Free access
Published Online: 4 April 2023

Annual Conference & Expo
March 4–6, 2023
San Antonio, Texas

Publication: Telemedicine and e-Health
Volume 29, Issue Number 4
“In support of improving patient care, this activity has been planned and implemented by the Renal Physicians Association and the University of Virginia School of Medicine and School of Nursing is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.”
The University of Virginia School of Medicine and School of Nursing designates this live virtual activity and enduring material, for a maximum of 26.0 AMA PRA Category 1 Credits.TM Physicians should claim only the credit commensurate with the extent of their participation in the activity.
The University of Virginia School of Medicine and School of Nursing awards 26.0 contact hours for nurses who participate in this educational activity and complete the post activity evaluation.
Successful completion of this CME activity enables the participant to earn MOC points equivalent to the amount of CME credits claimed for the activity for a maximum of 26.0 MOC Part II (ABMS) points.
“Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 26.0 MOC points [and patient safety MOC credit] in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.”.

ATA2023 – Research Abstracts
Oral Presentations


Sameer Berry, MD, MBA, 1 Jeffrey Berinstein, MD, MS,2 David Cook, MD, MHA,3 Michael Lahm, MS, OptumLabs,3 Walter Chan, MD, MPH, 4 John Allen, MD, MBA, 5 William Chey, MD5
1Oshi Health, New York Gastroenterology Associates
2Division of Gastroenterology, Department of Internal Medicine, University of Michigan School of Medicine
4Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital; Harvard Medical School
5Division of Gastroenterology, Department of Internal Medicine, University of Michigan School of Medicine
Description: We evaluated the efficacy of a virtual integrated care program among 234 patients with functional gastrointestinal disorders. Enrolled patients demonstrated fewer missed work days, reported improvement in work productivity, and high program engagement, satisfaction, and symptom improvement with significant savings in healthcare costs compared to matched controls.
Abstract: Functional gastrointestinal disorders (FGIDs) are common conditions characterized by chronic gastrointestinal (GI) symptoms without structural abnormalities. FGIDs are complex and may benefit from a virtual integrated‐care approach. We performed a prospective, single‐arm clinical trial with propensity‐score matched controls to evaluate the efficacy of a virtual integrated‐care program for patients with FGIDs and impact on outcomes, satisfaction, and costs. Analyses using two index events (GI_Visit_+Lookback and GI_Visit) compared differences when including upstream costs prior to the GI visit in the matched control group. 234 participants enrolled with 83% patient engagement, 98% satisfaction, and 92% symptom improvement. Participants reported fewer missed workdays and demonstrated lower healthcare utilization. After 6 months, patients in the virtual integrated‐care program had significantly lower GI‐related costs compared to the control group in both GI_Visit_+Lookback ($3,934 vs. $9,047, p < 0.0001) and GI_Visit ($3,674 vs. $5,996, p = 0.0026) analyses. Difference‐in‐difference analysis after 6‐months demonstrated lower GI‐related costs in the virtual program of $6,724 (GI_Visit_+Lookback, p < 0.0001) and $3,095 (GI_Visit, p = 0.0039). A virtual integrated program resulted in high patient engagement, satisfaction, and symptom improvement with significantly reduced healthcare utilization and costs compared to matched controls.
Classification of Research: Access to Care
Method: Single‐arm clinical trial with propensity score matched observational controls
Results: 234 participants enrolled with 83% patient engagement, 98% satisfaction, and 92% symptom improvement. Participants reported fewer missed workdays and demonstrated lower healthcare utilization. After 6 months, patients in the virtual integrated‐care program had significantly lower GI‐related costs compared to the control group with both the GI_Visit_+Lookback ($3,934 vs. $9,047, p < 0.0001) and GI_Visitanalyses ($3,674 vs. $5,996, p = 0.0026). Difference‐in‐difference analysis after 6‐months demonstrated lower GI‐related costs in the virtual program of $6,724 (GI_Visit_+Lookback, p < 0.0001) and $3,095 (GI_Visit, p = 0.0039).
Conclusions: A virtual integrated care program resulted in high patient engagement, satisfaction, symptom improvement, reduced healthcare utilization, and statistically significant cost‐savings compared to matched controls. Traditional care is often unable to address the needs of patients with functional gastrointestinal disorders resulting in poor outcomes, unnecessary cost, and tremendous patient suffering. This virtual integrated care program represents a high‐value intervention for patients with complex chronic gastrointestinal conditions refractory to traditional care models.
Grant Support: ADAPT UCSF.


Tram Thai, PharmD, 1 BCACP, AE‐C, Greg Downing, DO, PhD, 1 Melanie Plotke, 1 Eric Olmsted, 2 Farrukh Jafri, MD, 3
2CWH Advisors
3White Plains Hospital
Description: An efficacy study to assess an innovative care model in a Virtual Pharmacist Clinic to optimize medication management and increase patient‐provider engagement by facilitating multiple points of contact and leveraging multiple communication channels. The goals of this quality improvement program were to decrease hospital readmissions and improve patient satisfaction.
Abstract: Patient‐provider telehealth engagement is critical to impacting outcomes with optimal cost‐effective strategies still under investigation. Interactions made by clinical pharmacists and clinical support staff with post‐discharge adult patients transitioning home across one hospital and two health plans were studied in this retrospective analysis over the period of 8 months. Process of interest included strategies for: (1) patient outreach, (2) provider uptake of recommendations, and (3) patient satisfaction. First steps included scheduling patients for an appointment with a clinical pharmacist by contacting the patient via phone, SMS, and email for days 1‐10 post‐discharge utilizing the enrollment attempt process outlined in Figure 1. During the patient visit, clinical pharmacists completed a full medication review, including disease state and medication education, addressing barriers to access of medications, and managing patient questions or concerns. Medication optimization recommendations and safety threats were relayed to the patient's provider at the conclusion of the visit by fax, and by phone for urgent concerns at risk of readmission or adverse event that could lead to harm. Patients were asked to complete an optional 3‐question satisfaction survey regarding their visit with the clinical pharmacist scoring on a scale of strongly agree (1) to strongly disagree (4).
Classification of Research: Quality Improvement
Method: Descriptive
Results: A 6.9% decrease in 30‐day heart failure readmissions was observed in the health system group. Uptake of recommendations across all groups ranged from 58% to 81%, noting increased uptake with medication access interventions. Of 13,933 eligible patients, 6,843 (49.1%) patients scheduled a visit, with higher success secondary to reaching the patient within 72 hours post‐discharge. A total of 20.6% of patients completed the optional patient satisfaction survey, averaging 1.1 for satisfaction with care received, 1.2 for the ability to ask questions, and 1.2 for having a clear understanding of their medication purposes.
Conclusions: In our descriptive review, higher patient engagement was associated with contact within 72 hours post‐discharge. Provider engagement was found to be higher for concerns regarding access to medications. The impact of this virtual model led to a statistically significant reduction in 30‐day readmission for heart failure patients along with positive satisfaction scores among those who received care from the virtual pharmacy clinic.


Laura Christopherson, Ed.D. MBA, Angela Leuenb, MS
Mayo Clinic
Description: The value proposition should be considered when evaluating new virtual clinical care delivery programs. The overall assessment of the value proposition begins at discovery and informs the decision to proceed with program development. Once developed, an assessment plan should be utilized to measure program effectiveness against baselines and targets.
Abstract: We took a systematic approach to assess the value proposition of virtual clinical programs across the care continuum including low‐intensity and high‐intensity programs designed to monitor patient's biometric data and symptom assessments. This included remote patient monitoring programs and app‐based interactive care plans that utilize technology to monitor patients remotely, keeping them in their homes and engaged in managing their condition or health event. A framework was developed that considered the desirability, viability, and feasibility of each new program request. The framework requires input of the patient population volume, clinical goals, predicted clinical outcomes, impact on care team burden, cost of development, and patient and provider satisfaction targets. A multi‐disciplinary team of providers, nurses, operational leaders, and implementation scientists developed the inputs for this framework. The inputs were then scored to enable prioritization of program development based on anticipated impact for patients and care teams. This evaluation process ensured that programs with the highest potential for achieving clinical goals are prioritized while balancing costs and care team satisfaction. As plans were being designed, an assessment plan was developed to establish baselines and targets post‐implementation. This plan was deployed to gather data and develop reporting solutions to enable program evaluation post‐implementation.
Classification of Research: Measurement Frameworks & Tools
Method: Descriptive
Results: The assessment framework was developed and utilized across all virtual clinical care delivery programs from the discovery phase to program assessment post‐implementation. The discovery teams found that the framework enabled a more robust discovery process that promoted objective evaluation of new programs. The use of the framework strengthened the prioritization process to ensure that program development aligned with institutional priorities across the medical practice. Further, it fostered confidence amongst executive and physician leadership in the development and assessment of new programs, enabling the acceleration of virtual clinical care delivery across the institution.
Conclusions: The implementation of the framework enables prioritization of programs that have the highest potential to impact clinical outcomes, enable care team efficiencies and drive costs down. This framework provides utility for clinical and operational teams to evaluate new programs across both the care continuum and the development cycle. In practice, the framework is continually evolving as clinical and operational teams gain a deeper understanding of what measures drive the efficacy of virtual clinical care delivery programs to deliver maximum value to the patients and care teams.


Sy Saeed, MD, MS
The North Carolina Statewide Telepsychiatry Program (NC‐STEP), East Carolina University
Description: We will present research findings on ED boarding of patients; cost savings associated with the use of telepsychiatry; and how the COVID‐19 crisis has led a heightened demand for telepsychiatry consultations in NC, but there is a possible race disparity in these demands between black and white mental health patients.
Abstract: A growing body of literature now suggests that the use of telepsychiatry to provide mental health care has the potential to mitigate the workforce shortage that directly affects access to care, especially in remote and underserved areas.
The North Carolina Statewide Telepsychiatry Program (NC‐STeP) was developed in response to NC Session Law 2013‐360 and launched in October 2013. Since then, as of March 31, 2022, NC‐STeP has provided 52,764 telepsychiatry consults with 8,392 involuntary commitments being overturned, with associated savings of more than $45,316,800. Given the success of the program, in 2018 the North Carolina legislature expanded the scope of services provided to beyond emergency departments to the community‐based settings, using a collaborative care model. Since then, NC‐STeP has added 18 outpatient sites to its 40‐hospital network. We will present data from NC‐STeP published research that focuses on ED boarding of patients; cost savings associated with the use of telepsychiatry; and how the COVID‐19 crisis has led to a heightening demand for telepsychiatry consultations in NC, but there is a possible race disparity in these demands between black and white mental health patients. We will also discuss technological innovations from the program, including developing a web portal.
Classification of Research: Regulatory & Policy Research
Classification of Research ‐ Other (if different from options above): Findings in the areas of clinical outcomes, cost analysis, and access to care‐ all have implications for policy and regulations
Method: Descriptive. We will present findings from three different studies, including various methodologies.
Results: 1. Use of telepsychiatry can enhance patient and clinician experience; and reduce costs by impacting ED boarding time and reducing unnecessary psychiatric hospitalizations.
2. COVID‐19 has heightened demand for telepsychiatry consultations in NC, but there is a possible race disparity in these demands between black and white mental health patients.
Conclusions: 1. Use of telepsychiatry can enhance patient and clinician experience; and reduce costs by impacting ED boarding time and reducing unnecessary psychiatric hospitalizations.
2. COVID‐19 has heightened demand for telepsychiatry consultations in NC, but there is a possible race disparity in these demands between black and white mental health patients.


(Presentation combined with The Role of Tele‐OUD Treatment in Decreasing Healthcare Utilization)
Barbara Burke, MPH, Winifred Gallogly, BS, Brian Clear, MD, FASAM, Rebekah Rollston, MD, MPH
Bicycle Health
Description: An observational study was conducted to compare patient relapse risk factors, protective factors, and substance use prior to and 1 month after initiating tele‐OUD treatment. Two‐hundred seven patients completed a baseline and month 1 Brief Addiction Monitor (BAM). Preliminary results show more favorable scores at month 1 compared to baseline.
Abstract: The Brief Addiction Monitor (BAM) is used to monitor drug and alcohol use, relapse risk, and protective factors among patients in treatment for substance use disorders. The objective of this study is to assess how usage, risk factors, and protective factors changed over time after initiation of telehealth treatment for opioid use disorder (OUD). Two‐hundred seven patients completed a baseline and month 1 BAM survey via a mobile application as part of routine care. Preliminary results show that tele‐OUD treatment is associated with less usage of drugs and alcohol, fewer risk factors, and a lower risk‐to‐protective factor ratio.
Classification of Research: Clinical Outcomes
Method: Observational
Results: There were 207 patients who completed baseline and month 1 BAM surveys. The average subscore changes from baseline to month 1 are: 1) usage of drugs and alcohol decreased by 1.6 points out of 12 possible, 2) risk score decreased by 3.2 points out of 24 possible, and 3) protective score increased by 0.4 points out of 16 possible. The average risk‐to‐protective ratio at baseline was 0.77, and at month 1 was 0.51. While both of these ratios indicate more protection than risk, a decrease in ratio at month 1 indicates less risk for use.
Conclusions: Exposure to tele‐OUD treatment helps to reduce patient risks for relapse and usage of drugs and alcohol. The results demonstrate that tele‐OUD treatment is associated with less patient‐reported use of drugs and alcohol, fewer triggers or causes of substance use (risk factors), and a lower risk‐to‐protective factor ratio.


Derek Baughman, MD,1,2 Yalda Jabbarpour, MD,2 John Westfall, MD, MPH2
1WellSpan Health
2Robert Graham Center
Description: In this cohort study of 526,874 patients, telemedicine exposure was associated with significantly better performance or no difference in 13 of 16 quality performance comparisons. Findings suggest that telemedicine exposure poses a low risk for negatively affecting HEDIS performance, highlighting its potential to suitably augment care capacity.
Abstract: BACKGROUND: It is unknown how the pandemic‐driven rapid adoption of telemedicine has affected quality of patient care.
METHODS: HEDIS quality measures were retrospectively compared between patients with office‐only (in‐person) vs telemedicine visits (telemedicine‐exposed) from March 1, 2020, to November 30, 2021, across 200+ outpatient sites in Pennsylvania and Maryland. χ2 tests determined statistically significant differences in quality performance. Multivariable logistic regression controlled for sociodemographic factors and comorbidities.
CONCLUSIONS: Patients with telemedicine exposure had a largely favorable association with quality of primary care. This supports telemedicine's value potential for augmenting care capacity, especially in chronic disease management and preventive care.
Classification of Research: Clinical Effectiveness
Method: Descriptive
Results: The study included 526,874 patients (409,732 office‐only; 117,142 telemedicine‐exposed) with comparable demographics. Patients with office‐only visits performed better in medication‐based measures, but only 3 of 5 had significant differences: cardiovascular disease (CVD) receiving antiplatelets, CVD receiving statins, and avoiding antibiotics for in URIs (insignificant differences: heart failure receiving β‐blockers and diabetes receiving statins). Patients with telemedicine exposure had better performance in all testing‐based measures (CVD with lipid panels, diabetes with HbA1c testing and nephropathy testing, and blood pressure control) and all counseling‐based measures (cervical, breast, and colon, cancer screening; tobacco and vaccination counseling for influenza and pneumococcus; and depression screening).
Conclusions: This cohort study found early evidence of telemedicine's favorable association with the quality of primary care during COVID‐19. For chronic disease management and preventive care, telemedicine exposure appeared to have had a positive association with HEDIS quality performance, and this study highlights a gap in the literature: understanding the relationship between the ideal blend of telemedicine and in‐office care. For policy makers, these findings of comparable quality support telemedicine's continued funding. For practices and health systems, this study demonstrates telemedicine's value in appropriate populations: augmenting primary care capacity without negatively affecting care quality.


(Presentation combined with Synchronous Teleconsultation and Monitoring Service Targeting COVID‐19: Leveraging Insights for Healthcare).
Clara Oliveira, MD, MSc, PhD
Universidade Federal de Minas Gerais
Description: Data addressing the costs and the potential incremental access to healthcare service achieved by the establishment of a COVID‐19 teleconsultation service are incipient. We described the labor costs for running a public COVID‐19 teleconsultation service and the incremental access to healthcare allowed by the establishment of this service in Brazil.
Abstract: This study aimed to evaluate the labor costs for running a COVID‐19 telehealth system and its potential incremental access to healthcare service.
From July 2020 to July 2021, data from a public Brazilian teleconsultation service were analyzed. Labor costs were estimated by time‐driven activity‐based costing. A Generalized Reduced Gradient solving method was coded to maximize the mean incremental access rate and two scenarios were considered to compare the teleconsultation to the in‐person consultation: (i) only the length of time that patients spent with a clinician in an in‐person consultation was accounted; and (ii) in addition to the medical consultation, it was accounted the nursing screening.
Mean labor costs per medical and nursing teleconsultations are Int$ 24 and Int$ 10, based on data analyses from 25,258 patients. Telemonitoring a patient with a daily call for seven days costs, on average, Int$ 14. COVID‐19 teleconsultation service represents, on average, an incremental access to medical consultation rate of 35% to 52% for the scenarios (i) and (ii), respectively.
A COVID‐19 telehealth service contributes to increasing access to the healthcare service and can be included in the bundle of strategies offered in a public system that looks for more sustainable strategies to provide care.
Classification of Research: Cost Analyses
Method: Cost Analyses
Results: Throughout the study, 25,258 patients were accessed and 35,475 nursing teleconsultations, 20,876 medical teleconsultations and 100,890 telemonitoring calls performed by undergraduate students were carried out. Mean labor costs per medical and nursing teleconsultations were Int$ 24 and Int$ 10, respectively . Telemonitoring a patient with a daily call for seven days costed, on average, Int$ 14. The mean monthly cost for the medical teleconsultation service was Int$ 38,115, that represents, on average, an incremental access to medical consultation rate of 35% to 52% for the scenarios (i) and (ii), respectively, and considering the current consumed budget for this service.
Conclusions: COVID‐19 telehealth service can increase access to the healthcare system and is a cost‐saving strategy. This information is valuable for managers, to better allocate and plan public funding for healthcare services to the population. In the context of scarce resources to deliver care with quality and safety to the population, the study was also a pioneer in estimating how a telehealth service contributes to increasing access to the healthcare system to the population.


Anders Carlson, MD, Kristine Robb, Spat Shakya, Lisa Ide, MD
Zipnosis by DocSquad
Description: The antiviral combination medication nirmatrelvir/ritonavir has been FDA authorized for emergency use during the COVID‐19 public health emergency. When used in appropriate patients, treatment can significantly reduce COVID‐19 related hospitalization and death. We present the findings of an asynchronous telehealth solution for prescribing nirmatrelvir/ritonavir to appropriate candidates for therapy.
Abstract: The antiviral combination medication nirmatrelvir/ritonavir (Paxlovid, Pfizer, New York, NY) has been authorized for use in COVID‐19 positive patients over age 12 and weighing more than 88 pounds who are at high risk for disease related to the virus. It has been shown to greatly reduce hospitalization and death from COVID‐19. Primary care and urgent care clinics needed to quickly adapt to the high demand and uncertain availability of this medication shortly after it was authorized. To aid in this workflow, we created an asynchronous telehealth protocol for symptomatic adult patients who have tested positive for COVID‐19 and have 5 days or less of mild to moderate symptoms. The protocol asks detailed questions about symptoms and medical history, and also asks patients about their kidney and liver health. If known, patients can enter their most recent estimated glomerular filtration rate (eGFR). Patients are also asked to upload a photo of their positive COVID‐19 test, if accessible. Based on the response to the adaptive interview questions, a clinician then reviews the patient responses and, if appropriate, sends an electronic prescription to the patient's preferred pharmacy through the telehealth platform.
Classification of Research: Access to Care
Method: Observational
Results: From June 8 to August 26, 2022, 659 visits were started for nirmatrelvir/ritonavir (81.8% of visits were completed), of which 416 visits (77%) resulted in a nirmatrelvir/ritonavir prescription. 123 visits (23%) did not have a prescription for nirmatrelvir/ritonavir (most of which (80%) clinicians diagnosed “COVID‐19 Infection: Paxlovid not recommended”). Patients were majority age 30‐49, and mostly female. Average clinician response time was 5: 44 min (time from patient completion to clinician finalizing the diagnosis/treatment plan), with average diagnosis time of 50 seconds (time from clinician opening visit to rendering diagnosis/assessment). Support calls were mostly related to pharmacy questions regarding kidney function.
Conclusions: An asynchronous protocol to prescribe nirmatrelvir/ritonavir to appropriate symptomatic adult patients is an efficient alternative to conventional methods, with a high number of patients completing the protocol questions receiving a prescription for nirmatrelvir/ritonavir. Considering the time and resource burden to primary/urgent care clinicians and their staff, a telemedicine protocol assessing COVID‐19 positive patients for the appropriate use of antiviral therapy could be a time‐saving approach and keep symptomatic patients out of the physical clinic space. Support calls regarding kidney function remain an issue. Additional research into clinical outcomes and cost savings will be performed as more visits are completed.


