides a novel bridge between patient needs and available resources. On-demand telehealth visits provide urgent medical services in a virtual setting. Telehealth can be used to provide care for patients despite geographical distance. Emergency Medicine quickly adapted in response to the COVID-19 pandemic through utilization of telehealth to solve various problems. Tele-triage was used to coordinate COVID-19 testing and treatment. Greater utilization of all current and emerging telehealth modalities could increase access and quality of care for all Missourians.

Mental Health Implications for Aviators from COVID-19

Article

Oct 2022

Mental Health Implications for Aviators from COVID-19 Objective The authors present aeromedical implications from COVID-19 disruptions on the civil aviation sector, consider mental health impacts on pilots, and discuss possible helpful responses to support pilot mental health. Methods A multiple database review investigated articles from January 2002 to May 2021 on severe commercial aviation disruptions impacting pilot mental health and on pilot mental health coping or treatment. Fifteen papers were identified. Results During the COVID-19 pandemic, airline flights were severely reduced. By January 2021, airlines shed thousands of jobs and 24 airlines no longer existed. General population surveys found 13% of individuals had “serious distress” from the pandemic. In two aviation focused surveys, 40-66% of pilots agreed or strongly agreed that their mental health worsened since the COVID-19 pandemic. Compared to past Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS) patients, more COVID-19 patients have mental health symptoms in the acute phase of illness; while about 10% of COVID-19 patients appear to have chronic or “long haul” symptoms. Mental Health treatment and coping strategies found helpful to pilots are discussed. Conclusions Pilots remain at risk for mental health symptoms and illness due to the COVID-19 pandemic. For those who develop severe distress or mental illness from the effects of the pandemic (or COVID-19 infection), early treatment with psychotherapy and/or approved medications may be warranted. This may decrease the likelihood of persistent physical or cognitive or mental health symptoms that would delay a return to flying status.

Virtual Mental Health Care in the Veterans Health Administration’s Immediate Response to Coronavirus Disease-19

Article

Full-text available

Oct 2020

The coronavirus disease 2019 (COVID-19) pandemic has increased the need for psychological care in the global population and has created new barriers to accessing services. Hospitals, mental health facilities, and other clinics face the challenge of providing continued care to a population that is under severe stress, while minimizing in-person visits that risk spreading the virus. The Veterans Health Administration (VHA) is the largest integrated health care system in the United States, providing care at 1,286 sites. VHA ensured the continuity of mental health services after the COVID-19 outbreak by rapidly expanding its use of telemental health methods in the first weeks after the U.S. pandemic outbreak. VHA provided nearly 1.2 million telephone and video encounters to veterans in April 2020 and reduced in-person visits by approximately 80% when compared with the October 2019 to February 2020 period before the pandemic. By June 2020, VHA had an 11-fold increase in encounters using direct-to-home video and a fivefold increase in telephone contacts relative to before the pandemic. This article discusses research on the effectiveness of telemental health, VHA policies before COVID-19 that facilitated the use of telemental health systemwide, and VHA’s actions that rapidly scaled use of telemental health during the first months of the outbreak. Key challenges and lessons learned from VHA’s experience and implications for providers and health care systems regarding the use of telemental health to meet patients’ mental health care needs during the pandemic are also discussed.

Opportunities and challenges for telehealth within, and beyond, a pandemic

Article

Full-text available

Aug 2020

The Effects of COVID-19 on Telemedicine Could Outlive the Virus

Article

Full-text available

Jul 2020

Paying for Telemedicine After the Pandemic

Article

Feb 2021
J Am Med Assoc

One of the major positive changes in care delivery during the coronavirus disease 2019 (COVID-19) pandemic is the surge in telemedicine use. Because telemedicine eliminates the risk of viral transmission during travel and in the clinical setting, it has been a valuable tool for maintaining patient access to care for health issues both related and not related to COVID-19.

Ensuring Quality in the Era of Virtual Care

Article

Feb 2021
J Am Med Assoc

The coronavirus disease 2019 (COVID-19) pandemic, aided by a relaxation in federal telemedicine regulations, has ushered in a new era of virtual care. Physicians and patients have substantially increased their adoption and use of virtual care. According to one report, an estimated 1.6 million telemedicine visits were conducted early in the pandemic, between January and March 2020, representing approximately 50% more telemedicine visits than occurred in the same period in 2019.¹ Based on aggregated payer data covering 150 million privately insured individuals in the US, by April 2020 telemedicine visits accounted for 13% of all medical claims compared with 0.15% in April 2019, an 86-fold increase.

Trends in Outpatient Care Delivery and Telemedicine During the COVID-19 Pandemic in the US

Article

Nov 2020

This cohort study examines trends in the use of telemedicine and in-person outpatient visits in 2020 among a national sample of 16.7 million individuals with commercial or Medicare Advantage insurance.

Virtually Perfect? Telemedicine for Covid-19

Article

Mar 2020

Evolutionary Pressures on the Electronic Health Record: Caring for Complexity

Article

Aug 2016

But the evolution of EHRs has not kept pace with technology widely used to track, synthesize, and visualize information in many other domains of modern life. While clinicians can calculate a patient’s likelihood of future myocardial infarction, risk of osteoporotic fracture, and odds of developing certain cancers, most systems do not integrate these tools in a way that supports tailored treatment decisions based on an individual’s unique characteristics. Similarly, some algorithms (many developed by insurers) can identify patients at high risk for hospitalization,³ but evidence lags when it comes to using predictive analytics to deliver preventive care and services to targeted individuals. Existing EHRs also have yet to seize one of the greatest opportunities of comprehensive record systems—learning from what happened to similar patients and summarizing that experience for the treating physician and the patient.⁴ For instance, when a 55-year-old woman of Asian heritage presents to her physician with asthma and new-onset moderate hypertension, it would be helpful for an EHR system to find a personalized cohort of patients (based on key similarities or by using population data weighted by specific patient characteristics) to suggest a course of action based on how those patients responded to certain antihypertensive medication classes, thus providing practice-based evidence when randomized trial evidence is lacking.

Fostering human connection in the Covid-19 virtual health care realm. NEJM Catalyst website

L Cooley

Cooley L. Fostering human connection in the Covid-19 virtual health care realm. NEJM Catalyst website. Published May 20, 2020. Accessed December 28, 2020. https://catalyst.nejm.org/doi/ full/10.1056/CAT.20.0166

Humanism in telemedicine: connecting through virtual visits during the COVID-19 pandemic

M Shankar
M Fischer
C G Brown-Johnson
N Safaeinili
M C Haverfield
J G Shaw
A Verghese
D M Zulman

Shankar M, Fischer M, Brown-Johnson CG, Safaeinili N, Haverfield MC, Shaw JG, Verghese A, Zulman DM. Humanism in telemedicine: connecting through virtual visits during the COVID-19 pandemic. Annals of Family Medicine COVID-19

The bedside evaluation: ritual and reason.

Jan 2011
550

Verghese

10. Academy of Communication in Healthcare. Telehealth communication: quick tips. Accessed December 28, 2020. http://www.achonline.org/ Telehealth 11. Verghese A, Brady E, Kapur CC, Horwitz RI. The bedside evaluation: ritual and reason. Ann Intern Med. 2011;155(8):550-553. doi:10.7326/ 0003-4819-155-8-201110180-00013

Virtual Care, Telemedicine Visits, and Real Connection in the Era of COVID-19: Unforeseen Opportunity in the Face of Adversity

No full-text available

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