Joshua Briscoe
Emergency Physicians Central Florida, LLC
Description: Background: COVID‐19 surges led to excessive crowding in the ED and increases in patients leaving without being seen.
Objective: Evaluate virtual telehealth rounding (VTR) in the ED on the prevalence of left without being seen (LWBS) dispositions during the pandemic and its effect on mortality and patient safety.
Abstract: The trial of VTR took place for 107 days in December 2021‐April 2022 and ran for 65 days (8‐hours a day). The remaining 42 days served as a comparison group. During VTR, patients were triaged per usual upon arrival. Those patients with triage acuity categories II to V who were triaged to the waiting room were then evaluated virtually by a remote clinician after their initial screening examination using a secure virtual health platform. Patients were then reevaluated at 1‐2 hour intervals if necessary. They expedited care by ordering diagnostics, changing the patient's triage category, and determining early disposition according to usual clinical practice. Patients were then either left in the waiting room, taken for radiography and/or blood work, or taken back to a room in the ED where they were seen by an onsite ED physician. ED paramedics were available onsite to take vital signs, transport patients, and communicate directly with the onsite nurses and physicians. The main outcome was the LWBS rate, including LWBS before and after triage, patients leaving against medical advice and elopements. Secondary patient outcomes included in‐hospital mortality and improved patient safety defined as care that was urgently/emergently escalated by VTR.
Classification of Research: Clinical Outcomes
Method: We conducted a cross sectional study on patients presenting to a level 1 trauma and tertiary referral center who were triaged to the waiting room.
Results: There were 19,958 patients included, 6,953 (35%) evaluated via VTR & 13,006 (65%) received standard of care. Acuity levels at triage were II 24%, III 54%, IV 22%, & V 1%. Mean triage levels were 2.95 (95%CI 2.94‐2.97) in the VTR group & standard at 3.07 (95%CI 3.06 – 3.09). The proportion of LWBS was 565 (8%) in VTR patients & 3,246 (25%) in the standard group (p < 0.001). Overall, 27 (0.1%) patients did not survive to discharge, 7 (0.1%) VTR patients & 20 (0.2%) in the standard group (p = 0.421). VTR clinicians documented “great saves” in 5% of encounters.
Conclusions: This novel approach to triage in the ED significantly reduced the proportion of patients with LWBS dispositions by 17%. Although in‐hospital mortality was lower in the VTR group it was not statistically significant. Furthermore, VTR clinicians documented rapid escalations in care that may have otherwise been delayed or missed. This approach has the potential to improve patient care and provide relief from crowding.


Geoffrey Tso, MD, Ilya Valmianski, Ph.D., Varun Nair, Luladay Price, MS, Jack Craddock, BS, Xavier Amatriain, Anitha Kannan
Curai Health
Description: We present an approach that brings “physician‐in‐the‐loop” AI/ML systems into virtual care to dramatically scale the clinical capacity of a physician‐led care team through enhanced clinical decision support and workflow automation, while providing high‐quality, accessible, and cost‐optimized care to patients.
Abstract: Introduction: In this study, we describe an approach to using AI/ML to multiply the clinical capacity of a physician‐led care team and provide high‐quality, comprehensive care on a chat‐based telemedicine platform. The AI/ML systems integrate into the care team workflow and provide real‐time clinical decision support to reduce cognitive load, improve quality in medical decision making, and offload redundant tasks such as charting. Physicians, in turn, provide implicit feedback on recommendations by the AI/ML through their interactions with the EHR, enabling a learning AI/ML healthcare system.
Methods: Over a 6 month period on an acute care platform, we observed the workflow impact of care teams augmented by “physician‐in‐the‐loop” AI/ML implementations. The chat‐based virtual care model was designed using user‐centered design methodologies to tightly integrate care teams with state‐of‐the‐art AI/ML deep learning and natural language processing models such as GPT‐3. Through the AI‐enhanced virtual care platform, the physicians were aided by an automated history taking process that assists the diagnosis and triage process that leads to a dynamically generated history of present illness (HPI) notes. During the visit, an ML medication recommender also provides point of care clinical decision support to the physicians.
Classification of Research: Clinician Experience
Method: Observational
Results: An average of 24.4 clinical findings were elicited from patients through history taking with 21.8 (89%) of those findings elicited through automation features prior to the physician seeing the patient. 28.5% of the patients were routed to a different level of care (6.7%: ER, 3.29%: brick‐and‐mortar urgent care, 4.96%: non‐urgent in‐person care) prior to their physician visit. The HPI generation model had an F1‐score (harmonic mean of sensitivity and specificity) of 93.2% for clinical findings. The AI medication recommender had a top 1 accuracy of 30.4% and top 3 of 49.5%.
Conclusions: As machine learning in healthcare continues to improve, telemedicine platforms can benefit from the integration of “physician‐in‐the loop” systems. When appropriately implemented, AI/ML models can have a direct impact on increasing the scalability of telemedicine physicians. Continued investment in learning health systems that treat the AI as a member of the care team can provide a path towards providing scalable, high quality, appropriate, and cost‐optimized access to healthcare.


Bart Demaerschalk, MD, Julianne Lunde, Jordan Coffey
Mayo Clinic
Description: Utilization of digital healthcare has increased exponentially. With this rapid growth, there is a need to study the delivery of healthcare digitally. Historically, digital health research has lacked a coordinated effort at our institution.
Abstract: Mayo Clinic seeks to advance the delivery of digital health care through the meaningful study of efficacy, quality, safety, service, clinical, and economic value of digital practice and by exploring new technologies and approaches. The Research Unit within the Mayo Clinic Center for Digital Health aimed to develop a 5‐year research agenda around which to focus and align research efforts. This approach helps to proactively identify critical areas for evaluation, ensuring that evidence is available to inform key conversations and decisions. Other purposes of the agenda were to ensure that resources devoted to digital health research were targeted to arenas with the greatest perceived impact for our patient and provider population as well as to establish a balanced research portfolio.
Classification of Research: Quality Improvement
Method: Survey / Qualitative. An initial survey was developed to determine top research themes in digital health. The survey was sent to a cross‐section of 40 digital health thought leaders from academia, provider organizations, payers, and solution providers. Respondents were asked to identify five top themes of primary concern and focus for digital health. Themes were collected, collated, cross‐referenced for common elements, and affinitized. From this qualitative exercise, ten primary themes emerged (table 1). A second survey instrument was developed to facilitate ranking of these top themes and electronically distributed to ATA members and to digital heath leaders within Mayo Clinic (N = 6424). Two reminders were sent to respondents for completion of the ranking survey. Results of the survey were analyzed. The study was reviewed by the Mayo Clinic IRB and deemed not to require IRB approvals.
Results: Response proportion was 15/40 (37.5%) to the initial survey. From the initial survey, 25 total concepts were identified and subsequently grouped into 10 themes (table 1). Response proportion was 123/6424 (1.9%) to the ATA‐Mayo Clinic survey ranking instrument. The ranking of themes emerged (table 2). The top four themes were clinical appropriateness, equity/access, clinical parity and economics.
Conclusions: Digital health thought leaders agreed on top themes for research focus over the next five years. Next steps will be to assemble working groups surrounding the top four themes of importance. These groups will be comprised of up to ten researchers at Mayo Clinic. The goal of these groups is to identify answerable focused research questions and action on them.


Khyathi Gadag Venkataramana, MHA, Whitney Zahnd, PhD
University of Iowa
Description: This study aims to assess the uptake of telemental health services in FQHCs after pandemic‐related changes to telehealth policies and evaluate the resultant utilization of mental health services in FQHCs that adopted telemental health as a primary telehealth service.
Abstract: Historically, policy and resource barriers made it challenging for the Federally Qualified Healthcare Centers (FQHCs) to offer tele‐mental health. The healthcare needs of the pandemic were the impetus for many temporary waivers and relaxations to promote the use of tele‐mental health services. Congressional proposals to make these temporary changes permanent indicate the need for research on adopting tele‐mental health in health centers and the utilization of telemental health services after the telehealth policy relaxations. We used the Uniform Data Systems (UDS) annual performance data for 2019 and 2020 to examine changes in uptake of tele‐mental health as a primary telehealth service and its impact on utilization of mental health services in FQHCs related to pandemic. We used the McNemar test to assess the difference between the proportion of FQHCs delivering mental health as a primary telehealth service and negative binomial regression to analyze the effect of delivering mental health services as a primary telehealth service on the utilization of mental health services.
Classification of Research:Regulatory & Policy Research
Classification of Research ‐ Other (if different from options above):Access to care
Method: Observational
Results: There was a significant increase in the percentage of FQHCs offering primary tele‐mental health services from 32.2 percent in 2019 to 94.2 percent in 2020. For the year 2020, we observed 2.42, 2.3, and 2.2 higher rates of visits for depression, anxiety, and other mental disorder treatments, respectively, in healthcare centers that deliver mental health as a primary telehealth service compared to FQHCs that did not. Overall, the FQHCs that delivered mental health as their primary telehealth service saw an increased utilization rate of their mental health services compared to the FQHCs that did not offer them.
Conclusions: With a significant increase in FQHCs offering mental health as a primary telehealth service and an increase in the utilization rates of mental health services, this study offers a strong case for making pandemic‐driven waivers and policies permanent. Also, our finding suggests that tele‐mental health was a service that overall increased the use of the FQHC, not a substitute for what had been onsite visits.


(Presentation combined with Impact of Combine with Telehealth Access Among Low Income Communities)
Cynthia Williams, PhD MHA, PT
University of Central Florida
Description: There are considerable efforts to decrease inequities in healthcare access, however, the proliferation of technology and the pandemic of 2019 eclipse equity in access efforts. Although policies and reimbursement practice promoted the telehealth use, telehealth engagement is low. Without significant changes, this group will experience a greater divide in access.
Abstract: Due to reimbursement increases, policy changes, and the global pandemic, telehealth utilization increased across the United States. However, telehealth utilization remained low among Medicaid enrollees. Medicaid beneficiaries are of particular interest as this public insurance program serves low‐income people who experience health inequities in the traditional healthcare system. This group represents people who are vulnerable to the negative effects of unmet social needs and adverse health outcomes. The purpose of this study was to examine the telehealth use among Medicaid recipients after sweeping policy changes. We also examine demographic and socioeconomic factors that contribute to inequities in telehealth access. This study was conducted in partnership with a State of Florida Medicaid Managed Care program, who provides managed care services primarily through Medicaid and Medicare Advantage Insurance Plans. We examined 52,904 State of Florida Medicaid claims record of persons 21 years and older. The study period was March 2020 to December 2020. In order to examine the associations of socio‐economic factors with telehealth utilization, we retrieved data from American Community Survey Census and included persons whose income status are similar to those who qualify for Medicaid. Multiple logistic and linear regression, using R software, were used to examine study objectives.
Classification of Research: Regulatory & Policy Research
MethodCross Sectional
Results: Results suggest that Medicaid patients are 8% less likely to use telehealth as compared to Medicare patients. Male patients are 22% less likely than females to use telehealth. Patients with diabetes are more likely to use telehealth than persons with chronic obstructive pulmonary disease (‐5%) and heart failure (‐14% ). Medicaid enrollees in rural areas are 43% less likely to use telehealth than Medicaid enrollees in urban areas. Among vulnerable communities, multiple linear regression suggests that education and race was a statistically significant contributor to telehealth use, p‐value <0.01.
Conclusions: Despite policy changes, Medicaid beneficiaries remain low utilizers of telehealth services. Decision makers should be keenly aware of the impact that well‐meaning initiatives have Medicaid recipients. It is particularly concerning since the literature suggests that these initiatives are not maximized for people experiencing substantial inequities. Insurers and providers of services to Medicaid enrollees are uniquely positioned to mitigate health inequities. We provide recommendations to bolster telehealth use among low income persons who experience chronic diseases by increasing internet access and education, and encourage a team based approach in a hybrid model of telehealth to promote sustainability for this population.


Daniel Liebman, MD, MBA
Mass Eye and Ear
Description: We report on a novel telemedicine program used for follow‐up care of patients initially treated for minor ophthalmic complaints in an ophthalmic emergency department. In this implementation study, we describe development of the Virtual ED Follow‐Up Clinic (VEDFU), and present initial patient characteristics and outcomes over its initial six‐month period.
Abstract: Ophthalmic complaints comprise a significant proportion of emergency department (ED) visits, and often necessitate near‐term follow‐up examinations to assess for clinical improvement. However, such examinations can be logistically challenging to accommodate for patients, providers, and health systems. This implementation study describes the development of a novel Virtual Emergency Department Follow‐Up (VEDFU) clinic at Mass Eye and Ear (MEE), a tertiary referral and ophthalmic trauma center with an ophthalmic ED. We report on program characteristics, clinical processes, and outcomes of patients treated through this clinic in its first six months of operation.
Methods: Patients treated in the MEE ED were offered a VEDFU appointment if they lived in Massachusetts and required near‐term clinical reevaluation for conditions deemed suitable for virtual care. Video‐based appointments were conducted via Zoom and Doximity, with telephone‐based encounters utilized as a back‐up option. All patient encounters in the MEE VEDFU were assessed between December 6, 2021 and June 26, 2022. Primary outcome measures included missed appointment rate, clinical diagnoses, and rate of subsequent referrals to other clinics or back to the ED.
Classification of Research: Clinical Outcomes
Method: Implementation Science
Results: A total of 145 visits were scheduled in the VEDFU in its first six months of operation, with 99 patients (68.3%) attending their scheduled virtual appointments. The mean participant age was 38.1 years (SD ±14.2 years), and the mean time interval between ED evaluation and virtual follow up was 8.3 days (SD ±3.9). After a VEDFU appointment, 23 patients (23.2%) were subsequently referred for further subspecialty care. No patient re‐presented to the ED following their VEDFU appointment.
Conclusions: A novel telemedicine follow‐up program for ophthalmic emergency department patients enabled safe and timely virtual reevaluation for a range of minor conditions, while avoiding patient re‐presentations to the ED. Ophthalmic telemedicine may represent a promising alternative avenue for post‐acute near‐term follow‐up care after emergency department encounters for minor ophthalmic complaints. To our knowledge, this is the first program of its kind and may serve as a model for other subspecialties, for whom near‐term post‐acute clinical follow‐up can be similarly challenging to arrange.


Shawna Wright, Ryan Spaulding, PhD, Whitney Henley, MPH
Kansas University Medical Center ‐ Center for Telemedicine & Telehealth
Description: The Kansas University Center for Telemedicine & Telehealth (KUCTT) created and administered an online survey to learn more about school nurse's perceptions of school‐based telehealth (SBTH). This study identified factors in implementing and maintaining SBTH programs, with particular focus on policies and guidelines needed to support SBTH programs.
Abstract: In the summer of 2020, KUCTT was approached by nursing professionals who wanted to learn more about SBTH in the state of Kansas. In response to this request, the research team collaborated with the Kansas School Nurses Association (KSNA) to create and administer an online survey. The KSNA emailed a link to the survey to school nurses participating in the Association's conference. The KSNA also mentioned the survey to conference attendees in an attempt to gain as many respondents as possible. Of the 332 responses, 292 identified themselves as school nurses. Other respondents included recent hires (new school nurses who haven't begun school nursing work), nurses in other roles, and retirees. After collecting responses, the research team used the data to gather descriptive statistics and completed a qualitative analysis of the open‐ended response items that were on the survey. Two members of the research team coded responses, reached a consensus on individual codes, and used the codes to identify prevalent themes that were mentioned by respondents.
Classification of Research: Access to Care, Clinician Experience
Method: Survey / Qualitative
Results: While many participants indicated that SBTH programs would have been helpful during the COVID‐19 pandemic (79%) and that schools should consider implementing telehealth programs (65%), a minority indicated that their schools are considering adopting a SBTH program (26%). Qualitative analysis found that respondents report that a SBTH policy should cover: consent, liability, services needed/requested; privacy/confidentiality, and staff roles. When asked about ways telehealth is valuable, respondents overwhelmingly mentioned improved access to care. Additionally, reductions in travel/transportation needs, parental time away from work, and student's time away from school were frequently mentioned. Additional study details and data will be presented.
Conclusions: While the KUCTT has 25 years of SBTH experience, the surge in COVID‐driven telehealth provided context to better understand the current school environment. This study helped the research team understand perspectives of school nursing professionals and gain insight from their expertise. While school nursing professionals acknowledge benefits of SBTH implementation, it is difficult to address systemic changes (such as policy modifications, privacy/confidentiality, liability, physical space, and personnel) that are needed to start a program. Future efforts may seek to learn from administrators, board members, and others influence policies and program changes to address those individuals' perceptions of telehealth in schools.
Indicate number of authors:3


Alexa Mazur, BA,1 Harrison Constantino, BS,1 MS, Kathryn Dover, BS,1 Mei‐Hsin Cheng, PhD,1 Prentice Tom, MD,1,2 Herbert Harman, BS, MD, MBA2
1Kintsugi Mindful Wellness Inc.
Description: Depression‐related care accounts for 10% of primary care encounters, which are increasingly conducted virtually; however, general practitioners correctly identify patients for screening in only 47.3% of cases.1,2,3 Machine learning may be harnessed to analyze free speech samples to identify patients with signs of depression for screening in virtual care.
Abstract: Both males and females >18 years in the United States and Canada, recruited via social media, provided demographics and were enrolled in a cross‐sectional study to develop a machine learning model to detect signs of depression using >45‐second voice responses to the prompt, “how was your day?” and online self‐reported PHQ‐9 scores. The PHQ‐9 instrument has demonstrated both a sensitivity and specificity of 0.88.4 To determine the model's predictive performance for flagging severely depressed patients for screening, individuals with PHQ‐9 scores >20 were included in this training and validation analysis. Preliminary performance was measured using sensitivity and specificity metrics with 95% confidence intervals. Before inputting, responses were individually reviewed for authenticity, converted to homogeneous audio quality, transformed into numerical representations, and divided: 80% training (n = 1305) and 20% validation (n = 340) without sample overlap. The model was trained iteratively with the training data prior to validation where prediction outputs were scaled between 0 and 1. Quantitatively, signs of depression detected corresponded to a value >0.573 or equal to 1 and anticipated PHQ‐9 > 10. Signs of depression not detected corresponded to values equal to 0 and <0.427, and PHQ‐9 score <10. Values between 0.427 and 0.573 were labeled, further evaluation recommended.
Classification of Research: Measurement Frameworks & Tools
Method: Observational
Results: Evaluating the model's ability to detect signs of depression from at least 45 seconds of free speech in participants with a PHQ‐9 greater than or equal to 20 demonstrated a sensitivity of 0.91 (95% CI: 0.88,0.95) and specificity of undefined with no true negatives or false positives in this selection. A group of 73 participants were labeled, further evaluation recommended.
Conclusions: This cross‐sectional study to train and validate a machine learning model was feasible for detecting signs of depression in severely depressed participants utilizing at least 45 seconds of free speech when compared to the performance metrics for the PHQ‐9 and/or clinician judgment for assessment alone. Given that more than 50% of patients in primary care settings with depression will not undergo formal screening, harnessing machine learning to detect voice biomarkers for depression may help to prioritize and identify at risk patients with severe depression via tele‐health mediums for screening.


Jorge Palacios, Catalina Cumpanasoiu, Derek Richards, Gavin Doherty, Daniel Duffy, Angel Enrique
Description: Using ML to enhance feedback‐informed therapy (FIT) initiatives could prove beneficial to overall service performance and clinical outcomes. This study aims to assess both the performance and acceptability of an ML‐based prediction tool in enhancing treatment of depression and anxiety using iCBT.
Abstract: Feedback‐informed therapy (FIT), where the therapist is given feedback on the progress of their client, has been shown to enhance traditional CBT, as well as internet‐delivered CBT (iCBT). In recent years, FIT has been benefitting from advances in machine learning (ML), which allows for more complex models to be built to assist in the detection, diagnosis, and treatment of mental health problems. Using ML to enhance feedback‐informed therapy (FIT) initiatives, especially for technology‐delivered interventions such as iCBT, which allow for collection of large amounts of clinical data, could prove beneficial to overall service performance and clinical outcomes. We have recently developed a prediction tool using ML that calculates, with high accuracy, the probability of whether a patient is likely to improve or not at the end of treatment. This study aims to assess both the performance and acceptability of this tool in enhancing treatment of depression and anxiety using iCBT, utilizing a randomized controlled trial design. Questions on acceptability, deliberate practice, and clinical decision making will be asked at baseline, 4 and 12 week follow‐up, and clinical outcomes, including reliable improvement of depression and anxiety symptoms, will be assessed between the groups.
Classification of Research: Clinical Outcomes
Method: Randomized Controlled Trial
Results: Training on the use of the prediction tool and recruitment took place in February 2022, followed by the kickoff of the trial. 29 therapists used the tool for 6 months, and data collection was completed in September 2022. Full results including clinical outcomes, as well as impact on deliberate practice and clinical decision‐making, will be presented at the conference.
Conclusions: This study encompasses the development, design, and implementation of a machine‐learning prediction tool that may prove to enhance delivery of iCBT through improved clinical decision‐making within a routine clinical setting. A tool of this nature which is found to be acceptable and improves upon the clinical experience of delivering digital therapy has great potential to ultimately improve patient outcomes and service provision. Besides clinical contributions, this RCT will contribute to the scientific field by leveraging machine learning methods to employ FIT and enhance iCBT delivery and effectiveness.


(Presentation combined with Randomized Trial of Patient and Clinician Alerts to Decrease Follow‐up Time Following Suicidal Crises)
Akshay Swaminathan, Iván López
Description: Patients send chat messages to their care team via EMR chat portal, sometimes seeking support for mental health crises. Rapid response times are critical to ensure patient safety. We built and deployed an NLP system to triage high‐risk messages and send alerts to the Crisis Management Team to quickly intervene.
Abstract: We trained a logistic regression model with TF‐IDF features on 1202 EMR chat messages, of which 382 were potential crises (suicidal/homicidal ideation, domestic violence, or non‐suicidal self injury). The probability threshold was selected to reflect a 20: 1 relative preference for false positives over false negatives. In a prospective validation with 65,850 messages, the model surfaced 505 (0.008%) potential crises with 98.7% sensitivity, 93.7% specificity, 44.7% positive predictive value, 100.0% negative predictive value and average time to message triage of 8.7 minutes (95% CI: 8.3‐9.5).
We built and deployed an NLP‐based machine learning model to identify crisis EMR messages sent by patients in a large, national tele‐mental health provider platform. The model had high sensitivity and specificity and allowed crisis specialists to triage crisis messages in less than 9 minutes. Our system successfully integrated into existing clinical workflows, suggesting that with appropriate training, humans can successfully leverage ML systems to facilitate triage of crisis messages.
Classification of Research: Quality Improvement
Method: Implementation Science
Results: We trained a logistic regression model with TF‐IDF features on 1202 EMR chat messages, of which 382 were potential crises (suicidal/homicidal ideation, domestic violence, or non‐suicidal self injury). The probability threshold was selected to reflect a 20: 1 relative preference for false positives over false negatives. In a prospective validation with 65,850 messages, the model surfaced 505 (0.008%) potential crises with 98.7% sensitivity, 93.7% specificity, 44.7% positive predictive value, 100.0% negative predictive value and average time to message triage of 8.7 minutes (95% CI: 8.3‐9.5).
Conclusions: We built and deployed an NLP‐based machine learning model to identify crisis EMR messages sent by patients in a large, national tele‐mental health provider platform. The model had high sensitivity and specificity and allowed crisis specialists to triage crisis messages in less than 9 minutes. Our system successfully integrated into existing clinical workflows, suggesting that with appropriate training, humans can successfully leverage ML systems to facilitate triage of crisis messages.


Daniel Rosenfield, MD, MHI, FRCPC (Peds, PEM)
University of Toronto
Description: Emergency departments (EDs) suffer from systemic issues and resource constraints. Before the pandemic, virtual solutions were rarely offered in the ED. The pandemic changed this, with an accelerated push to virtual care in all clinical areas including the ED.
Abstract: Our digital front door includes a simple, efficient symptom checker tool used by patients and families to establish their primary reason for seeking care. Next, they select a secondary symptom, related to, and streamlined from their primary complaint. Based on their primary and secondary symptoms, they are then directed to one of three encounter outcomes–to a local emergency department for in‐person care, to their primary care provider, or a virtual visit. Providers utilize a dashboard fully integrated into the EMR to connect with patients via secure video chat and document contemporaneously.
After implementing this technology during the peak of COVID's third wave, patients and their families had access to information 24 hours a day, 7 days a week, and virtual access to providers 15 hours per day, 7 days a week, if eligible.
Since launching in April 2021, we have seen over 6000 families use the service.
Virtual emergency medicine care is uniquely patient‐driven and must coordinate the right patient to be seen at the right time by the right provider using the right technology. Effective emergency care must understand the needs of the community it serves and apply a virtual strategy that can be optimized to that environment.
Classification of Research: Information Technology
Method: Descriptive
Results: To date, we have had 6218 unique encounters, 36% of patients being sent to their local ED, 25% referred to their primary care provider and 24% were eligible for a virtual visit. The most common chief complaints were fever (24%), Cough/Cold (10%) and vomiting/diarrhea (6%). Most encounters occurred between 6 and 8 PM. Two‐thirds of users reached out to their primary care provider before accessing our service. Overall, 64% of patients would have gone to the ED in person if the offering was not available and 90% of patients felt at ease after using the on‐demand service.
Conclusions: Virtual care in the pediatric emergency department is in its infancy but is growing and innovating at a significant speed. As virtual offerings become standard, guiding principles will help build the most robust and appropriate care model required for each community. The principle of “the right patient to be seen at the right time by the right provider and using the right technology” communicates the idea of maintaining close links with patient populations, advocating to build systems and remove barriers and connect with community health providers. These unprecedented times allow us to shape care models for years to come.


(Presentation combined with Reaching Patients Where They Are: Travel Averted by Using Telehealth for Abortion in the United States)
Leah Koenig, MSPH,1 Courtney Lyles, PhD,1 Jennifer Ko, MLIS,1 Ushma Upadhyay, MPH,1; Ena Valladeres, MPH,2 Francine Coeytaux, MPH,3 Elisa Wells, MPH3
1University of California, San Francisco
2California Latinas for Reproductive Justice
3Plan C
Description: Direct‐to‐patient telehealth medication abortion care first became widely available in the United States (US) in 2021. This study evaluated the acceptability of this model of abortion care and compared the experiences of patients who received asynchronous vs. synchronous care among patients of 3 virtual clinics in 2021 and 2022.
Abstract: In the wake of the US Supreme Court's Dobbs vs. Jackson Women's Health decision that has led to at least 14 states banning abortion, telehealth medication abortion care is playing an increasingly vital role, alleviating surges in demand and facilitating abortion access caused by thousands of patients traveling from banned to legal states. In this model, patients are screened synchronously (over a video or phone visit) or asynchronously (with communication over messaging) by an abortion provider licensed in their home state and are subsequently mailed medications from a mail‐order pharmacy. This method has been demonstrated to be safe and effective. However, the experiences of patients who receive medication abortion care through telehealth are not well understood. We analyzed surveys from 1,312 patients of 3 US virtual abortion clinics who received care between April 2021 and January 2022. We measured acceptability using indicators of overall satisfaction, whether telehealth was the right decision, and feeling trust in the telehealth provider. We described acceptability by patient characteristics, including age, race/ethnicity, and pregnancy duration. We then used multivariable logistic regression to evaluate differences in acceptability by patient characteristics and between synchronous and asynchronous care.
Classification of Research: Patient Experience
Method: Survey / Qualitative
Results: Most participants were very satisfied with telehealth care (90%), felt telehealth was the right decision (97%), and trusted their provider (98%). The most common benefits of telehealth were expediency (76%) and feeling comfortable at home (74%). Over one third (37%) were unsure if the service was safe or legitimate. Participants who received synchronous care were more likely to report that telehealth was the right decision (98% vs. 96%, p = 0.027) but there were no significant differences in overall satisfaction or trust. Asian participants were less likely than white participants to be very satisfied with telehealth abortion care (90% vs. 79%, p = 0.007).
Conclusions: Medication abortion care by telehealth is highly acceptable, with most patients indicating they were satisfied with the model, trusted in the provider, and felt cared for and few differences between synchronous and asynchronous models. The benefits of telehealth include privacy and expediency, which is particularly important for this stigmatized medical treatment. Additionally, uncertainty about the legitimacy of telehealth abortion services remains and could be reduced as knowledge of this option spreads. Telehealth for abortion care holds substantial promise to expand reach given the increasing regional disparities in access to legal abortion care in the U.S.


(Presentation title: Improving Management of Suicidal Crises through Automated Clinician Alerts and Natural Language Processing / Presentation combined with Natural Language Processing (NLP) for Faster Detection and Intervention of Mental Health Crisis Messages)
Akshay Swaminathan, Camilla Calmasini, MS
Description: Following an episode of active suicidal ideation (SI‐A), patients should be evaluated by a clinician as soon as possible. We conducted a randomized trial to test the effect of patient‐facing and clinician‐facing alerts on time to clinician encounter following SI‐A.
Abstract: 294 patients with recent SI‐A were randomized to either: control (treatment as usual, n = 98), patient alert (patient receives a text message reminder to schedule a follow‐up, n = 95), or clinician alert (clinician receives an email alert to complete a check‐in call with the at‐risk, n = 101). Median time from SI‐A to clinician encounter in the control, patient alert, and prescriber alert arms was 24, 22, and 7 days respectively. Compared to the control, patients in the clinician alert arm had a 43% greater chance of completing a clinician encounter (hazard ratio = 1.43, p = 0.05).
Given the increased risk of suicide patients face after an episode of active suicidal ideation, timely follow up care is critical. In a randomized quality improvement trial, we found that alerting a clinician to an at‐risk patient and compensating them for conducting a check in call with the patient decreased time to clinician encounter by 70% following a suicidal crisis. Future work may further explore the cost effectiveness of clinician alerts and their impact on suicidal ideation.
Classification of Research: Quality Improvement
Method: Randomized Controlled Trial
Results: 294 patients with recent SI‐A were randomized to either: control (treatment as usual, n = 98), patient alert (patient receives a text message reminder to schedule a follow‐up, n = 95), or clinician alert (clinician receives an email alert to complete a check‐in call with the at‐risk, n = 101). Median time from SI‐A to clinician encounter in the control, patient alert, and prescriber alert arms was 24, 22, and 7 days respectively. Compared to the control, patients in the clinician alert arm had a 43% greater chance of completing a clinician encounter (hazard ratio = 1.43, p = 0.05).
Conclusions: Given the increased risk of suicide patients face after an episode of active suicidal ideation, timely follow up care is critical. In a randomized quality improvement trial, we found that alerting a clinician to an at‐risk patient and compensating them for conducting a check in call with the patient decreased time to clinician encounter by 70% following a suicidal crisis. Future work may further explore the cost effectiveness of clinician alerts and their impact on suicidal ideation.


(Presentation combined with Patient Acceptability of Asynchronous vs Synchronous Telehealth Medication Abortion Care in the US)
Leah Koenig, MSPH, Jennifer Ko, MLIS, Ushma Upadhyay, PhD, MPH, Andréa Becker, PhD, MA
University of California, San Francisco
Description: In the wake of the recent overturning of Roe v. Wade, telehealth abortion will play a critical role in mitigating increased demand for abortion in protected access states. However, telehealth's impact on reducing travel for abortion is not understood. We quantify the travel averted by using telehealth for abortion care.
Abstract: We aimed to describe the amount of driving and public transit distance and time to the closest abortion facility that patients averted by using telehealth for abortion care. We used data from the California Home Abortion by Telehealth study which includes anonymized clinical chart data and study surveys completed at the time of intake. The study sample included consecutive patients of 3 virtual clinics who received care from these clinics for a period between April 2021 and January 2022. We also used ANSIRH's Abortion Facility Database to identify the closest publicly advertising abortion facility. We quantified round‐trip driving and public transit travel averted from patients' resident ZIP code to their closest abortion provider and examined regional variation using linear regression. We used logistic regression to evaluate associations between travel averted and whether patients believe they would have been able to access abortion soon without telehealth.
Classification of Research: Access to Care
Method: Observational
Results: Across 6,106 included abortions living in 24 states and Washington, DC, patients averted 173,032 driving miles and 3,910 driving hours through telehealth. The mean round‐trip drive averted was 28 miles (range: 0.13 to 566 miles) and 38 minutes (range: <1 minute to 9 hours). Patients avoided 11,152 hours total on public transit, a mean of 2.2 hours (range: 2 minutes – 40 hours). Those in the South and Midwest avoided more travel through telehealth. Patients living further from a clinic were less likely to state that they would have accessed an in‐clinic abortion soon without telehealth services.
Conclusions: Telehealth for abortion can drastically reduce geographic barriers to abortion and, for some, may make the difference in being able to obtain a wanted abortion. Telehealth can reduce travel childcare expenses, which is critical for this patient population, 3/4ths of whom are living on low incomes. The benefits of telehealth are critical, particularly for those in the South and Midwest, where bans are making abortion illegal and inaccessible after the reversal of Roe v Wade.


Andy Vu
Castle Hill Eye Centers
Description: A 1‐year reflection on the impact of utilizing a telemedicine model to provide eye care in a remote rural ophthalmology practice. Our reflection highlights the access to ophthalmic care, cost analysis, patient experience, effectiveness, and outcomes in private practice.
Abstract: The COVID‐19 pandemic unraveled the frontier of telemedicine in all fields of medicine. Regarding tele‐ophthalmology, several research articles were published highlighting the accuracy of tele‐ophthalmology under conditions of limited access to machinery and imaging. Often, they are consultation calls with an ophthalmologist via a video communication apps for the next course of action. In combat, the military employs this model in which there was an 86% agreement within 24 hours of the initial telemedicine diagnosis followed by an in‐person visit. Illustrating that even with resource scarcity, utilization of telemedicine is still a viable and effective model.
Within the last year we implemented a newer model utilizing real‐time tele‐ophthalmology in a rural community 143 miles away from San Antonio, TX. Our model employs Optical Coherence Tomography (OCT), fundus photography, Virtual Reality (VR) visual field testing, vision testing, and refraction on‐site with the aid of an ophthalmic technician. All results are then uploaded to the EMR and shared with the patient in real‐time via videoconferencing with a remote ophthalmologist. Conditions such as cataracts, glaucoma, macular degeneration, eyelid problems, and diabetic retinopathy are being diagnosed and treated. When surgery is needed, patients travel to San Antonio, meanwhile, postoperative care is provided remotely.
Classification of Research: Clinical Outcomes, Access to Care, Cost Analyses, Patient Experience, Clinical Effectiveness
Method: Survey / Qualitative, Observational, Implementation Science, Cost Analysis
Results: Our analysis utilized a 6‐question survey assessing cost savings, patient experience, and access to care. Cost‐saving analysis accounted for gas, insurance, and travel fees; saving patients $46 and 2.5+hour on average per visit. Overall, patients rated our care 4.7/5, which is a rating above satisfactory (3/5). Additionally, we utilized questionnaires to assess follow‐up frequency and willingness to travel for ophthalmic care. Patients report an 88% increased frequency in follow‐up for care after visiting our remote clinic and a 96% increased willingness to travel for additional ophthalmic care. With our model, technology, and clinical judgment, diagnosis and procedures engendered 100% congruence.
Conclusions: We believe robust specialized ophthalmic care can be accessible to everyone. Our model and results illustrate a viable option that doesn't sacrifice an accurate diagnosis. One may argue that this model lacks in‐person eye examination, possibly leaving room for misdiagnosis. The clinical experience and sound judgment of an ophthalmologist should be of consideration in these cases. Moreover, imaging and testing provide adequate information for most diagnoses. However, under concerning circumstances, patients are immediately scheduled for in‐office visits. This is a proven and currently working model with few limitations. Additionally, its accessibility and cost‐effectiveness increase follow‐up and compliancy overall benefiting patients.


John Kosmeh, PhD
Description: This session describes how using cutting edge technology coupled with 24/7 telemedicine services has proven to not only increase quality of care for residents in ALF and SNF, but also dramatically cut down the unnecessary transports of residents from communities by over 94% and to date has eliminated 30‐day readmissions.
Abstract: Issues involving the quick attention from PCP to residents and staff of skilled nursing facilities caring for our senior population throughout the country has long been ignored. The inability for nurses and caregivers to get the required orders for treatment in timely manners, especially afterhours, on weekends or holidays has caused a surge in unnecessary transports to emergency departments across the country. These unnecessary transports have put a huge financial burden on federal and state funding as well as individual facilities and residents. CMS reports show that over 4.6 billion dollars has been spent yearly on treatment for 30‐day readmission patients with 3.2 billion of that considered avoidable. Those reports also show that over 80% of ER transports from senior care facilities also fell into that category resulting in surging fees for facilities nationwide.
With the use of cutting‐edge technology and a structured 24/7 telemedicine program, incorporating the use of POCUS, 12 lead ekg, CMP, vital signs, otoscope usage and Bluetooth technology we have created a system that thus far to date has resulted in a reduction of unnecessary transports to Er's by over 94% and has completely eliminated 30‐day readmissions in senior care communities.
Classification of Research: Quality Improvement
Method: Controlled 12 month pilot program
Results: Over 94% reduction in unnecessary of senior care residents out of facilities to local Emergency rooms, complete reduction in 30‐day readmissions and significant cost saving to ALF and SNF.
Conclusions: The use a standardized telemedicine process with required onsite equipment to provide definitive medical care to senior care residents can greatly reduce the number of unnecessary transports, added risks associated with ER visits for members of the geriatric population and can create significant cost saving for individuals, facilities, and state and federal agencies.
Creating a National Certification Program could significantly increase the quality of life and care for senior care residents nationally.


William Frazier, MD
Description: This is an observational study of 1,102 consecutive patients enrolled in RPM. Patients were divided into Quartiles based on initial BP and into 6 groups based on number of measurements per month. Average BP after 6 months of RPM as a function of initial BP and measurement group is reported
Abstract: Background: Remote Physiologic Monitoring (RPM) is a form of telehealth whereby automatic reporting technology is used to measure parameters such as vital signs in a non‐traditional clinical setting. Codes for Medicare reimbursement were introduced in 2019 and RPM use is expanding as new providers enter the marketplace. Potential obstacles to RPM growth are the lack of published clinical outcomes data and the CMS requirement that monitoring be done on a minimum of 16 different days per month before the service can be billed. No evidence base is available to support the “16 day” rule.
Methods: 1,102 consecutive patients enrolled in RPM were followed for 6 months. The patients were divided into quartiles based on initial average BP and into 6 groups based on number of days per month BP was measured. We report blood pressure (BP) changes in patients after 6 months of RPM as function of initial BP (primary outcome) and of number of days per month BP was monitored (secondary outcome).
Classification of Research: Clinical Outcomes
Method: Observational
Results: After 6 months of RPM, BP dropped from 139/77, mean arterial pressure (MAP) 97 to 132/73 MAP 93. This drop was driven by reductions in the 50% of patients who were initially hypertensive. Quartile 3 and 4 saw reductions from 144/79 MAP 101 and 156/88 MAP 111 to 135/79 MAP 94 and 142/88 MAP 100, respectively (p < .001) and improved from hypertensive to normotensive. Significant BP reduction occurred in the initially hypertensive patients whether they measured more or less than 16 days per month. No minimum threshold for number of measurements was found which predicted success or failure of RPM.
Conclusions: To our knowledge, this is the first report showing RPM was associated with clinically and statistically significant reductions in average BP in patients who were initially hypertensive. This benefit occurred regardless of the number of days per month patients reported BP measurements. We urge Medicare to consider lowering the measurement threshold necessary for billing compliance to encourage wider adoption of RPM.


Satyamurthy Lakkavalli,1 Bhagawat Singh Ratta, MBBS, MS2
1Suquino Teleheath LLP (India)
2Ruby Hall, Clinic, Azad Nagar, Pune, India
Description: “Ayushman Bharat” mission, an Indian government funded Health care delivery system launched in the year 2018, has created a new paradigm shift in providing comprehensive health care to the Indian population. This mission has adopted the Block chain technology and created unique portal for providing COVID care through tele‐health services.
Abstract: “Ayushman Bharat” meaning blessings of longevity for Indians, is a national flagship mission, federally funded government Health care delivery system, launched in 2018. It is an umbrella of two major healthcare initiatives namely National Health protection scheme applicable for over 100 million poor and vulnerable families across the country; Health and Wellness centers applicable for many Health and Wellness centers to provide comprehensive health care, covering non‐communicable diseases and maternal/child healthcare services.
Ayushman Bharath and Telehealth: The Telemedicine Program in India was primarily spearheaded by the Indian Space Research Organization ( ISRO ) in 2001. The important factor of providing satellite connectivity without any charge by ISRO was the major step in this effort. More than 1 million Tele‐consultations took place with several lifesaving instances during the period.
Ayushman Bharath and COVID Pandemic: Ayushman Bharat Digital Mission got big fillip to stitch the silos in Indian health system. Blockchain technology has the potential to revamp currently existing processes as seen in the pharmaceutical supply chain. Ayushman Bharath mission adopted the Block chain to register every next provider of healthcare in the country including government/ private/ corporate hospitals and diagnostic Labs on the portal to provide the Tele‐health services.
Classification of Research: Information Technology; New paradigm in health care mission
Method: Observational; Critical Review and Informational
Results: With the success of Blockchain technology in various Government sponsored programs in India such as Aadhar, world's largest unified ID based system (1.2 billion bio metrics) and others, Ayushman Bharat Health App created with unified health interface and sandbox integration using block chain technology permits online search of health care services, for creation of electronic health record for Tele‐health services. This mission has taken off with 240 million e Cards issued to beneficiaries covering about 8 million hospital admissions, 144787 healthcare facilities have already been registered. This system has built in security at different stages to prevent fraud.
Conclusions: “Ayushman Bharat”, a federally funded government Health care delivery system was launched in the year 2018 with integrated healthcare initiatives namely National Health protection scheme for secondary and tertiary care; Health and Wellness centers for comprehensive primary care.
Satcom based Telemedicine Program spearheaded by the Indian Space Research Organization ( ISRO ) in 2001 was the beginning of Telehealth services era in India. Having experienced the success of Block Chain technology in government programs Ayushman Bharath mission adopted the Block chain to register every next health care provider in the country on the portal to provide the Tele‐health services in India.


Andrew Talal, MD,1 Suzanne Dickerson, PhD RN,1 Arpan Dharia, MD,1 Ana Ventuneac, PhD,2 Saliyah George, MPH,3
1SUNY, University at Buffalo
2START Treatment & Recovery Center
3Icahn School of Medicine at Mount Sinai
Description: Our study sought to understand factors that may impact sustainability capacity of a facilitated telemedicine hepatitis C treatment model integrated at opioid treatment programs (OTPs). OTP clinical staff and administrators provided their feedback for sustaining and scaling patient‐centered healthcare delivery through telemedicine for patients with opioid use disorders (OUD).
Abstract: Telemedicine is increasingly utilized due to the COVID‐19 pandemic and the need to avoid in‐person healthcare interactions. As part of a stepped‐wedge randomized control trial initiated in 2017, we investigated the integration of telemedicine in OTPs for hepatitis C virus (HCV) management among patients receiving treatment for OUD. HCV infection has become almost universally curable with medication; yet, access to treatment remains the leading barrier for individuals with the highest HCV prevalence. Our study demonstrated the feasibility of implementing a facilitated telemedicine model in OTPs providing virtual access to healthcare specialists to connect with vulnerable patients. A crucial next step is the OTP's capacity to sustain the facilitated telemedicine model, an important consideration for continued maintenance and expansion of the model after trial completion. We sought to understand the practical advice and lessons learned from OTP clinical staff and administrators for sustaining and scaling patient‐centered healthcare delivery through telemedicine to a vulnerable population and the influence of the COVID pandemic on subsequent practice changes. Interviews elicited feedback on staffing and infrastructure needs, clinical workflow and workarounds for the integration of telemedicine with usual care, ways in which COVID disrupted care, and regulatory and billing considerations.
Classification of Research: Clinician Experience
Method: Survey / Qualitative
Results: Three themes emerged on sustaining the telemedicine model: sustaining an innovative technology, telemedicine as transformative of space and time, and COVID as a disruptive force fueling change in healthcare for vulnerable populations. Participants identified that skilled staff, ongoing training, technology infrastructure and support, and an effective marketing campaign as key to maintain the facilitated telemedicine program. Participants highlighted the case manager's role in managing the technology to transcend temporal and geographical challenges to treatment access. COVID disruptions drove the use of the telemedicine model to expand the OTP mission to serve as a medical home for people with OUD.
Conclusions: Our results demonstrate the capacity of the OTP to sustain a facilitated telemedicine treatment model for vulnerable populations. As practical advice and lessons learned, participants agreed that sustaining and scaling facilitated telemedicine would expand access to care. This study highlights how COVID‐induced disruptions lead to innovative methods and policy changes recognizing the utility of telemedicine in improving healthcare access to vulnerable individuals.
This work was supported by a Patient‐Centered Outcomes Research Institute (PCORI) Award (IHS‐1507‐31640) and partially supported by the Troup Fund of the Kaleida Health Foundation. The statements in this work are solely the responsibility of the authors and do not necessarily represent the views of PCORI, its Board of Governors or Methodology Committee.


(Presentation combined with COVID‐19 telehealth service can increase access to the healthcare system and become a cost‐saving strategy)
Clara Oliveira, MD, MSc, PhD
Universidade Federal de Minas Gerais
Description: The COVID‐19 pandemic represented a great stimulus for telehealth. Considering the new demands generated by the pandemic, the Telehealth Network of Minas Gerais (TNMG) implemented a teleconsultation and monitoring service for patients with respiratory symptoms in two Brazilian medium‐sized cities and as a health support program of a federal university.
Abstract: The COVID‐19 pandemic has brought challenges of great magnitude that represented a boost for the development of healthcare solutions to mitigate the impact of the disease on individual health and health systems. In this context, the TNMG implemented a public COVID‐19 teleconsultation service in two Brazilian cities and as a part of a health support program of a federal university. The service was developed for assessing patients with respiratory symptoms and providing the population with COVID‐19 evidence‐based information. User access and screening is done via chatbot or phone call and, according to the severity of symptoms, patients are assessed by a nurse or a physician. All patients are telemonitored for at least ten days after the onset of symptoms. From May 2020 to July 2022, 178,754 teleconsultations were performed and 37,286 patients were accessed. 95% of the patients were oriented to keep home isolation and only 5% were advised to seek onsite evaluation (1.5% at primary care and 3.5% at an emergency unit). These results indicate that COVID‐19 telehealth programs are valuable tools to deal with the new demands generated by the pandemic, contributing for preserving physical distancing and isolation, reducing infection rates and the demand on strained healthcare infrastructure.
Classification of Research: Access to Care
Method: Descriptive
Results: From May 2020 to July 2022, 37,286 patients were accessed through nursing, medical and/or monitoring teleconsultations, that resulted in 178,754 teleconsultations carried out in the period. Among the accessed patients, 95% were oriented to keep home isolation, under telemonitoring, and only 5% were advised to seek onsite evaluation, 1.5% at a primary care center and 3.5% at an emergency unit. Mean time for nursing, medical and monitoring teleconsultations were 12, 17 and 11 minutes, respectively. 1,001 users had no respiratory complaints and accessed the telehealth service only to clarify general doubts about COVID‐19.
Conclusions: This public Brazilian COVID‐19 telehealth service succeed in responding to the needs generated by the pandemic, as it offered the necessary health support to the patients with suspected and confirmed COVID‐19 while it contributed to preserve physical distance, to increase patient access to care in places with scarce health resources and to reduce the demand on strained healthcare infrastructure. This experience can be an attractive alternative to the healthcare systems and must be considered in other similar scenarios.


(Presentation combined with Impact of Telehealth Initiatives Among Medicaid Beneficiaries in Florida)
Cynthia Williams, PhD, MHA, PT
University of Central Florida
Description: Telehealth access was critical during the public health emergency and will continue to be an integral aspect of healthcare delivery. It is imperative that we not only examine factors that contribute to low utilization, but we should apply our insights to develop strategies that support sustainable progress toward telehealth equity.
Abstract: During COVID‐19, through policy and reimbursement initiatives telehealth was strongly encouraged to promote safe access to healthcare services. While there were significant increases in telehealth use, people in low income communities do not share in this trend. The purpose of this study was to investigate demographic, socio‐economic, and behavioral causes for the low telehealth utilization among people who are in low income positions. The COVID‐19 Research Database Consortium provided data for the study. The study period was March 2020 to April 2021. The consortium provided access to the Office Ally and Analytics IQ PeopleCore Consumer linked databases. The Office Ally database provided claims data from 100 million unique patients and 3.4 billion medical claims. The Analytics IQ PeopleCore consumer database is a national representation of 242.5 million US adults aged 19 and older. Descriptive statistics used an analysis of variance and chi‐squared test for continuous and categorical variables, respectively, to compare demographic, socioeconomic and health behavior characteristics. Multiple logistic regression was used to determine the odds of using telehealth services. Based on the results of this study and the body of research, we made several recommendations for sustainable progress towards telehealth use beyond the pandemic.
Classification of Research: Access to Care
Method: Cross Sectional/Quantitative
Results: We examined 2.85 million patients whose household income is below the Federal Poverty Level. The results suggest that male patients are 12% less likely than females to use telehealth; patients aged 18‐44 are 32% more likely to use telehealth than the age group of 65+. Additionally, patients with high school or less education are 5% less likely to utilize telehealth. While patients with full‐time employment are 15% more likely to use telehealth than unemployed patients. For patients in household with between 3 and 10 members, income is significantly (p‐value <0.01) associated patients using telehealth across poverty levels
Conclusions: COVID‐19 magnified the burden of telehealth inequities in the low‐income communities. Prior research suggests that social determinants of health do not differ between traditional and digital access to healthcare. Community based interventions must support vulnerable communities. Increasing access to telehealth must go beyond federal policy promulgation and include local, actionable interventions that encourage impoverish communities to use telehealth. We recommend strategies to increase telehealth engagement among low‐income communities.


Stephen Martin,1 Stephanie Papes Strong,2
1UMass Chan Medical School
2Boulder Care
Description: Opioid use disorder (OUD) is leading to record overdose deaths and ongoing harm to people and their loved ones. Pandemic‐induced regulatory action in March 2020 has expanded access to telehealth and created an unprecedented opportunity to meet people's needs. We sought to understand the quality of this telehealth care.
Abstract: Objective: To determine retention in care for opioid use disorder (OUD) when treated solely via telehealth with a harm reduction, low‐threshold model. A secondary objective was to examine any differences in retention between patients with governmental healthcare insurance and those with commercial healthcare insurance.
Methods: Retrospective cohort analysis of aggregated, anonymized data from 991 patients in telehealth‐based buprenorphine treatment. The cohort consisted of patients with commercial or governmental insurance who enrolled between May 17, 2019 and September 28, 2021. Analysis was extended to a maximum of one year for each patient.
Results: At one year, retention in care was 55% overall. When analyzed separately, retention at one year was 62% for patients with commercial insurance and 53% for those with governmental insurance. In comparison, national data just prior to the pandemic showed 29% retention at 6 months.
Conclusions: Telehealth‐based treatment of opioid use disorder can achieve retention in care for patients—with governmental or commercial healthcare insurance—that is superior to in‐person treatment as usual.
Classification of Research: Clinical Outcomes
Method: Observational
Results: Our cohort consisted of 991 patients who enrolled between May 17, 2019 and September 28, 2021. 899 enrolled after March 2020 changes in telehealth regulation.
82.7% of our insured patients had government coverage (78.3% Medicaid and 4.4% Medicare), and 17.3% had commercial coverage. Retention by insurance type modestly favored commercial insurance. Differences in retention at 30, 90 and 180 days were statistically significant (p30 < 0.001, p90 < 0.001, p180 < 0.001), with a maximum absolute difference of 17.7% at 200 days.
Conclusions: This retrospective cohort analysis of telehealth care for OUD demonstrates retention levels that are superior to usual treatment. Patients with both commercial and government insurance were retained at higher rates via telehealth, suggesting efficacy across diverse patient backgrounds.
We must now find ways to fully achieve equity for patients no matter their demographics. To do so, legislative and regulatory changes must be made permanent, allowing this improved access and quality of care for OUD, both of which are desperately needed, to continue via telehealth.


Meagan Moyer, MPH, RD,1 Lubna Qureshi, MS,1Cassandra Thiel, PhD,2
1Stanford Health Care
2NYU Langone Health/Clinically Sustainable Consulting LLC
Description: This study assesses the life cycle environmental impact of telemedicine compared to in‐person care at Stanford Health Care between 2019 and 2021. We include transportation, energy used, and clinical supplies. Results show a 13% increase in patient clinic visits, but due to telemedicine, a 36% decrease in greenhouse gas emissions.
Abstract: Healthcare emits nearly 10% of greenhouse gases (GHG) in the United States, and more commitments are being made to reduce the sector's carbon footprint. Telemedicine has been identified as a possible tool in achieving these goals by reducing patient traveling to clinic locations which often requires burning fossil fuels. Most studies to date focus solely on the GHGs from patient travel when assessing telemedicine; this study examines a larger scope of potential emissions to compare telemedicine with in‐person visits. This study uses ISO 14040‐compliant environmental Life Cycle Assessment (LCA) methods and data from Stanford Health Care (SHC) to compare in‐person and telehealth visits between 2019‐2021. The LCA for in‐person visits included patient transportation to and from the clinic; energy used in space conditioning and lighting the exam room; supplies used, and waste generated. For the virtual visit, we include electricity to power a cellular phone or video conference software and the electricity use of the clinician. Sensitivity analyses of model inputs included variation in patient travel mode, differences in exam room size, building energy intensity, and energy sources. Finally, we analyzed the effect of different electric grid mixes on the outcomes of both in‐person and virtual visits.
Classification of Research: Quality Improvement
Method: Observational
Results: Total visits increased 13% between 2019 and 2021, from 1,733,020 to 1,961,768. Due to the rapid expansion of telemedicine, SHC experienced a 36% drop in their GHG emissions from clinic visits from 40,600 metric tons of CO2e to 25,900. In 2021, SHC's average in‐person visit emitted approximately 20 kg CO2e, while a virtual visit (phone or video), emitted only 0.04. Telemedicine visits at SHC reduced 2021's GHG emissions by nearly 17,000 metric tons. This is the equivalent of over 2,000 homes energy use for a year or the CO2 sequestered by nearly 21,000 acres of US forest in one year.
Conclusions: This study concludes that reducing the travel demand of care has the highest impact on reducing carbon emissions. It is likely that the wide adoption of telemedicine will carry with it a significant reduction in overall GHG emissions associated with the delivery of care. As with many aspects in medicine, implementation of a new model for patient care will need to confer equivalent or added convenience, cost and clinical effectiveness when compared to the standard of care, in‐person visits. These benefits should exist for both the patient, the provider and now, the environment.


Asia Evangelista, Emily Perrinez, Brett Meyer
UC San Diego Health
Description: Telehealth bridges gaps between patient needs and provider availability. UCSD Tele‐Untethered (TU) allows patients to join visits, bypassing virtual waiting rooms. TU's text‐to‐video link improves clinic flow and patient/provider satisfaction.
Abstract: As an expansion of our original small pilot (IRB #210364QI) we included a larger series of patients seen in a single vascular neurology clinic. Staff were educated to new standard work, including patient instructions, scripting, and workflows. Patients provided a cellphone number to receive a text‐link when the provider was ready to see them. Metrics included demographics, volumes, percentage seen early/ late, time saved, and satisfaction data. Our expanded analysis shows that UCSD Tele‐Untethered benefits patients and providers by allowing scheduling flexibility and eliminating waiting rooms. Providers can see patients in order without being limited to exact appointment times, can improve throughput, and save time. Expansion to other clinic settings is underway.
Classification of Research: Quality Improvement
Method: Observational
Results: Over 15 months, 82 patients were scheduled. Of those arriving, 93% were “Tele‐Untethered” and 7% were “Standard Telemedicine”. 77% were seen early. There was a 47 minute/clinic saved. The “likelihood to recommend” score (82.7% to 92.6%) and “method of connection was easy” (49.5% to 60.7%) improved though did not reach statistical significance.
Conclusions: Our expanded analysis shows that UCSD Tele‐Untethered benefits patients and providers by allowing scheduling flexibility and eliminating waiting rooms. Providers can see patients in order without being limited to exact appointment times, can improve throughput, and save time. Expansion to other clinic settings is underway.


Arnold Saperstein, MD, FACP, Amy Bradshaw, CDCES, RD
Cecelia Health
Description: In 2019, well before the pandemic, the Virtual Diabetes Specialty Clinic (VDISC) study was developed to establish sustainable virtual care practices to improve access, introduce and provide diabetes technology support, and deliver whole‐person, comprehensive support to drive better outcomes.
Abstract: Many challenges contribute to the growing diabetes crisis in America, including the fragmented healthcare system and dearth of practicing endocrinologists, with a national person with diabetes (PWD)‐to‐endocrinologist ratio of 30K: 1. As a key component of the VDISC study, Cecelia Health improved access to quality diabetes care through the development of a fully virtual national diabetes clinic.
A team of highly skilled Certified Diabetes Care & Education Specialists (CDCES) are the core of the virtual clinic. Under supervision of endocrinologists licensed in each state supporting the virtual clinic, CDCES's have authority to manage diabetes medication adjustments while providing comprehensive education and clinical support for enrolled participants. If needed, escalation to virtual endocrinology consultation is available through CDCES referral. In addition, a team of behavioral health experts, supervised by licensed psychologists, provided additional remote support for mental health needs impacting the management of the participant's diabetes.
Enrolled US participants living with T1D or T2D were at least 18 years old who used daily insulin (pump or at least three daily injections). Participants used the Dexcom G6 CGM during the study.
Classification of Research: Access to Care
Method: Descriptive
Results: This study of 234 participants with T1D (N = 160) or T2D (N = 74), many of whom were not currently using CGM (N = 187), showed extremely high patient satisfaction and significant positive clinical results related to improved glycemic control, time‐in‐range, and overall quality of life through the initial six‐month follow‐up period. Ongoing follow‐up is underway and full results will be available in 2023.
Conclusions: For hybrid care delivery to truly bridge the gap for patients who are increasingly overwhelmed by navigation of their complex diagnosis and a fragmented healthcare system, telehealth solutions need to consider both the appropriate models and the right success measures.
The VDiSC investigators recognized the value of a fully virtual model well before the impact of COVID‐19 and continue to see the value in and sustainability of this virtual coordinated care approach. While the study is still ongoing, the infrastructure developed through this virtual clinic model has already translated care to practice models outside of the study.


(Presentation combined with Change in Patient Risk Factors, Protective Factors, and Substance Use
Before and After Initiation of Telehealth Treatment for Opioid Use Disorder)
Barbara Burke, MPH, Winifred Gallogly, BS, Brian Clear, MD, FASAM, Rebekah Rollston, MD, MPH
Bicycle Health
Description: A retrospective, one group pretest‐posttest study was conducted to estimate the effect of MOUD care provision via telehealth on patient rates of healthcare utilization. Study patients all received OUD treatment from Bicycle Health and had at least one emergency visit or hospital stay captured through a partnership with Bamboo Health.
Abstract: Individuals with opioid use disorder (OUD) are estimated to have more healthcare visits than individuals without OUD. To reduce healthcare utilization among this population, OUD treatment must become more accessible. Tele‐OUD treatment is a potential solution to increasing access to OUD care, although its effect on healthcare utilization is unknown. To quantify the effect of tele‐OUD treatment on healthcare utilization, a retrospective, one group pretest‐posttest study was conducted.
Using healthcare visit data captured through a partnership with Bamboo Health, 1598 visits from 542 Bicycle Health patients were captured, with 78% of all visits being emergency department visits. Exposure to tele‐OUD treatment reduced the rate of healthcare utilization by a highly significant average of 1.6 fewer visits per year. Among patients with high healthcare utilization in the year prior to initiation with Bicycle Health (5 or more visits), a highly significant average of 7.7 fewer visits per year was estimated.
These findings indicate that tele‐OUD treatment is a promising approach to help mitigate high usage of healthcare resources among patients with OUD. The results highlight the potential benefit payor organizations may gain by covering tele‐OUD treatment services, while at the same time addressing the public health need for accessible OUD care.
Classification of Research: Clinical Outcomes
Method: Observational
Results: A total of 1598 visits from 542 Bicycle Health patients were captured, with 78% of all visits being emergency department visits. In sum, 394 Bamboo Health‐participating facilities supplied at least one healthcare visit with hospitals reflecting more than 97% percent of all reporting facilities. Overall, exposure to tele‐OUD treatment significantly reduced the rate of healthcare utilization by an average of 1.6 visits per year. An average reduction of 7.7 fewer visits per year was observed for those considered high users, with 5 or more visits in the year prior to Bicycle Health treatment.
Conclusions: These results show the benefit of tele‐OUD treatment on patient healthcare utilization. While the reduction in number of visits was significant overall, the reduction among high utilizers was high with almost 8 fewer visits per year. These findings show that tele‐OUD treatment could help mitigate high usage of healthcare resources among patients with OUD. The results support alignment of public health, patient care needs, and cost. The findings show payor organizations may benefit by covering telehealth services as tele‐OUD treatment is estimated to lead to fewer visits and, subsequently, lower costs. Ultimately, payor coverage will support sustainability of these services.


Jason Goldwater, MA, MPA, Yael Harris, PhD, MHA
Laurel Health Advisors, LLC
Description: Value‐based care trends are significantly impacting the decisions made by provider organizations and creating an environment that encourages high‐quality, coordinated care. Value‐based care trends have led to a greater concentration on population health approaches and the use of telehealth to provide specialty care improves patient health and financial bottom lines.
Abstract: This research study sought to examine how to optimize remote interventions with specialist care amongst populations with multiple chronic conditions. These conditions of these individuals have exacerbated to a state in which their quality of life is compromised, the cost to the healthcare system is high, and the burden on patients, their caregivers, and the health system is significant. The study focused on multiple chronic conditions including the following metabolic diseases: cardiovascular disease (CVD), acute myocardial infarction (AMI), chronic kidney disease (CKD – 3a and 3b), and Type II Diabetes. The study examined the costs associated with patients with multiple chronic conditions and the lack of available specialty providers in Louisiana, Mississippi, and Alabama. We then examined the capitated per patient per month for Medicaid Managed Care. the fee‐for‐service payment for classic Medicare, and the capitated per patient per month arrangement for Medicare Advantage, factoring in the risk adjustment factor for each. The analysis showed limited access to specialty care and demonstrated that the total cost of care greatly exceeded the payment amount. However, using remote specialty care in a value‐based care model helped providers reach the 5% bonus payment and lowered the total costs to match the payment amount.
Classification of Research: Cost Analyses
Method: Cost Analyses
Results: Most of the individuals with multiple chronic conditions have a 50% or lower 10‐year survival rate and have conditions that would require at least one, if not two, specialists to provide the appropriate and needed care. Including remote specialty care within value‐based care programs as it helps providers meet the thresholds for their quality bonus. payments and payers meet their PMPM targets. The cost‐benefit of remote specialty care ranges from $1200 ‐ $1900 per person for Medicaid and $1100 ‐ $1800 for Medicare.
Conclusions: There are significant cost‐benefits for individuals using remote specialty care as it mitigates the risk of unnecessary referrals, eliminates patient travel, and limits the impact on patient productivity. Research also shows cost‐benefits to remote weight management and nutrition programs as well as using community workers.


Olivia Tran, MPH, Divya Madhusudhan, MPH, Michael Jensen, MS
Crossover Health
Description: To assess the impact of hybrid care (in‐person and virtual care) in management of population health screening and care management among employees
Abstract: A comprehensive population health management strategy is critical to drive clinical and economic outcomes. While there is extensive research on surveillance and population health interventions within underserved and uninsured populations, there is limited research on the effectiveness of population health management programs and use of preventive care services within commercially‐insured employer populations. Further, to the best of our knowledge, there is no research on the effectiveness of utilizing both in‐person and virtual care services in this context. This study assessed the impact of integrating both in‐person and virtual care (hybrid care) to manage population health at National employer‐sponsored health centers.
We conducted a retrospective cohort study comparing visit patterns, preventive screening and care gap closure rates of employees receiving in‐person and/or virtual primary care at employer‐sponsored health centers between July 2019 through August 2022. A total of 95,446 patients (mean [SD] age, 39 (10) years; 45% male) were included in the study population.
Classification of Research: Clinical Outcomes
Method: Retrospective cohort study
Results: Uptake of virtual care differed among service lines and across a patient's journey — 81% and 48% of initial primary care and mental health visits occurred in‐person, respectively. The rate of virtual visits during subsequent encounters increased across all service lines. By August 2022, the majority of members engaged in virtual primary care (54%) at least once. Diabetic patients receiving hybrid care were 1.3 times more likely to have glucose controlled than diabetics receiving in‐person only care. Hypertensive patients utilizing hybrid care were 1.1 times more likely to have controlled blood pressure than hypertensive patients receiving in‐person only care.
Conclusions: Hybrid care offers flexibility and choice in addressing population health needs, particularly during the COVID‐19 pandemic and specifically for services that can be provided virtually. Uptake of virtual care increased over time and across all service lines, including primary care, mental health and physical medicine. Initial data suggest that following establishment of care in an in‐person setting, members were comfortable transitioning care to a virtual setting in subsequent encounters. Employer‐sponsored health models may benefit from hybrid approaches that optimize use of virtual visits and asynchronous communication to enhance patient engagement and accelerate care gap closures.


James Shore, MD, MPH
Description: An adapted integrated care telehealth service model showed value increasing access to care and decreasing overall costs over time, for Medicaid Health Plan Members.
Abstract: Integrated care models delivered via telehealth hold promise to reduce costs while improving quality and access to care. An integrated care telehealth service, VCCI (Virtual Care Collaboration and Integration), was developed in partnership with a Medicaid Healthcare Plan. The model supports primary care practices' ability to identify and address behavioral health issues through collaborative consultation and direct‐to‐patient evaluation and treatment. The service was created drawing from national models of evidence‐based integrated care and then specifically tailored to the healthcare plan practices and member environment. We examined the value proposition of this model for access to care and total health care costs using a subset of Medicaid members who used the service between 2021 and 2022. The access to care analysis compared members receiving VCCI (N = 23) to those who did not. A total cost comparison analysis using a pre‐post intervention quasi‐experimental design (N = 139) was conducted using 6 months immediately prior to beginning VCCI vs 6 months (0‐6 months) immediately after first enrollment and 6 months from the end of the intervention (6‐11 months).
Classification of Research: Cost Analyses; Return on Investment and Access
Method: Cost Analyses
Results: For VCCI patients, time to see a therapist after a new mental health diagnosis was half (< 6 days) the time for those not participating (> 12 days). There was a demonstratable decrease in total cost of care from before and after the intervention. This cost decrease was associated with a decrease in office visits to the Primary Care Provider. VCCI was associated with a lower new baseline monthly cost per member using the service.
Conclusions: An adapted integrated care telehealth service model, VCCI, showed value increasing access to care and decreasing overall costs over time, for Medicaid Health Plan Members. Lessons learned include the importance of collaboration between service providers and health plan for tailoring and adapting integrated care services to the patient and member environment.


Lok Samson, PhD, MHS
Description: This research session highlights quantitative and qualitative analyses conducted by the Department of Health and Human Services ‐ Assistant Secretary for Planning and Evaluation (ASPE) Office of Health Policy on telehealth use in Medicare and Medicaid before and during the COVID‐19 pandemic from 2019 to 2021, including broadband access.
Abstract: To assess telehealth flexibilities provided by CMS and states in response to the COVID‐19 pandemic, we conducted analyses using Medicare FFS claims and Medicare Advantage encounter data, Medicaid claims, data from the Federal Communications Commission on broadband access and participation in the Emergency Broadband Benefit (EBB) program to examine trends in telehealth use from 2019‐2021 and factors associated with telehealth use. Previously, Medicare policies limited telehealth to health care facilities in rural areas. Recent 2021 Medicare data shows continued but lower use of telehealth across visit specialists, with highest use for behavioral health, followed by primary care and specialists, with telehealth mostly used for existing chronic conditions or other. Telehealth use was associated with broadband availability. ASPE also engaged stakeholders ‐ providers, commercial insurers, state Medicaid officials, advocates ‐ to gather lessons learned on telehealth use during the PHE. While state Medicaid programs have long had discretion on their telehealth policies, during the COVID‐19 pandemic many states made changes to expand telehealth access, payment, and covered services and modalities. Several states made permanent changes through state legislation to telehealth coverage in Medicaid. Remaining states' Medicaid telehealth flexibilities are still in effect contingent on federal or state public health emergencies.
Classification of Research: Regulatory & Policy Research; Trends in health care utilization
Method: Observational; quantitative descriptive and regression analyses; qualitative interviews
Results: Medicare FFS data showed telehealth use increased from <1% of total visits to a high of 10‐56% of visits by visit specialty at the start of the pandemic in 2020, an increase from <1 million in 2019 to 53 million in 2020 and 37 million telehealth visits in 2021. MA data showed similar trends. Reversing prior trends, telehealth use was lower in rural areas than urban areas, and lower among socially vulnerable communities and race/ethnic minorities. Medicaid data also showed a surge in telehealth utilization in the early months of the pandemic. Broadband availability was associated with telehealth use.
Conclusions: Analyses conducted by ASPE highlight the continuing telehealth use trends throughout the pandemic for Medicare and Medicaid beneficiaries and areas of disparities in access to and use of telehealth. Geographic availability of broadband access was one factor explaining higher use of telehealth among Medicare beneficiaries in urban areas compared with rural areas. Low‐income households and those residing in rural areas with limited broadband access may need further support to overcome structural barriers to telehealth access, given low participation in the Emergency Broadband Benefit program in counties with more rural populations, more older adults, and more adults with limited English proficiency.


Carolyn Rutledge, PhD, FNP, Tina Gustin, DNP, RN, CNS
Old Dominion University
Description: While online module‐based learning can be effective, end users do not have opportunities to practice their learned skills and receive feedback in a safe, supportive, and real‐time environment. A 10‐module telehealth certification course paired with an Online Standardized Patient (SP) experience has increased provider confidence and skills in delivering Telehealth.
Abstract: The rapid growth of telehealth prohibited critical consideration of provider training. Educators were challenged preparing interprofessional clinicians on the nuances of a safe and effective telehealth visit. The use of SPs is an established training and assessment technique in clinical education that can be useful for experiential training and feedback. Prior to participating in an online 1‐to‐1 SP session, learners completed a self‐paced, asynchronous 10 module‐based training program utilizing the 4 Ps Framework. Throughout the course, learners participated in immersive experiences. At course completion, learners selected a predetermined SP based on their profession: Pediatric Primary Care, Adult Primary Care, Social Work, Mental Health, Physical Therapy, Pharmacy, Anesthesia. SP scenarios included social determinants of health, with different genders, ages, and ethnicities. The SP experience was designed to assess learner competency in assessment, physical examination, medication reviews, patient education, and telehealth etiquette using validated tools. To date, 204 digital SP sessions have been completed. Data suggests that this type of telehealth training can be effectively and conveniently delivered through digital SP sessions that easily integrates into onsite, online, or distance learning courses, and provides the ability to increase the scale of online telehealth education to meet the current demands for training.
Classification of Research: Measurement Frameworks & Tools
Method: Survey / Qualitative; Standardized Patient Evaluations
Results: Ninety‐four percent of learners found their digital SP session to be more helpful / as helpful as face‐to‐face SP sessions. Initially the SP case was built for a 20‐minute experience, though learners requested additional time, so they have been extended. All students agreed/strongly agreed that the session was helpful in improving their overall telehealth skills. Data from the validated “Teaching Interpersonal Skills for Telehealth Checklist” (TIPS‐TC) includes quantitative results on a five‐point scale across 12 items and qualitative data from coaching comments added by participants. The research will report results from the TIPS‐TC evaluation instrument at the session.
Conclusions: The incorporation of the SP experience into the 10‐module certification course has proven to be effective. Due to the national outreach of the certificate program, learners from different time zones have self‐scheduled sessions at times convenient for them. This offers a simple and affordable way for providers and healthcare students to have access to SPs and to tap into a reliable and validated program. SP recruiting, training, case design specific to telehealth encounters, as well as learner preparation, SP/learner scheduling, and learner outcomes will be provided. Programs such as this demonstrate innovative ways to overcome barriers of access and distance.


Navdeep Sangha
Kaiser Permanente
Description: We aim to describe a pilot study of virtual emergent ophthalmologic examination utilizing fundus photography with remote review in a single emergency department with the subsequent larger implementation over multiple medical centers in an integrated health care system in Southern California.
Abstract: Direct ophthalmoscopy, while routinely performed by Ophthalmologists to detect sight‐threatening conditions such as retinal vascular occlusions, remains a challenging exam for clinicians outside the specialty. After‐hours, this discrepancy requires Ophthalmologists to come into the emergency department (ED) to evaluate patients with acute monocular vision loss (MVL) which can result in a diagnostic delay with therapeutic implications. A Scientific Statement by the AHA in 2021 concluded that retinal vascular occlusions could be treated with thrombolytics, and when feasible, the emergency provider should be guided by an eye care specialist, either in person or remotely via fundus photography to confirm the diagnosis.
An initial multi‐disciplinary pilot involving ED, Ophthalmology and Neurology teams was conducted from 4/20‐6/30/2020 to assess the feasibility of emergent diagnosis of MVL. Patients who arrived in the ED with MVL had their fundus photo taken in the ED, which was then electronically sent to the Ophthalmologist on call for remote viewing on their laptop or mobile phone. The Ophthalmologist would then relay their interpretation to the ED or Neurology clinician allowing for emergent therapeutic intervention if warranted. Based on this pilot, a larger regionalization across an initial 7 medical centers followed by 8 additional medical centers is now underway.
Classification of Research: Access to Care
Method: Implementation Science
Results: In the initial pilot we captured 15 patients with either acute monocular vision loss or vision changes who underwent fundus photography. Fundus photographs were taken either by Neurology residents or ED physicians. Two patients had positive findings that changed management, including worsening papilledema and a branched retinal artery occlusion. Median time from ED arrival to result was 82 minutes. Subsequently, the data was used to procure additional fundus cameras for placement in 7 emergency departments.
Conclusions: Fundus Photography with remote Ophthalmological interpretation is a feasible telehealth alternative to direct ophthalmoscopy to detect the cause of acute vision loss in the ED. It can lead to changes in management that may preserve a patient's vision and decrease the risk of future vascular events with the emergent administration of therapeutic and preventative therapies.


Amit Agrawal, MD
Envision Physician Services
Description: Virtual Neonatal Support Program (VINES) has allowed neonatologists and nurse practitioners to support patients outside of the 4 walls of the ICU. By providing dual‐pronged virtual support with scheduled and on‐demand visits, it has allowed for a safety and support structure serving vulnerable and fragile infants after their NICU discharge.
Abstract: Traditionally, neonatologists and neonatal nurse practitioners (NNP) have been confined to the four walls of the intensive care unit. Virtual Neonatal Support Program (VINES) is the first program that allows for these norms to be broken, providing highly subspecialized support during the most vulnerable period for premature infants discharged from any NICU across the state of Arizona. The average LOS for infants in the NICU exceeds 20 days, with some over 100, and their exists an inherent gap between hospital discharge and the transition to home for these fragile infants. VINES provides scheduled visits and an on‐demand NICU Virtual Urgent Care, giving patients access to Neonatologists and NNP's after discharge. This new safety net has already shown to decrease ED and urgent care visits, unnecessary trips to the PCP, and has averted several “near miss” events by providing the right care, at the right time. Completed visits have prevented parents from seeking the ED or Urgent Care 76% of the time, leading to a modeled cost savings of 1.2M dollars per 1M insured lives. The clinical and financial value of a virtual neonatal support program should be considered nationally.
Classification of Research: Clinical Outcomes; Also inclusive of Cost Analyses and Access to Care
Method: Descriptive
Results: Live March of 2021; 602 visits have been completed; 357 unique families.
• 391 Family surveys after the visit (65%).
• NPS for patient satisfaction is 98
• NPS for “would you use again” is 96
• 99% felt all questions were answered to their satisfaction
• 76% felt visit helped avoid an emergency room or urgent care visit
• 433 Provider surveys after the visit.
• 22% felt they prevented an emergency room or urgent care visit
• Recommendation to PCP 63% of the time.
Discussion topics included feeding, respiratory care, developmental care, medications, and NICU diagnoses. Cost modeling calculates to a 1.2M dollar savings per 1M lives.
Conclusions: The VINES program has effectively captured a vulnerable time for NICU patients after their discharge from the hospital. National trends show more than 20% of NICU graduates will be readmitted after their discharge. The trauma families experience in the NICU leads to significant anxiety and unpreparedness after they transition home. By providing virtual support by specialized providers, VINES has created a safety net that is showing significant clinical and financial value to the patients and the community. The program solidifies the need for neonatal post‐discharge support, and its success is demonstrated by exemplary patient satisfaction.


Roberta Lins Gonçalves,1 Tainá Costa Pereira Lopes,1 Sarah Almeida Cordeiro,1 Adriana Silvina Pagano, Zilma Reis,2 Julia Macedo Nunes,2 Antônio Luiz Pinho Ribeiro,2 Ken Brackstone,3 Michael Head,3 James Batchelor,3 Seth Kwaku Afagbedzi4
1Universidade Federal do Amazonas
2Universidade Federal de Minas Gerais
3University of Southampton
4University of Ghana
Description: The COVID‐19 pandemic has limited human interactions. It has prompted healthcare systems to adapt to continue providing healthcare. Telehealth was one of the strategies used. However, there is little evidence of healthcare providers' perceptions of the usability of telehealth for hypertension and diabetes from the pandemic onwards.
Abstract: Introduction: The COVID‐19 pandemic has caused changes in the way healthcare services are provided. Telehealth expanded from there. However, the perception of its usability by health professionals remains uncertain.
Objective: To synthesize evidence on the perception of health professionals about the usability of telehealth in the care of individuals with hypertension and diabetes from the COVID‐19 pandemic.
Method: Systematic review. The study population was health professionals who used telehealth to care for patients with hypertension and diabetes from the COVID‐19 pandemic. The primary outcome was the usability of telehealth. Prospective cohort studies, retrospective observational studies, and studies that used qualitative data collection methods were eligible. The databases consulted were MEDLINE, Embase, BIREME, IEEE Xplore, BVS, Google Scholar (manual search), and gray lit. The risk of bias and methodological quality of included studies were analyzed using the JBI, the Critical Appraisal Skills Program Qualitative Research Checklist, and confidence in the synthesis results with the GRADE‐CERQual approach.
Results: Eleven studies with 248 health professionals were included. With a moderate confidence level, we concluded that health professionals considered the usability of telehealth good and feel comfortable and satisfied with using telehealth to care for patients with hypertension and diabetes in primary care.
Classification of Research: Clinician Experience
Method: A systematic review of qualitative research.
Results: Four hundred seventeen abstracts were selected, and 11 full‐text articles were evaluated and met our inclusion criteria. Eight of the studies sampled were from high‐income countries: Australia (2), Canada (1), the United States of America (2), Nordland (1), Portugal (1), and Saud Arabia (1). Three studies sampled were from middle‐income countries: Brazil (2) and Iran (1), with 248 health professionals, most physicians, and nurses. The main finding of this review was that health professionals considered the usability of telehealth to be good and feel comfortable and satisfied using telehealth for the care of patients with hypertension and diabetes.
Conclusions: With moderate quality of evidence, health professionals who assist patients with hypertension and diabetes in primary care considered that the telehealth systems presented good usability. Moderate concerns were found regarding methodological limitations/coherence/adequacy/relevance that reduced confidence in the findings of the review, being considered in the quality assessment. Additionally, this review included high‐income countries and middle‐income countries, but no low‐income country. It is possible that further research in different contexts of use will affect the confidence of this finding and could change this prediction. However, the finding is probably a reasonable representation of the phenomenon of interest.
This research is funded by the Worldwide Universities Network (WUN RESEARCH PROJECTS), as part of the project: Leveraging digital healthcare experiences for post‐pandemic non‐communicable disease research ‐ a multidisciplinary network engaging Brazil, Ghana, and the UK.

Poster Presentations


Isabela Borges, Clara Oliveira
Telehealth Network of Minas Gerais
Description: Regulation of telemedicine in Brazil has changed dramatically during the pandemic, and teleconsultations have become an attractive model of care, especially for acute COVID‐19. But the pandemic has also posed challenges for the management of non‐communicable diseases. Therefore, telehealth tools were developed to support primary health care in this scenario.
Abstract: Brazil has a large territory with unequal distribution of healthcare resources. Telehealth is an effective approach to support primary care practitioners based in remote locations, especially for managing patients with non‐communicable diseases. At the same time, primary health care (PHC) is developed with the highest degree of capillarity, working as closely as possible to patients' lives. Therefore, a significant concern during the conception of this multimodal platform of telehealth strategies was to preserve the fundamental principles of continuity, coordination, and comprehensiveness of care centralized on the PHC team of the participating municipalities. Teleconsultations and teleinterconsultations with secondary care specialists should be offered in association with tele‐education strategies and communication tools to promote an excellent primary‐secondary care interface and a collaborative practice. Also, implementing patient‐centered solutions to encourage autonomy and self‐management was identified as necessary to achieve comprehensive and quality assistance based on best practices. The multimodal telehealth platform that was developed consists of the following: a decision support system to improve control of hypertension and diabetes; a text messaging patient‐centered intervention to promote healthy habits and therapeutic adherence; the most varied tele‐education materials; multi‐professional mentoring groups; teleinterconsultations and teleconsultations in cardiology, endocrinology, nutrition, nursing, and physiotherapy.
Classification of Research: Access to Care
Method: Descriptive
Results: The platform proved feasible and has been offered in 14 municipalities since 2021. The model allows excellent proximity between the PHC team, users, and the team of specialists who work remotely in assistance and educational activities. The teleconsultation and teleinterconsultation registration system was structured in the SBAR format, an effective technique with a situational briefing that provides a practical roadmap to concise, meaningful, and brief communication to overcome barriers to transitioning and coordinating care across specialists and PHC practitioners. As a result, the PHC offers more dynamic care, with expanded access to specialists through telehealth tools.
Conclusions: The emergence of COVID‐19 defined a fruitful moment for expanding telehealth uses and applications. The concomitant use of these tools is overcoming distances, offering health education and quality and scientifically based health care more dynamically, with apparent cost savings and reduced workload. Therefore, based on this model that overcomes the traditional limits of referral and counter‐referral, telehealth services should continue to be part of the health care in Brazil's public service in the medium and long term, becoming a permanent part of the available care resources.


George Gellert, MD, MPH, MPA, Roberto Sicconi, MSEE
Description: Surveyed use patterns, patient‐user and system impact of virtual triage within a multinational population of 2113 patient‐users. Pre‐triage, 40.5% didn't know what healthcare to utilize. Virtual triage helped users (75%) decide care level. Triage successfully redirected patient‐users who initially planned to seek inappropriate care acuity, and increased openness/acceptance of telemedicine.
Abstract: The public increasingly seeks healthcare information, primarily through the internet, to make informed decisions about their health, including acute illness. Nearly seven percent of daily Google searches concern healthcare topics—representing over 1 billion searches per day. Virtual patient triage engines, commonly referred to as “symptom checkers”, are being positioned on the digital front door of healthcare systems in order to serve as effective digital guides that connect patient end users to the right acuity level and locus of healthcare services, and in so doing, potentially optimizing utilization of the appropriate – most clinically‐effective and cost‐effective – site of healthcare service delivery. This presentation conveys data from a survey of 2113 users of a leading virtual trial engine in order to understand who users are, what potential value their user experience of virtual triage delivers, and what some of the greatest challenges are to the science and technology driving this industry vertical.
Classification of Research: Patient Experience
Method: Survey / Qualitative
Results: Virtual triage users were 78% female; 63% were 18‐44 years old; 41.2% were from U.S., 12.5% from U.K., 9.1% from Canada. Motivations were to determine need to consult a physician (44.2%), or secure medical advice without visiting a physician (21.0%). Pre‐triage, 40.5% didn't know level of healthcare to utilize. Triage recommended 56.8% consult a physician, 33.8% seek ED and 9.4% self‐care. In three‐fourths, triage helped users decide care level; in 74.1% triage recommendations differed from pre‐triage intentions. Post‐triage, those remaining uncertain decreased 25.4%. Patient‐user amenability to using telemedicine/virtual health doubled, and satisfaction with virtual triage was very high (80.1%).
Conclusions: Virtual triage successfully redirected patient‐users who initially planned to seek an inappropriate level of care acuity, reduced patient uncertainty of care path, and resulted in patient‐users being highly satisfied with virtual triage. A large majority will use virtual triage recurrently in the future and indicated that their experience using online triage increased their receptivity to using telemedicine.


Kevin Riley
Description: A Customer Data Platform (CDP) has become a critical infrastructure component and capability for healthcare organizations, especially those supporting telemedicine.
Abstract: A CDP has become a critical infrastructure component and capability for healthcare organizations While unifying disparate data into a CDP may sound straightforward, it is not a mechanistic process. There are five dimensions of data, referred to by Salesforce as “the five V's,” that such a tool needs to integrate: velocity, variety, veracity, volume and value.
Having a CDP as part of a healthcare organization's information infrastructure facilitates and accelerates this process, and that matters for three main reasons.
1. Delivering on expectations for personalization. Customer expectations have changed due to interactions with other brands that offer consistently individualized experiences.
2. Ensuring privacy. As consumers pay increasing attention to how their privacy is managed, there is a pressing need for hospitals and health systems to move away from using second‐ and third‐party cookies to build audience segments and outreach lists.
3. Providing trusted, compliant communication.
Real‐time engagement and personalization are enablers of value‐based care, and their role should be reflected not only in how organizations deliver care, but also in how they communicate with patients and other users.
Classification of Research: Patient Experience
Method: Observational
Results: A Customer Data Platform (CDP) facilitates digital interactions that are personalized and providing meaningful clinical information; furnishing access to on‐demand content delivered through a user's preferred communication channel; and offering a hybrid engagement model that adapts to the virtual and physical worlds, depending on patient needs.
Conclusions: Customer Data Platform (CDP) CDP is a game changer in how healthcare marketers are able to engage and interact with patients in a personalized, effective and compliant way. Yet, for all its virtues and future‐forward design, a CDP often works best in combination with other engagement tools, such as chat bots and secure instant messengers, that patients often use to establish first contact with a provider organization.


Michelle Elsener, RN, BSN‐BC, Veronica Van Pelt, RN, BSN‐TNCC
White Plains Hospital
Description: We developed a telehealth program to improve access to services for transitional care patients with the desired outcomes of decreasing hospital readmission, emergency department utilization and improving patient satisfaction. Our program leverages a collaborative community approach to connect patients with needed resources, empower individuals, and improve overall quality of care.
Abstract: We built out four telehealth‐based components under one umbrella since 2018, including: (1) Clinical Outreach Team, (2) Complex Care Team, (3) Virtual Acute Clinic and (4) Access Navigation. The program is overseen by 2 directors (Medical & Administrative), and has been developed internally without external funding. Guided by registered nurses with social work support, the Clinical Outreach Team targets all patients discharged home from the hospital, emergency department, and ambulatory surgery to review discharge instructions, access to medications, home care services, and follow‐up appointments. The Complex Care Team, run by Advanced Practice Providers, follows Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD) and Pneumonia (PNA) patients discharged home for 30 days. The Virtual Acute Clinic, run by Advanced Practice Providers, offers an escalation pathway for the Clinical Outreach Team as well as an outlet for patients who do not meet admission criteria for managing acute cases safely at home. Access Navigation focuses on ensuring urgent access to follow up visits post discharge. This program has clearly designed escalation pathways as well as a data driven questionnaire on our electronic health record that translates into dynamic dashboards for performance improvement opportunities from findings detected post hospital discharge.
Classification of Research: Quality Improvement
Method: Observational
Results: 6,233 patients, on average, are outreached monthly with a mean contact rate of 65%. Medicare readmission rate reduction from 2018 to 2022 are: Total (14.8% to 10.6%), CHF (21.3% to 7.2%), COPD (19.3% to 16.1%), and PNA (15.9% to 11.3%). ED 48‐hour return rates were lower for patients contacted (2% vs 7%, OR: 2.5, p < 0.001). From Press Ganey, patients ranked us in the 92nd and 93rd percentile against national benchmarks (inpatient and ED) if they received a call and a text compared to 16th and 14th percentile.
Conclusions: We leveraged a novel, multi‐faceted, telehealth approach to improve patient engagement and access with the result of sustained decrease in acute care utilization and improvements in patient satisfaction. This program is internally built with clear templates and escalation pathways for ease of replication at other institutions.


Jean Anne Schnittker, MS
Sonova AG
Description: By adopting new service delivery methods, such as remote hearing aid fitting, hearing healthcare professionals aim to increase satisfaction and benefit. Instead of a rigid hearing journey with the professional making all the decisions, consumers will be engaged and empowered to make decisions at multiple touchpoints along the hearing care process.
Abstract: Hearing healthcare is changing from a clinician directed process to a collaborative and connected process. New choices are being offered to clients in omnichannel models, empowering consumers to make choices that are most appropriate to meet their hearing healthcare needs. Study results show remote hearing aid fitting provides personalized and adaptive care, compared to traditional hearing aid fittings. Remote hearing aid fitting results are as good as, and sometimes even better, than traditional hearing aid fittings completed face‐to‐face. Clinician attitudes towards tele‐audiology, willingness to perform clinical tasks, and willingness to conduct tele‐audiology appointments with different patient populations has also played a role in the uptake and adoption of new service delivery methods.
Classification of Research: Clinician Experience; Patient experience
Method: Randomized Controlled Trial; questionnaire
Results: Some patient populations may be better suited for remote hearing aid fitting than others. Providing care using alternative service delivery models can empower and engage the patient, therefore increasing satisfaction and benefit. Remote fitting is as good as, and sometimes better than face to face hearing aid fitting. Clinician willingness to use tele‐audiology depends on the clinical task and patient population.
Conclusions: Tele‐audiology is a growing area of hearing healthcare. Tools such as remote fitting and self adjustment of hearing aids via an app are being offered to patients and can potentially increase satisfaction and benefit. This type of care is personalized to each patient's unique hearing healthcare journey, making it an adaptive and dynamic experience. The patient is able to make choices about their care, not just be directed by the clinician.


Caroline Cotton
University of Virginia
Description: The University of Virginia's Ophthalmology Department leads a Diabetic Retinopathy Screening Program in which portable fundus cameras are sent to primary care sites across Virginia for remote eye screening. This project aimed to investigate follow‐up rates and factors affecting gaps in care in patients referred to ophthalmology for abnormal findings.
Abstract: Diabetic retinopathy is a severe microvascular complication of diabetes that may go undetected for years and eventually lead to devastating and irreversible outcomes, including blindness. Screening for this disease is thus essential to reduce the risk of sight loss in this population. At the University of Virginia (UVA), the Ophthalmology Department has created a Diabetic Retinopathy Screening Program to provide retinal tele‐screening for more remote, underserved populations throughout Virginia. However, although the ophthalmologists at UVA can provide recommendations for patients with abnormal findings on retinal imaging to see an ophthalmologist, the actual follow‐up rates for these patients have not been assessed. Thus, the goal of this project was to investigate follow‐up rates and factors affecting gaps in care in 165 patients recommended to see ophthalmology from 6 different primary cares sites from January ‐ December 2021. Identifying specific follow‐up rates and further investigating factors that may contribute to poor follow‐up, such as demographics, insurance coverage and referral process, are essential to identify current limitations, make any necessary improvements, and create a more effective tele‐screening program.
Classification of Research: Access to Care
Method: Survey / Qualitative
Results: Preliminary data shows follow‐up rates of less than 50% for patients recommended to see an ophthalmologist. Many of these patients are uninsured, homeless, and/or do not see a physician on a regular basis. Diseases identified included mild to severe non‐proliferative diabetic retinopathy, suspected glaucoma, retinal detachment, and macular degeneration. Sites also varied in their referral process. Some made referrals to local ophthalmologists and followed‐up with patients regarding attending the ophthalmology appointment, while other sites did not refer or follow‐up with their patients.
Conclusions: The total follow‐up rates at these remote primary care sites were suboptimal, demonstrating a clear limitation in the process of tele‐screening and connecting patients to the medical care they need. Some factors may not be easily overcome, such as individuals' barriers with insurance, transportation, or finances. But there are definitive steps that could be taken for more tangible improvements. Communication between the primary care sites and UVA Ophthalmology could be better streamlined for more timely, efficient recommendations. The referral process to an ophthalmology practice and the communication with patients concerning this process could also be further standardized to improve follow‐up.


Elizabeth Faust Murdoch,1 Neil Parikh,1 Brett Ashton,1 Glenn Loomis,1; Kristen Miranda,1, 2 Adam Cohen,3, 4
1Thirty Madison
3Yale New Haven Health System
4The Johns Hopkins University Applied Physics Lab (JHU APL)
Description: Chronic conditions are often underdiagnosed and undertreated due to lack of access to specialty care. Telemedicine may increase access for patients seeking chronic care, particularly in medically underserved areas (MUA). The study objective was to describe the geographic impedance and timeliness of care for patients seeking specialty care via telemedicine.
Abstract: This retrospective study evaluated patients who self‐enrolled in a specialty telemedicine platform, Nurx, which provides patients with access primarily to dermatologic and sexual health care, but also neurologic and mental health services. Patients learned about the platform via paid online advertisements or patient‐driven search. Patients receiving care had access to asynchronous expert consultation and evidence‐based care, continuous patient‐reported monitoring, ongoing messaging, and e‐pharmacy. At intake, patients complete a comprehensive questionnaire including demographic information, treatment and disease history, and patient‐reported clinical data. The intake is condition‐specific and may include baseline photographs of skin conditions, self‐recorded neurological videos, and labs.
Patients seeking specialty care from the telemedicine platform between September 2021 and 2022 were included in the analysis. Patient sociodemographic characteristics, including age, sex, and geographic location were summarized. ZIP codes were used to determine the percentage of patients residing in a MUA county as defined by the Health Resources and Services Administration. Conservatively, ZIP code boundaries had to reside fully within a designated county for MUA consideration (i.e., ZIP codes spanning multiple counties were not assigned MUA designation). Lastly, wait time, defined as time from patient intake to first outreach from a provider was reported.
Classification of Research: Access to Care
Method: Descriptive
Results: Data from a total of 502,021 patients were analyzed; 30% were treated for dermatologic conditions, 75% for sexual health, 1% for migraine, and 1% for mental health.
The average patient age was 31 years; 4% were 50 years or older, and 94% were female. Patients were geographically diverse with 22% of patients living in counties designated as rural/partially rural, 63% in non‐rural, and 15% with multiple/undefined designations. Notably, 67% of patients were living in a MUA county across 49 states.
The median time from patient intake to provider outreach was 3 days (equivalent for patients in MUA counties vs. non‐MUA counties).
Conclusions: This study highlights the potential of telemedicine to improve access to specialty care. Patients in this study were geographically diverse indicative of the reach of novel telemedicine platforms to MUAs. More than two‐thirds of patients reside in a county with MUA designation underscoring the significance of providing healthcare access to a population that may otherwise experience unmet healthcare needs. Beyond geographic access, patients treated via the telemedicine platform experienced reduced wait times than typically observed for in‐person care (3 versus 26 days).
Future studies should assess the impact of telemedicine on access for additional factors including income, stigma, and insurance.


Renee Dixson, MSN, RN,1 Jane Trombetta,2
2Optum Everycare Now
Description: An Antimicrobial Stewardship Program (ASP) is essential to improve quality of care, reduce unnecessary prescribing and decrease antibiotic resistance in our community. As virtual healthcare visits increase nationally, we need to optimize our virtual resources for a continued and successful ASP.
Abstract: Introduction: Nearly 2.8 million anti‐microbial resistant infections occur in the Unites States each year, and more than 35,000 people each year die as a result. When Clostridioides difficile is associated with antibiotic use and added to these statistics, the U.S. toll of all the threats exceeds 3 million infections and 48,000 deaths.
Objectives: Our objective is to improve compliance with our Acute Bronchitis (AB) quality metric across both our Virtual Urgent Care (vUC) and Virtual Primary Care (vPC) service lines. Compliance is defined as not prescribing an antibiotic unless indicated based on clinical practice guidelines. Secondly, our objective is to optimize our use of technology to promote performance improvement as we partner with our patients.
Baseline Data: In Q1 for 2022, compliance with the Acute Bronchitis quality measure was: 58% for Virtual Urgent Care and 42% for Virtual Primary Care.
Classification of Research: Quality Improvement
Method/Interventions: Antibiotic stewardship measures were selected for quality monitoring and improvement based upon our scope of service and patient population. To drive this metric forward, we had leadership support and focused on our technology capabilities in the virtual setting. Tactics included:
• Collaborated with our EMR report analysts to build an electronic report (AB) to determine compliance data by service line and individual provider.
• Created a shared TEAMS page to house our electronic dashboard data for monthly tracking across EMRs.
• Developed and posted (AB) Clinical Practice Guidelines on a shared digital resource page for all providers to access and reference.
• Utilized online daily ‘huddles' with providers and support staff to share high‐level data, educate and drive improvement.
• Empowered providers with talking points to address patient expectations if antibiotics were not clinically indicated.
• Providers were reminded to utilize our EMR tools to select patient education, explain the safe use of antibiotics, and populate this information on the patient after‐visit sheet.
• Effectively utilized data to educate individual providers in need of improvement.
Results: Q2 Acute Bronchitis compliance has improved for both service lines; 76% for vUC (58% in QTR1), and 65% for vPC (42% in QTR1). Q3 2022 to date has vUC sustaining this improvement at 76% and vPC with another 11% increase to 76%. The use of technology, shared electronic sites and tools have been integral in supporting our ASP program while improving patient safety and quality of care.
Conclusions: Antimicrobial stewardship plays an important quality and safety role regardless of the healthcare setting. Evaluation of the current virtual state is essential to identify gaps. There are effective strategies which can be implemented to optimize ASP. Finding creative ways to utilize technology and the deliverables can improve compliance with antimicrobial stewardship. ASP continues to be a shared partnership between the provider and patient and is a national focus for healthcare. On‐going performance monitoring is critical to assess prescribing practices and provide feedback.


Melinda Cooling, DNP, MBA, APRN, FAANP, Colleen Klein, PhD, APRN
OSF HealthCare
Description: OSF OnCall is comprised of centralized teams of nurses, providers, and support staff that can care for a large number of patients by using telehealth. Both quantitative and qualitative methods of research will be used to evaluate our digital health programs in terms of patient care outcomes and patient engagement.
Abstract: Research related to digital health and remote patient monitoring remains understudied, but within the past decade, published reports have focused on the use of wearable devices for managing hypertension, diabetes, cardiovascular and pulmonary disease. Digital and health literacy on the part of patients, as well as provider challenges have been cited as additional barriers to use of these technological advances to remote health care management. OSF HealthCare has had first‐hand experiences as part of a pandemic health response while partnering with the State of Illinois to create a pandemic health worker (PHW) program that would serve 110 counties in Illinois. The program was designed as an end‐to‐end digital health care response to achieve rapid scale, while maintaining the patient centered focus of trust building, anxiety reduction, patient engagement, and optimized clinical outcomes. This early work led us to propose to explore the intervention effectiveness and dissemination of digital health care delivery models for improving selected health outcomes in the Medicaid population with five specific aims. The importance and benefits of digital health in conjunction with the CHW role to health systems, patients, and policy makers will be examined as part of this research proposal.
Classification of Research: Clinical Outcomes
Method: Descriptive
Results: We are in the early phases of a five year journey for this research including qualitative and quantitative analysis. Using the Sprout conceptual framework, we have specific aims and statistical analysis planned. Early results indicate that we can improve outcomes with SdOH evaluation and action as well as increase engagement of the population with digital tools. With over 19,000 patients planned for enrollment, the data collected will have significant value for the body of evidence that will support digital health adoption.
Conclusions: Digital health plays a significant role in the future of healthcare. This study has the potential to determine whether the value of virtual care and remote monitoring for management of prenatal care and chronic conditions in the Medicaid population. This is important considering that, pre COVID‐19 pandemic, hospitals were already experiencing the negative impacts of staffing issues and clinician burnout and access to care remains particularly challenging for the Medicaid population. This large, longitudinal study will inform clinician practice and will help to advance new knowledge in this type of care.


Kim Tarver, Ashley Allen, MSN, Denise Lafferty, BSN
University of Mississippi Medical Center
Description: Caregiver University is a training and support program designed to alleviate caregiver stress and burden while providing care for their loved ones living with Alzheimer's and related dementias.
“This abstract was made possible by grant number U6631459 from the Office for the Advancement of Telehealth, Health Resources and Services Administration, DHHS”
Abstract: Caregiver University (CGU) is a training program that provides information on essential topics for caregivers who are navigating the healthcare continuum for a loved one with Alzheimer's or related dementia (ADRD). This training is a 9‐day course of informational topics that are presented via Zoom so that caregivers are allowed to attend sessions from their homes. The sessions are 1‐1.5 hours long with 1‐2 sessions per day and Video‐On‐Demand technology available for additional information. All sessions are recorded so that participants may refer back to an informational session. These sessions are conducted quarterly with new participants each 9‐day session. Providing the sessions in a live format via Zoom allows the participants to engage in an interactive learning experience with the medical team and other caregivers. A range of topics are covered to help the caregivers know what to expect while caring for someone living with Alzheimer's or a related dementia. Topics include but are not limited to healthy aging, assessment/diagnosis, personal care, alleviating caregiver stress, managing challenging behaviors, managing safety, addressing modifiable risk factors, legal planning /considerations, and end of life/palliative care.
Classification of Research: Patient Experience
Method: Survey / Qualitative; The American Geriatrics Society's Caregiver Self‐Assessment Questionnaire is administered prior to, one week post‐session, at 3 months, and again at 6 months after session completion to monitor caregiver challenges and stress.
Results: The AGS Caregiver Self‐Assessment Questionnaire was implemented with the May 2022 CGU session. 100% completed the survey prior to starting the May 2022 session. There was reduced participation in the 1‐week post session survey. The 3‐ and 6‐month post session surveys will be administered August and November 2022.
Conclusions: Based on the responses to the Caregiver University Course Evaluations, positive reviews were demonstrated with only 2 reports of areas that need improvement. One area was related to content complexity and the other to timing of video availability. In the positive reviews, qualitative responses were recorded to allow participants to express which sessions were most valuable to their learning experience and if there was information they would have liked explained further. Official metrics from the Caregiver Self‐Assessment Questionnaire are pending review at this time.


Traci Barnes, MD, Meredith Laguna, MD, MPH
University of California, San Francisco
Description: Telehealth use in pediatric practices has expanded due to the COVID‐19 pandemic. Some conditions are still best suited to an in‐person visit due to need for exams or testing. We evaluated characteristics of telehealth visits that required in person follow‐up in order to better identify these conditions.
Abstract: The UCSF pediatric acute care clinic sees children for acute complaints/sick visits by telehealth and in‐person. Some children have required an in‐person visit following a video visit. We analyzed characteristics of telehealth visits which required an in‐person visit on the same day to better predict when patients should be seen in‐person initially.
We conducted a cross‐sectional analysis of telehealth visits over the months of July – October 2021, when the majority of sick visits were still by telehealth but could also be scheduled in‐person. We gathered demographic information (age, gender, interpreter need, ethnicity, insurance), past medical history (asthma, immunocompromised, obesity), recent ED history, vaccination status, chief complaint of telehealth and subsequent in‐person visits, what tests were ordered, and final diagnosis.We used Pearson chi‐squared tests to analyze visit characteristics and made a variable importance plot model to assess possible predictors of needing an in‐person visit after telehealth.
Classification of Research: Quality Improvement
Method: Observational
Results: There were 3,235 telehealth visits during the study period, of which 120 required a subsequent in‐person visit. Our study found that those with throat, ear, or male genitourinary chief complaints were the most likely to require an in‐person visit following the video visit. There were no statistically significant differences in insurance type, age, or gender for those requiring a follow up in‐person visit. Visits which required a subsequent in‐person follow‐up were more likely to result in albuterol prescription, antibiotic prescription, urinalysis, respiratory viral panel, and strep testing, but not COVID testing.
Conclusions: This study found that a wide range of pediatric acute complaints can be managed by telehealth. Patients with chief complaints relating to ear and throat symptoms, or male genitourinary symptoms may be better served by in‐person visits. Patients who were seen in‐person had more testing and prescriptions result from the visit than those who were seen only over video, perhaps driven by need for exam findings such as ear exam for diagnosis of acute otitis media or strep testing. This work can be used to help inform future triage algorithms so that telehealth is used for appropriate situations.


Nancy Downing, PhD, RN, SANE‐A, SANE‐P, FAAN, Heather Clark, DrPH
Texas A&M University
Description: A mixed methods study using Wade and colleagues' clinician acceptance of telehealth framework to examine rural nurse acceptance of a statewide telehealth sexual assault nurse examiner (SANE) program. Data examined include pre‐ and post‐training surveys of rural nurses and post‐telehealth encounter documentation by telehealth SANEs.
Abstract: Background. Clinician acceptance of telehealth is critical to a program's sustainability. We used Wade and colleague's clinician acceptance model as a framework to examine rural nurse attitudes toward the Texas Teleforensic Remote Assistance Center (Tex‐TRAC) program. Tex‐TRAC provides rural nurses with 24/7 access to expert sexual assault nurse examiners (SANEs) via telehealth to provide consultation during sexual assault medical forensic examinations (MFEs).
Methods. We examined data for modulators of clinician acceptance, including champions promoting telehealth, relationships between providers, beliefs about telehealth, clinician demand, resourcing, workforce availability, and quality of technology. Data included pre‐ and post‐training surveys from rural nurses undergoing training to use the Tex‐TRAC service, qualitative data from 20 telehealth SANE post‐encounter notes, and descriptive and observational data.
Results. Preliminary data indicated rural nurses felt less positive about technology and using the service prior to training compared with after training. Post‐encounter data indicated using Tex‐TRAC increased rural nurses' comfort and confidence providing MFEs, and patients appeared comfortable with the service. Greater consistency of the technology (e.g., reliable connectivity of the camera feeds) would improve the experience for rural nurses.
Conclusion. Top‐down buy‐in, effective training, continued engagement, and using the service promote positive beliefs about telehealth and clinician acceptance.
Classification of Research: Clinician Experience
Method: Survey / Qualitative
Results: Rural nurses' beliefs about technology and Tex‐TRAC were measured before and after training on the telehealth service. Data collection is ongoing; preliminary results revealed that technology beliefs before training were generally not positive; 48% of nurses agreed with the statement, “Tex‐TRAC brings a lot of challenges.” Beliefs about technology use in general were more positive. Following training, beliefs about Tex‐TRAC improved, with nurses agreeing there were fewer challenges, and the program brings value to their work and patients. Post‐encounter, nurses said consistency with the technology would improve the program, though their comfort with FMEs increased and patients appeared comfortable.
Conclusions: Clinician acceptance of telehealth interventions are critical to sustainability. Rural hospital nurses might not initially have positive beliefs about using a telehealth sexual assault nurse examiner (SANE) service, though beliefs might improve after training and after using the service during a patient encounter. Strategies to increase rural nurses' positive beliefs about using the telehealth SANE program include emphasizing the importance of providing high‐quality sexual assault medical forensic exams instead of transferring patients and ensuring technology works consistently. The clinician acceptance model is useful for identifying elements to strengthen to increase positive beliefs about telehealth and clinician acceptance.


Toni Mesha Thomas, BSN, ADN,1 Renee Hoeksel,1 Jennifer Martinson, ARNP, FNP‐BC, FNP‐C,2
1Washington State University
2Care Medical
Description: Telehealth offers convenient care access for many patients yet is limited when best practices require a physical exam or in‐person screening test. By incorporating nurse‐provided in‐home care with telemedicine visits, one clinic was able to bridge the care gap of comprehensive evidence‐based foot care for patients with diabetes.
Abstract: An estimated 20% of patients newly diagnosed with Diabetes Mellitus type II have asymptomatic loss of protective sensation at the time of diagnosis. The American Diabetes Association (ADA) has acknowledged there is little evidence to support an intervention that will prevent a first‐time foot ulcer but has promoted screening assessments for early recognition of loss of protective sensation. This quality improvement project sought to close the care gap by providing in‐person foot exams as a supplement to telehealth primary care. This project was guided by Nola Pender's Health Promotion Model in addition to Malcolm Knowles' Adult Learning Theory using the Plan‐Do‐Study‐Act framework. Education was offered to providers through clinical practice guidelines adopted from the ADA guidelines and to all clinicians through an online learning module that included proper technique and interpretation of testing in addition to patient education for self‐care and self‐examination. DNP student‐developed surveys measuring nurse and provider outcomes were distributed via a secure university platform pre‐education and again at launch of the service. All efforts to protect the anonymity of respondents and their patients were taken. Aggregate anonymous data were downloaded to Excel spreadsheets for analysis using descriptive mixed methods.
Classification of Research: Quality Improvement
Method: Mixed Methods
Results: Greater than 80% of responding providers expressed proficiency in the interpretation of comprehensive diabetic foot exams. However, 75% of providers identified having adequate resources needed to address an abnormal foot exam as a barrier to care. Subjective data revealed concern around management within the virtual clinic and referral to external specialists. Most nurses had no prior experience with diabetic foot exams and understandably identified learning needs of foot inspection and patient self‐care education. Despite these shortcomings, this quality improvement project was ultimately successful with several comprehensive foot exams ordered, completed, and reviewed by the clinicians.
Conclusions: This study was limited in both participant numbers and duration due to the abrupt closure of the clinic only three weeks after launch of this service. Despite these limitations there is opportunity to expand and improve upon patient care by offering physical exams in conjunction with telehealth care. Recommendations include a diabetic care specialist within the clinic, a network of specialty providers and treatment in the community, and a care coordination team to prioritize and monitor referrals. With additional education and collaboration with community resources, telehealth can become a convenient, efficient, and effective mode of patient care delivery.


Laura Ospina‐Pinillos, MD, PhD,
Pontificia Universidad Javeriana
Description: Through a well‐tested R&D cycle involving end‐users, we developed a Minimum Viable Product (MVP) that empowers young people to self‐manage their mental health. The platform provides targeted resources from the largest psychoeducational repository in Spanish, free tele‐counselling (fully integrated), and monitoring surveys to track their health and monitor their progress.
Abstract: Health Information Technologies (HITs) have the potential to collect near real‐time data on health variables which can be harnessed by health systems to improve access and quality of mental health care. However, adoption in low‐and middle‐income countries faces barriers such as low attrition rates and scarcity of tools developed in, or adapted to, cultural contexts and home languages. A possible solution is to implement participatory design (PD) methodologies, which involve all stakeholders (end‐users [young people, individuals with lived experience, their supportive others, health professionals, and service providers], developers, and researchers) in the process of conceptualizing, refining, and adapting technologies to ensure that the final product meets end‐users' needs. In this study, we implemented a well‐tested research and development (R&D) cycle consisting of 6 concurrently running phases: i) PD workshops and ii) knowledge translation sessions to produce mockups, wireframes and content tailoring. Subsequently, iii) rapid prototyping & user testing sessions to assess the acceptability of the alpha build; iv) rapid prototyping; v) user testing to assess the usability of the beta build; and, vi) real‐world trialing of the MVP (currently underway).
Classification of Research: Information Technology
Method: Participatory design
Results: 19 PD workshops were run with 110 end‐users. Suggested functionalities included: authentication and guardian consent, screening tests, periodic surveys, easy‐to‐understand graphs, online counseling sessions, targeted psychoeducational resources, a customizable wellbeing plan, avatar and an SOS button. Participants reported that the platform should assist young people in their help‐seeking process as well as empower them to self‐manage their problems mostly related to relationships, self‐esteem and emotions. 16 users tested the alpha build and, after refinement, 20 users tested the beta build. Task completion times were low, both in the alpha and beta prototypes, and participants reported minor to no difficulties.
Conclusions: By involving end‐users in the codesign and build of a help‐seeking and self‐management online platform, we developed an MVP that effectively addresses users' needs. Additionally, it presents a technologically‐advanced and clinically‐useful method that can be implemented to many and varied settings in which there is the opportunity to connect with young people. The final prototype shows promising results in terms of acceptability, as assessed in user testing sessions, as well as usability, as shown by tasks completion times and usability scores. Future research will evaluate the platform in real world settings.


Laura Ospina‐Pinillos, MD, PhD
Pontificia Universidad Javeriana
Description: Collective Minds is a university‐based program that aims to provide free and available active listening, emotional support, and counseling services, to people over 18 years of age in Colombia. Mediated by diverse information and communications technologies such as: traditional phone and SMS, to Internet mediated chat and videocalls.
Abstract: The counselling and support program of the Collective Minds Ecosystem [Mentes Colectivas] was implemented as a response to reduce negative effects of the SARS‐COV‐2 pandemic and its socioeconomic impacts on individuals' mental health. Furthermore, aimed to provide an alternative to mitigate the stress on the health system; particularly the high demand for mental health care, and to increase capacity to respond to the urgent and most prevalent mental health problems of the Colombian population. The objective of this study was to characterize the users and to identify the psychological distress level among them.
Data was obtained from the database of users who accessed the program through 9/2020 to 7/2022. Descriptive statistics were employed to report the users' sociodemographic information. The level of psychological distress was measured using the Kessler 6 (K6) scale in Spanish as a self‐rated measure implemented in the log‐in process. Once registered, the user schedules an appointment (either immediately or in the next 72h). Then, the system automatically allocates the level of distress with the of expertise (students, psychologists, general practitioners, psychiatrists). Sessions can be performed by chat, phone‐call, or video‐call; and up to 5 follow‐up sessions were offered according to the users' preferences.
Classification of Research: Access to Care
Method: Descriptive
Results: To date, 4248 users have been counseled, most of them are female (77%, n = 3,278/4,248), with an average age of 36.1 years. The program has extended to most of the Colombian territory, reaching 28/32 departments; as expected, the 4 remained are in the Amazon region, which is the area with the lowest internet connectivity. Most of the counseled (69%) had some type of psychological distress: 58% were classified as having mild psychological discomfort, 37.4% moderate and 4.7% severe. In order to increase capacity, more than 210 students and health professionals have been trained as counselors in emotional support.
Conclusions: By making use of diverse technologies, the Collective Minds program has managed to reach different parts of Colombia, providing free counselling and support to individuals in need. It has also assisted to mitigate the COVID‐19 negative effects on mental health by breaking down economic, geographic, and specialized human capital barriers providing psychological first aid, first line care and opportune risk identification.


Xinbei Guan, Kristofer Caya
A retrospective observational study aimed to understand the effect of using virtual care on healthcare cost, measured by cost per member per month (PMPM). Results show that utilizations of virtual care for behavior health, specialist and primary care visits do not result in significant difference in cost for Aetna members.
Abstract: The widespread adoption of virtual care at the outbreak of COVID‐19 in 2020 gave rise to an opportunity to examine the effect of virtual care on healthcare cost. This study examines the cost difference in a 12‐month period between Aetna Commercial and Medicare members who solely utilized virtual care and those who did not utilize virtual care.
Members are segmented into mutually exclusive cohorts based on their utilization in cost drivers including behavior health, physical therapy, specialist, and primary care visits. The definition period for cohort segmentation is 2H2020.
Treatment and control groups in each cohort are comprised of members who meets the target utilization threshold of virtual or in‐person utilization respectively. The cost difference is estimated by accounting for differences between treatment (virtual) and control (in‐person) groups during the pre‐period using risk adjustment features including demographic, geographic, social determinants of health factors, risk factors, prior diagnosis of chronic conditions, prior medical utilization, and whether members are new to target visit type. In addition to overall cost difference, and cost differences by medical cost categories are also evaluated using the same risk adjustment model. The Targeted Maximum Likelihood Estimation (TMLE) model is used for the risk adjustment.
Classification of Research: Cost Analyses
Method: Observational
Results: Our study showed no significant difference in overall cost for either Commercial or Medicare members. Significant cost differences are found analyzing virtual and in‐person cohorts within medical cost categories. Commercial members using virtual care for Specialist or PCP visits had lower specialist costs than non‐virtual members. Commercial and Medicare members who used virtual care for Behavioral Health visits had higher home health costs than those who did not. There is significant difference in costs between virtual and in‐person groups for mental health, lab, and home health services, but not consistently across cohorts.
Conclusions: Utilizing virtual care does not impact overall cost (PMPM) for both Aetna Commercial and Medicare members while also not increasing overall utilization. Based on the results, virtual care can be a valuable tool for increasing access to and convenience of care without creating additional cost burden on payers. In addition, we also see opportunities for targeted use cases to be explored further focusing on specialty care, behavioral health, and primary care that have potential to reduce overall costs for payers.


Puja Sasankan, BS Psychology
George Washington University School of Medicine and Health Sciences
Description: Effective medical procedure training requires instructors to guide learners through the steps using verbal descriptions and gestures. In this study, we aim to compare in‐person, 2D video, and mixed reality (MR) teaching modalities for ultrasound‐guided central venous catheter placement (US‐CVC).
Abstract: In the new age of remote medical procedure training, technologies such as two‐dimensional (2D) video, virtual reality (VR), augmented reality (AR), and mixed reality (MR) may be feasible alternative training methods to traditional in‐person teaching. However, how these teaching methods affect the learning experience and how instructors adapt to different modes of teaching remains unclear. In this study, we developed three training modules to train 26 students on how to perform ultrasound‐guided central venous catheter placement (US‐CVC): in‐person (IP) (n = 10), 2D video (n = 6) and MR (n = 10) training. In all training methods, instructors provided training for the procedure from vessel identification to flushing the lines of the placed catheter. For the 2D video and MR training methods, instructors were broadcast to the learners via remote video conferencing or via HoloLens 2, respectively. The entirety of all training sessions was recorded, and sixteen steps were evaluated by two reviewers for how the instructor taught the step (gesture only (1), mostly gesture with some verbal (2), 50/50 gestural/verbal (3), mostly verbal with some gestures (4), or verbal only (5)) and the time it took each learner to gain proficiency in the step.
Classification of Research: Clinician Experience
Method: Observational
Results: Two training steps that showed a difference in teaching methods among training modules were: positioning the US probe to acquire a transverse view of the target vessel ((4) for IP and 2D video; (5) for MR) and making an incision through the skin prior to dilator placement ((2) for IP; (5) for MR, and not assessable for 2D video). Overall completion of the procedure was observed to similar length of time, where IP, 2D, and MR training were 48 minutes and 16 seconds, 45 minutes and 57 seconds, and 41 minutes and 40 seconds, respectively.
Conclusions: The preliminary results of this data analysis suggest that instructors taught steps differently based on the teaching modality. For example, the presence of movable objects for demonstration encouraged the use of gestural communication with augmented objects in MR. Additionally, the overall time for completing the procedure was similar among the training modalities. This could indicate that usage of 2D video and MR training are comparable to the gold‐standard of in person training. Future work should further analyze the specific verbal communication and enumerate the hand gestures used within each step as well as examine the effect of practice.


Sara Belay, BS, Neal Sikka, MD, Colton Hood, MBI, MD, David Li, BS
George Washington University Medical Faculty Associates
Description: HealthDesk, a model to provide community based digital health coaching (DHC), was used with a cohort of Emergency Department (ED) patients to study how DHC might impact self‐management of health conditions.
Abstract: Introduction: Low levels of digital health literacy have been found to be one of the most powerful predictors of poor health outcomes in underserved communities. Improving health outcomes for vulnerable populations living in Washington DC is an increasingly urgent issue. African American residents (in Wards 5, 7, and 8) continue to experience barriers to effective use of digital health tools.
Methods: We recruited Medicaid and Medicare patients with hypertension to participate. 24 patients were enrolled from the ED and 10 received a study phone, while 14 decided to utilize their existing smartphone. Participants received initial coaching on how to install applications, access patient portals, and search for health information online. Participants were given connected blood pressure monitors and received coaching on how to properly use the monitor and sync their results to the mobile application. The DHC was conducted in‐person or virtually via Zoom. At each monthly session, participants completed a variety of questionnaires assessing changes in self‐confidence in managing their health, loneliness, and others. Some participants submitted video diaries about their experience. We analyzed survey results and changes in self‐confidence over time.
Classification of Research: Health Equity Research
Method: Observational
Results: Participants were 58% female. 91.7% of patients were African American, 45.8% of patients have no internet plan, and 91.7% are unemployed. 14 participants completed at least 3 sessions. Initial average self‐confidence for one's ability to track physical activity using their smartphone was 18.8% improving to 42.9% at 3 months. Initial average self‐confidence for one's ability to find health information on the internet was 56.1% improving to 71.4% at 3 months. Initial average self‐confidence for one's ability to manage their health information was 56.3% improving to 71.4% at 3 months.
Conclusions: Our preliminary results support initiatives on digital health literacy coaching which may increase the ability to manage one's health. Improving health literacy through DHC could be effective in increasing self‐tracking, like physical activity as well as reducing misinformation. Further research is warranted to understand the impact of DHC on individual and public health in vulnerable populations.


Kat Marriott, PhD
Description: This is a study of the potential for a digital screening tool to improve healthcare provider's (HCP) perceptions of screening for perinatal mental health (PMH) issues via enhanced experience.
Abstract: Perinatal mental health issues (PMH), including postpartum depression (PPD), threaten the well‐being of entire families. Evidence from national studies indicate that although effective treatment options are available and increasingly accessible via telehealth, PMH concerns including PPD remain underrecognized and undertreated due in part to a lack of wide‐spread screening by healthcare providers. Furthermore, low rates of screening are attributed HCPs lack of time, knowledge around screening, as well as unfamiliarity with resources for referral and low rates of reimbursement. Importantly, HCPs report feeling overwhelmed by the responsibility of staying up to date with screening and referrals for PMH issues.
To understand how a digital screening tool might improve HCPs perceptions of screening, we surveyed 10 obstetrician‐gynecologists on their perceptions around PMH screening pre‐ and post‐implementation of a pilot program in which HCPs were given access and a brief introduction to a simple digital screening tool. HCPs were asked to complete close‐ended questionnaires on screening perceptions and behavior pre‐ and post‐implementation; a subsample of the HCPs participated in a semi‐structured interview post‐intervention designed to elicit insights as to how digital screening tools might improve the referral to telehealth services for PMH conditions and processes for HCP reimbursement.
Classification of Research: Clinician Experience; Clinical Outcomes
Method: Survey / Qualitative
Results: All enrolled HCPs completed surveys and 2 HCPs additionally completed semi‐structured interviews addressing screening processes, frequency of screening, demographics of screened patients, processes followed for positively screened patients and processes for screening reimbursement. Analyses of differences in pre‐ post‐implementation response were conducted indicating changes related to screening rates, populations receiving screening, resources provided to positive screening patients and reimbursement practices. Qualitative interview data were analyzed within context to generate deeper insights into shifts in screening perspectives and to further understandings of persisting barriers to screening a well as facilitators to telehealth referrals.
Conclusions: Digital tools may improve rates of screening and referral to telemental health services for post‐partum mothers through improved HCP screening experience, including referral and reimbursement resource availability. The clinician's experience is critical to making positive strides and improving PMH screening for a vulnerable patient population.


Laura Christopherson, Ed.D. MBA, Dom Pahl, MSN
Mayo Clinic
Description: The demand for telehealth programs, such as RPM, that deliver virtual care while keeping patients in their homes continues to grow. This was accelerated by the COVID‐19 pandemic and is being utilized to reduce readmissions, preserve hospital capacity, maintain continuity of care, and engage patients in self‐care management.
Abstract: Design: We took a programmatic approach to understanding RPM program cost by applying time driven activity‐based costing to the clinical and non‐clinical patient support activities of our teams. For the RPM Nurses, this included active monitoring of biometric data and symptom assessment, clinical documentation, care team interactions, and patient communication. For non‐clinical patient support staff, this included onboarding activities, compliance monitoring, program graduation, patient communication and documentation. A combination of RPM platform generated data, time studies and observations were used to calculate time spent on each of these activities for each unique workflow. A cost was then calculated using the time spent on each activity to derive a total cost for each workflow across all RPM programs. We then utilized the costing data to measure the effectiveness of program changes to quantify time and cost savings. One application of the costing data included assessment of the cost impact of automating patient creation in the RPM platform. Using costing data, the cost savings of automating this non‐clinical process resulted in an estimated annual savings of $22,000. Though small, this demonstrated the efficacy of using costing data to quantify savings from program optimization and enhancement of processes.
Classification of Research: Cost Analyses
Method: Cost Analyses
Results: The total cost per enrollment was $60.52 on average across all programs and workflows. The time spent by clinical staff (RPM Nurses) accounted for 70% of the total cost per patient, making them the most expensive staff resource. Of clinical time spent, 30% was spent on active daily monitoring of biometric data and symptom assessment, 20% on documentation, 5% on care team interactions, and 40% on patient communication (through secure message and telephone). For non‐clinical staff, 70% was spent on onboarding activities, 5% on compliance monitoring, 5% on program graduation, 10% on patient communication, and 5% on documentation.
Conclusions: The scalability and sustainability of remote patient monitoring (RPM) programs requires the implementation of clinical and operational activities that can be measured to drive efficiencies in delivery of virtual care and non‐clinical patient support. Time driven activity‐based costing has been shown to be an effective approach to calculate costs of RPM programs that can then be utilized to measure the effectiveness of both clinical and non‐clinical programmatic changes. The ability to quantify the impact of programmatic changes through the application of TDABC reinforces the value proposition of virtual clinical care delivery for executive and physician leaders.


Derek Richards, Jorge Palacios
Description: Little research exists on the long term effects of internet‐delivered cognitive behavioral therapy (iCBT). This study investigates post‐treatment relapse and remission rates 3, 6 and 9 months after completion of an acute phase of a clinician‐supported iCBT for anxiety and depressive symptoms, within a routine care setting.
Abstract: The goal of this study is to investigate post‐treatment relapse and remission rates 3, 6 and 9 months after completion of an acute phase of a clinician‐supported internet‐delivered cognitive‐behavioural therapy (iCBT) for anxiety and depressive symptoms, within a routine care setting. The study utilized a secondary analysis from a 12‐month pragmatic randomized‐controlled trial delivered within the Improving Access to Psychological Therapies (IAPT) programme in England. Participants in the intervention arm were included if they met criteria for reliable recovery from depression (PHQ‐9) and anxiety (GAD‐7) at post‐treatment assessment. Survival analysis was used to assess durability of treatment effects and determine predictors to relapse at 3‐, 6‐ and 9‐month follow‐up. Hazard ratios predicting time‐to‐relapse were estimated with semi‐parametric Cox proportional hazards model. As one of the first studies to explore remission and relapse rates of iCBT interventions, the findings are important to advancing the understanding of the long term effects of iCBT and support the idea that iCBT interventions can be similarly as effective as other treatment methods.
Classification of Research: Clinical Outcomes
Method: Randomized Controlled Trial
Results: Of the 241 participants in the intervention arm, 89 participants met the criteria for reliable recovery from depression and anxiety at the post‐treatment assessment. Of these 89 eligible cases, 29.2% relapsed within the 9‐month period, with 70.8% remaining in remission at 9 months post‐treatment. Of those who relapsed, 53.8% experienced a relapse of depression and anxiety; 7.7% experienced a relapse of depression only; and 38.4% experienced a relapse of anxiety only. Younger age, having a long‐term condition, and residual symptoms of anxiety at end‐of‐treatment were all significant predictors of relapse.
Conclusions: This study is the first to explore the remission and relapse rates after an acute phase of iCBT treatment, within a routine, stepped‐care setting. The results add to the scarce literature on the durability of the effects of iCBT treatment in routine care settings, where patients are not typically followed up after receiving a completed course of treatment.


Michael Weiss, DO
Children's Health of Orange County
Description: There still remains a great deal of debate around how to measure the quality of care being delivered via telehealth. Various domains have been proposed in the literature to measure telehealth quality. We aimed to test the validity of ED visits following telehealth as a proxy measure of telehealth quality.
Abstract: Inclusion criteria for this study was pediatric patients completing an outpatient (primary or specialty care clinic), emergency department, or inpatient visit between 2015 and 2019 at our Orange, CA facilities. Among these patients, those with in‐person and/or telehealth sick visits between March 2020 and December 2021 defined the final study cohort. Demographic data on patients age, gender, and ethnicity were collected as baseline control information. For each clinic visit (in‐person or telehealth), a retrospective review was performed to see if an ED visit followed the index visit, within 7‐days, with at least one aligned ICD‐10 subcategory (first 3 characters) common between both encounters. The outcome variable tracked was ED visits within 7‐days of an in‐person or telehealth visit for the same reason as the index visit. Our hypothesis was that we would not expect to see a higher number of ED visits following telehealth index visits vs in‐person index visits. A random intercept logistic regression model was built to capture baseline differences between patients and to account for within‐subject correlation. The effect of encounter type (in‐person vs telehealth) on ED visits was assessed as the primary variable of interest. Corresponding odds ratios and 95% confidence intervals were calculated.
Classification of Research: Clinical Outcomes
Method: Observational
Results: A total of 66,160 patients met the inclusion criteria; 45.9% female and 50.5% Hispanic or Latino. These patients experienced 307,484 non‐well‐child visit encounters during the study period, of which 84,494 (27.7%) were telehealth and 222,990 (72.3%) were in‐person. There were a total of 4053 ED visits within 7‐days of these index visits: 3,215 (79%) of these ED visits followed, within 7‐days, an in‐person clinic visit and 838 (21%) followed a telehealth visit. After controlling for demographics, the results indicate that telehealth visits were associated with a lower odds ratio of a subsequent ED visit, within 7‐days, than an in‐person visit.
Conclusions: Our study represents a cohort of pediatric patients followed over a 21‐month period. Knowing our baseline rate of telehealth use for our primary and specialty care clinics was 27.7%, we hypothesized that comparing that rate to the rate of ED visits within 7‐days of an index visit for the same diagnosis/condition could serve as a proxy for quality. If telehealth was inferior to in‐person visits, one would expect a higher percentage of ED visits following telehealth than the baseline ratio of telehealth to in‐person visits. Indeed we saw a lower percentage (21%) of ED visits following telehealth than in‐person visits.


Shintaro Ueda, PhD, Kuriko Kudo, PhD, Yukiko Hisada, PhD, Shunta Tomimatsu, PhD, Shuji Shimizu, MD, PhD, Tomohiko Moriyama, PhD
Kyushu University Hospital
Description: We herein report our success in transmission of high‐quality live endoscopy demonstrations from multiple countries using Zoom Breakout Rooms. The congress was carried out in a hybrid style due to the COVID‐19 situation, where transmitted images were shown both in the venue and online.
Abstract: Telemedicine or distant learning in the form of medical conferences and live demonstrations is an effective method to close the gap in the international medical divide. We herein report a successful transmission method of sessions consisting of multiple stations, including remote international chairs.
During the live demonstration sessions in the 3rd World Congress of GI Endoscopy in 2022, we were in charge of receiving real‐time endoscopy procedure images from 3 medical institutions in Korea, China, and India. A single session was made up of at most live feeds from three institutions, thus requiring scheduled switching of images from one institution to another. We used a single Zoom meeting to connect with all three institutions and divided them into three breakout rooms. The final image shown at the venue and transmitted online was the image received from the breakout room that was giving the demonstration. A questionnaire about the contents and quality of the live transmission was conducted, and the transmitted image resolution and bit rate were collected from the Zoom dashboard logs.
From the results, majority mentioned that the live demonstrations were high‐quality. Dividing multiple institutions into different breakout rooms allowed smooth organization and switching of image feeds.
Classification of Research: Information Technology
Method: Implementation Science
Results: Throughout the two days of the live demonstration, high‐quality images of resolution full high definition (1920*1080), an average bit rate of 4620kbps, and a maximum bit rate of 6548kbps were transmitted. 310 participants responded to the questionnaire and of which, 82.6% rated the image quality positively. 90.6% rated concentration toward the live demonstration highly. 84.2% and 74.4% mentioned that the live demonstration interested them and gained new findings, respectively.
Conclusions: Dividing the three institutions into breakout rooms enabled testing image layout and quality behind the scenes, which allowed switching images from multiple institutions smoothly, resulting in positive responses concerning image quality. It was also convenient for the international remote chairs to virtually switch from one room to another without having to disconnect and connect to a different URL again such as in the conventional method, a Zoom meeting is created for each institution transmitting the live endoscopy demonstration.


Kim Boyd, MD, Kaelen L. Medeiros, MS, Daniel Kramer, Christine Celio, PhD, Kristin Baier, MD, Isabelle Kenyon
Description: Combining pharmacotherapy with intensive lifestyle intervention (ILI) is effective treatment for obesity. In this real‐world observational study, we sought to determine the extent to which engagement with digital ILI‐behavior tracking along with remote monitoring using connected devices improved weight loss outcomes in patients treated with GLP‐1 receptor agonist medications (GLP‐1s).
Abstract: The incidence of obesity and associated cardiometabolic disease is increasing rapidly. Unfortunately, there is a stark mismatch between the 189 million US adults who qualify for treatment and the roughly 5,000 obesity‐specialized physicians. GLP‐1 agonists have demonstrated high efficacy and safety in treating patients with obesity. Clinical trials show the combination of GLP‐1 treatment along with ILI contributes to significant weight loss. To expand access to treatment, we established an all‐digital metabolic health program providing medically‐supervised obesity treatment using GLP‐1s combined with ILI driving behavior change for weight loss and metabolic health improvements at scale. The digital program includes async questionnaires, video physician visits, 1: 1 video coaching, and behavior tracking via remote monitoring and app usage. To date, over 20,000 patients have enrolled. In June 2022, data were analyzed for individuals who had reached 12 months in the core program. At enrollment, weight was verified on a connected scale, and subsequent weights were submitted electronically or self‐reported. Patients engaged in weight tracking and behavior tracking for habits critical for lifestyle change throughout the program using a mobile app and/or desktop. Coach session attendance, weight reporting, and food and energy tracking results were analyzed.
Classification of Research: Clinical Outcomes
Method: Observational
Results: This cohort included 1176 patients (80.4% completion rate), starting BMI 37.4 ± 6.9 kg/m2. At 12 months, average weight loss was 14.8% among program completers (N = 843). Average biweekly coaching attendance for the cohort, including dropouts, was 83% for the year. The cohort tracked 1 metric at least 3 times per week for 71.18% of weeks. Importantly, frequency of engagement was positively correlated with total weight loss (p < 1 x 10^‐5), particularly for weight tracking (p = 1.5 x 10^‐13). The effect of tracking on total weight loss increased with increasing starting BMI.
Conclusions: Barriers to obesity treatment access necessitate finding novel approaches to address a critical unmet need. Our commercial digital metabolic health program delivered robust weight loss outcomes. We demonstrate patients' willingness to engage in digital treatment with significant and sustained engagement over the course of a year‐long program. More frequent tracking was associated with improved weight loss outcomes as compared with GLP‐1s and ILI without tracking, especially at higher starting BMIs. These results demonstrate a digital care program expands access to effective obesity treatment and suggest a tech‐enabled platform can elicit substantial engagement to drive improved results.


Melinda Stretzinger, RN, Fiona Winterbottom, DNP, MSN, Melanie Kendrick, MSN
Description: Sepsis represents a major healthcare burden accounting for high morbidity and mortality. Electronic surveillance and clinical decision support systems can improve detection, expedite interventions, automate feedback, and reduction of alarm fatigue.
Abstract: A sepsis program was initiated that reinforced team based, time dependent care for patients with design elements taken from video game design usability experts. Based on studies supporting daily sepsis screening, alert‐driven notifications stratified to risk and powered by artificial intelligence were initiated. A second level pilot was involved a virtual e‐Rapid Response nurse(eRRN) in one community hospital who screened a high‐risk patient list. An interactive sepsis checklist and a suite of CDS tools driven by a predictive algorithm were piloted for clinician interaction. “Alert to action” ratios were visualized for rapid cycle feedback and performance improvement.
Classification of Research: Clinical Outcomes; Quality Improvement
Method: Implementation Science
Results: The pilot program was implemented in 20 facilities over a 12‐month period with 6000 screens prompted. Results in the E‐Rapid Response hospital showed 1566 sepsis alerts fired over a 7‐ month period, impacting 250 unique patients. The average number of screens completed by eRRN was 260 per month in contrast to 26 by bedside teams with 31 screens prompting sepsis protocol initiation. Appropriate treatment was rendered in 243 screens. There has been a decrease in risk adjusted mortality and length of stay since pilot initiation.
Conclusions: A sepsis‐focused E‐Rapid Response program can support bedside staff to improve processes and outcomes


Helena Lyson, PhD,1 Leanne Kaye, PhD, MPH,1 Meredith Barrett, PhD,1 Bobbi Olson,2 Jade Le, PharmD, APh, BCACP,3 Thomas Brazeal, PharmD, APh, BCACP, 3
2Propeller Health
3Desert Oasis Healthcare
Description: A clinical pharmacist‐led digital health intervention, paired with proactive technical support outreach, may improve recruitment, clinician engagement, and clinical outcomes for patients with asthma and COPD. We explored the feasibility of this model of care as a replicable approach to digitally‐enhanced clinical care for the self‐management of chronic respiratory conditions.
Abstract: Clinical pharmacists increasingly use digital tools to support clinical care. Coupled with proactive technical support for patients, a clinical pharmacist‐led approach to digital health may be a promising model of care for respiratory health. In this quality improvement program, clinical pharmacists from an integrated delivery network (Desert Oasis Healthcare) enrolled patients with COPD or asthma onto a digital health platform (Propeller Health) from June 2021 through May 2022 to further enhance their current pulmonary care management approach. The platform leverages electronic medication monitors (EMMs), which were mailed to patients, a paired patient mobile app, and a web‐based clinician portal to remotely monitor medication use. Clinical pharmacists received notifications for patients with increased short‐acting beta‐agonist (SABA) use and/or low adherence to maintenance treatment and could access patient data through the clinician portal to guide clinical decisions and enable early intervention. After enrollment, patients received proactive outreach to assist with technical setup of the EMMs and troubleshooting. We examined the feasibility of this digitally enhanced clinical care model by exploring: 1) pharmacist utilization of the clinician portal, 2) frequency of technical support outreach cases, and 3) patient outcomes, including change in mean SABA puffs/day and mean SABA‐free days (SFD, %).
Classification of Research: Quality Improvement
Method: Descriptive
Results: 46 patients (41 (89%) COPD, 5 (11%) asthma) were enrolled, mailed an EMM, and received a proactive outreach call. 34 patients (74%) synced their EMM to enable monitoring. Among 18 active clinical pharmacists, most visited clinician portal webpages (mean views/month) included: individual patient data (41), all‐patient summary ‐ COPD (33) or asthma (26), and notifications overview (29). At baseline (30 days post‐first SABA sync), COPD patients used 2.56 SABA puffs/day and had 46% SFDs. At 6 months, SABA use was 1.33 SABA puffs/day (Δ: ‐1.23 puffs/day), and SFDs was 57% (Δ: 11%).
Conclusions: Our results demonstrate that a pharmacist‐led digital health intervention, paired with proactive technical support, is feasible within an integrated delivery network. We also observed reductions in daily SABA medication use and an increase in SFDs at six months. While clinical outcomes should be confirmed with a larger cohort, these findings combined with feasibility insights underscore the importance of incorporating technical support and pharmacist‐led clinical oversight to digital health interventions in order to support patient self‐management in asthma and COPD.


Michael Choma, MD, PhD,1 Narinder Singh, MBA, MTM,1 LaDonna Shore, RN,2 Armando Bedoya, MD, MMCi,2 Deborah Allen, PhD, RN, CNS, FNP‐BC, AOCNP,3
1LookDeep Health
2Duke University Medical Center
3Duke University Health System
Description: The emerging ubiquity of cameras in inpatient settings has the potential to vastly improve continuous patient monitoring. Building upon initial exploratory research, we conducted a preliminary ethnographic study to identify opportunities for integrating AI/computer vision (CV) observations focus on patient movement/activity and visitors/staff bedside activity into clinical workflows and decision‐making.
Abstract: The rising demand for in‐room telemedicine services and virtual nursing care to aid in safety monitoring (eg tele‐sitting) is driving rapid deployment of cameras in hospitals. Once deployed, these cameras have the potential to enable powerful AI/CV monitoring of patients.
We previously conducted an exploratory study in the Medical Intensive Care Unit that analyzed >2000 hours of inpatient video using LookDeep Health AI/CV technology, focusing on patient movement/activity, staff bedside activity, and in‐room environment. Findings suggested AI/CV may be particularly powerful for overnight monitoring, particularly rest/wake status, staff activity, as a measure of patient acuity.
Building on these findings, we conducted an ethnographic study to identify opportunities to incorporate AI/CV into rounding and clinical decision‐making. The study was conducted on the Duke University Hospital Medical Stepdown Unit. Observations were focused on shift reporting of pertinent care issues by one trained observer; ten change‐of‐shift nursing observations were performed (five morning and five night). A checklist of patient care priorities and quality of addressing the issue was used; field notes were captured for additional comments and behavioral observations. Qualitative analyses were used to describe current care issue reporting. This study was determined to meet quality improvement exemption by the Institutional Review Board.
Classification of Research: Information Technology
Method: Observational
Results: Commonly communicated care issues were: medical condition (n = 10), length of stay (LOS; n = 10), activity/mobility (n = 9), procedures/diagnostics (n = 8), problem list (n = 7), activity status (n = 7), assessment tool use (n = 7). Less commonly reported (n < 5) were sleep/rest, risk/presence of HAI, visitor presence, in‐room environment impact, expected LOS/transitions. Observed shift differences include absence of reporting HAI‐risks, care environment impact, and visitor presence; assessment tool use reported less in morning change‐of‐shift. The majority of reported issues were briefly mentioned and not well described for impact on care; exceptions were medical condition and activity/mobility. There were no observed differences between shifts on how well issues were addressed.
Conclusions: This observational study revealed care priorities reported during nursing rounds. Observed gaps illustrate areas of opportunity for AI/CV data input on patient responses, particularly overnight. As inpatient care becomes increasingly complex, AI/CV technology can become an integral aid for virtual nursing for care coordination and remote monitoring for care priorities. With a patient‐centered dashboard report, AI/CV will aid health care professionals in their communication of patient needs through real‐time monitoring. Next steps: additional interdisciplinary observations to complete this gap analyses, prototype AI/CV algorithm testing for dashboard and real‐time monitoring perspectives and impact analyses for risk awareness and injury prevention.


Siobhán Harty, Angel Enrique, Derek Richards
Description: A retrospective, observational study evaluating the first year of a supported digital CBT (cognitive behavioral therapy) service provided by a national health service. The results support the successful implementation of the service for treating depression and anxiety, and substantially reducing the mental healthcare burden of an under‐resourced national health service.
Abstract: Digital cognitive behavioral therapy (CBT) can provide cost‐effective, accessible, and resource efficient interventions for addressing mental health issues. However, there is increasing recognition that several contextual factors can impact both the implementation and outcomes of effective interventions. This study evaluated the first year of a supported digital CBT service provided by a national health service. The provision of this service included a group of stakeholders that made decisions around implementation, strategy, goals and service development. From a provider side, there were representatives from customer success, research, clinical operations, and commercial teams. From the customer side, there were leadership members from the national health service. The digital CBT service has been accessible to individuals who receive a referral from primary care physicians and specialist mental health providers. During the course of the digital CBT users receive guidance and feedback from trained supporters via asynchronous reviews. Data on referrals, account activations, user demographics, programme usage, user satisfaction, and pre‐to‐post clinical outcomes for depression measured by the Patient Health Questionnaire‐9 and for anxiety measured by the Generalised Anxiety Disorder‐7 were analysed.
Classification of Research: Access to Care; Patient Experience, Clinical Outcomes and Information Technology also apply.
Method: Observational
Results: Stakeholder engagement remained high, with regular meetings throughout the year. The number of account activations exceeded the initial 12‐month target almost 6 months ahead of schedule, ultimately, amounting to 5,298 referrals and 3,236 (61%) account activations within the year. The majority of users were female (72.9%) and aged between 18‐44 years (75.4%). Intention‐to‐treat analyses on the clinical outcomes measures revealed significant reductions in both anxiety (p < .001) and depression (p < .001) with large effect sizes (Cohen's d > 0.8). User satisfaction ratings were also very high, exceeding 94% for overall satisfaction.
Conclusions: The results support the successful implementation of a national digital CBT service for treating depression and anxiety, and substantially reducing the mental healthcare burden of an under‐resourced national health service. The findings provide justification for the continued use and expansion of this service, and the more widespread implementation of similar services in other international public healthcare settings.


Daniel Duffy, PhD, Derek Richards, PhD, Ladislav Timulak, PhD
Description: Internet‐delivered cognitive behavioral therapy (iCBT) is an empirically supported treatment, but a decline in outcomes is observed when the intervention transitions from laboratory to real‐world settings. The current research presents an overview of 3 studies that sought to establish a list of evidence‐based strategies to support iCBT implementation.
Abstract: The overall work consisted of three studies. 1) A mixed methods systematic review, which was conducted to identify any relevant implementation processes or insights within the published, peer‐reviewed literature on iCBT for depression and anxiety in adults. The review identified several procedural aspects of relevance to the implementation of iCBT across the 40 included studies. 2) A qualitative exploration of the experience of stakeholders (N = 19; 7 patients, 6 commercial iCBT representatives, 6 service providers) who interact with iCBT implementation, and further identified several relevant categories associated with the experience of implementing iCBT, as well as findings related to implementation barriers and facilitators present within the service context.
The results of the previous two studies were then synthesised, resulting in 31 strategies associated with implementation success. These implementation strategies were grouped across domains pertaining to leadership in healthcare service delivery, training stakeholders in iCBT, processes and procedures for staff delivering iCBT, managing the delivery of the iCBT service and iCBT intervention developers. Study 3 validated these strategies using the delphi methodology, where a panel of experts (N = 9) with both iCBT research and implementation experience were recruited to participate across 2 rounds of feedback.
Classification of Research: Patient Experience; Clinician Experience, Quality Improvement, Internet‐Delivered CBT
Method: Survey / Qualitative; Descriptive, Implementation Science, Mixed Methods Systematic Review, Delphi Research
Results: 7/31 strategies did not achieve consensus at the end of round two, and expert participants provided qualitative rationales to support their rankings across rounds. The highest ranked strategies included information governance standards for iCBT, designing and revising care pathways for iCBT, and having a committed management team that set clear goals and create an organizational culture conducive to iCBT usage. In contrast, the lowest ranked strategies pertained to setting individual therapist goals for iCBT usage, the creation of online training resources and training to address negative biases around iCBT.
Conclusions: The current work presents a curated list of iCBT‐relevant implementation strategies, based on both the scientific literature and lived experience of stakeholders implementing iCBT. At the time of writing, this is the first study within the field of iCBT to conduct such a research endeavour and represents a novel contribution to the field. The findings present a call‐to‐action for future studies to test the effectiveness of specific implementation strategies within routine care settings. The list of strategies could be enhanced by incorporating study procedures that allow for the gathering of detailed participant feedback (e.g. focus group, interview).


Melissa Anderson, OTD
Kintinu Telerehab
Description: Extensive, interdisciplinary rehabilitation following stroke is necessary to promote neuroplasticity and optimize recovery. Telerehabilitation is an appropriate model for delivering such services. However, limited information exists exploring interprofessional coordination as a guiding framework on recovery. This case example reports the development, implementation, and progression of post‐acute treatment delivered by interdisciplinary telerehabilitation specialists.
Abstract: Access to extensive, interdisciplinary rehabilitation following stroke is necessary to optimize recovery. Telerehabilitation is an appropriate model for delivering these services. However, given its relatively recent increase in popularity as a service delivery model, researchers have yet to explore the feasibility of interprofessional coordination and collaboration as a guiding framework for telerehabilitation and the effects of team‐based remote service delivery on recovery of body functions and activities. This case example reports the development, implementation, and progression of a post‐acute treatment program delivered via telerehabilitation to a woman with left hemorrhagic stroke. As is typical, therapy time alone afforded insufficient practice to exploit neuroplasticity and ensure maintenance and generalization of improved functioning; hence, the team worked collaboratively to encourage interdisciplinary activities outside scheduled treatment sessions. Standardized and informal assessments administered at the start and conclusion of treatment confirmed improved functioning as did the client's progress toward independent living and return to work. Implications for telerehabilitation practices are discussed.
Classification of Research: Clinical Outcomes
Method: Descriptive
Results: Telerehabilitation as an alternative to in‐person services has gained popularity in recent years. Factors such as client and therapist convenience, cost, and evidence of effectiveness are likely to affect the long‐term acceptance of telerehabilitation as a preferred service delivery model. Regarding the presented case, the client's assessment results and resumption of independent living and gainful employment provide evidence that an approach incorporating numerous repetitions of interdisciplinary activities serving functional purposes can aid recovery efforts and achievement of long‐term goals. A critical factor in bolstering telerehabilitation treatment efficacy is that efforts must extend beyond being merely multidisciplinary.
Conclusions: Telerehabilitation as an alternative to in‐person services has, at least in part, gained popularity because of restrictions imposed by the COVID‐19 pandemic. Factors such as client and therapist convenience, cost, and evidence of effectiveness are likely to affect the long‐term acceptance of telerehabilitation as a preferred service delivery method. A risk to this acceptance is the potential for professionals to work in isolation rather than as an interdisciplinary team. As such, establishing ways in which professionals can work collaboratively and cooperatively when delivering services via telecommunication technologies is critical.


Andrew Talal, MD, 1 Suzanne Dickerson, PhD RN,1 Arpan Dharia, MD,1 Saliyah George, BA, MPH,2 Ana Ventuneac, PhD,3
1SUNY, University at Buffalo
2Icahn School of Medicine at Mount Sinai
3START Treatment
Description: This study explicates staff experiences in 11 Opioid Treatment Programs (OTP) during an efficacy study integrating facilitated telemedicine for hepatitis C treatment. Staff felt it made sense to integrate telemedicine treatment in a familiar and nonjudgmental environment within the OPT for the benefit of an HCV cure for their patients.
Abstract: Telemedicine has the potential to remove geographic and temporal obstacles to healthcare delivery. In an ongoing efficacy study, we are assessing the integration of a facilitated telemedicine model within opioid treatment programs (OTP) for management of hepatitis C virus (HCV) among persons with opioid use disorder. The purpose of this study was to understand OTP staffs' common meanings and shared practices of integrating care for HCV through facilitated telemedicine. Forty‐five staff from 11 OPTs included 15 administrators, 16 clinical and 14 patient engagement staff. Potential staff participants who participated in the efficacy study were contacted by study supported case managers regarding their interest in participating. Interested staff were interviewed by the choice of virtual, in person or phone. Forty‐four interviews were conducted by Zoom. Transcripts were de‐identified and verified by the interviewer for accuracy. The qualitative interviews provided data for the analysis conducted by the research team using Hermeneutic Phenomenological Research to understand the meaning of integrating facilitated telemedicine for HCV treatment in the context of the OTP and provide practical advice for integration of telemedicine in this setting.
Classification of Research: Clinician Experience
Method: Survey / Qualitative
Results: Four overarching themes illustrated the meanings of care integration for staff providing insight into study implementation. First, integration requires understanding of the challenges, goals, and values of the OTP. Second, participants valued the increased accessibility of HCV treatment and convenience of integrated HCV care. They recognized the value of having “eyes on” patients during telemedicine encounters and valued the HCV cure as a “win” for their patients. Third, participants described high levels of interprofessional collaboration and blurring of lines between disciplines while providing treatment for their patients. Fourth, administrators endorsed sustaining and scaling the model to address other healthcare needs.
Conclusions: OTP staff were highly enthusiastic about facilitated telemedicine care for a vulnerable population, persons with opioid use disorder seeking care in an opioid treatment program (OTP). Due to patient reluctance in seeking care in traditional healthcare settings, integrating care within the OPT with familiar staff using facilitated telemedicine and administering treatments concurrently was convenient for patients. Staff described high levels of collaboration and integration, comparable with relevant integrative frameworks. These experiences support sustaining and scaling facilitated telemedicine in comparable settings.
This work was supported by a Patient‐Centered Outcomes Research Institute (PCORI) Award (IHS‐1507‐31640) and partially supported by the Troup Fund of the Kaleida Health Foundation. The statements in this work are solely the responsibility of the authors and do not necessarily represent the views of PCORI, its Board of Governors or Methodology Committee. References: Talal AH, Markatou M, Sofikitou EM, Brown LS, Perumalswami P, Dinani A, et al. Patient‐centered HCV care via telemedicine for individuals on medication for opioid use disorder: Telemedicine for Evaluation, Adherence and Medication for Hepatitis C (TEAM‐C). Contemp Clin Trials. 2022;112: 106632. https: //doi.org/10.1016/j.cct.2021.106632 Dibley L, Dickerson S, Duffy M, Vandermause R. Doing hermeneutic phenomenological research: A practical guide. Thousand Oaks, CA: SAGE; 2020.


Madeline Niemann, BA,1 Sean Hagan, BA,1 Jhoely Duque, BS,2; Shivank Singh, BS; Evangeline Grove, BA,1; Emma Morrison, BS, 1 Rinat Jonas, MD,1 Laurie Douglass, MD1
1Boston Medical Center
2Boston University School of Medicine
Description: We designed and evaluated a virtual volunteer team operating in a large safety‐net hospital from March‐2020 to March‐2022 using a RE‐AIM framework.1 Trained volunteers 1) helped patients navigate telehealth; 2) screened for social health factors; and 3) implemented relevant research objectives at minimal cost. Results support a sustainable delivery model.
Abstract: Background: The “health neighborhood” model aims to fulfill an individual's developmental, social, and medical needs through sustained community connections.2 Telehealth tools are well‐positioned to integrate this social‐ecological framework in order to improve patients' access to care.
Objectives: At the onset of COVID‐19, BMC researchers tested the ability of community volunteers to help pediatric neurology patients and caregivers navigate new telehealth services while integrating a “health neighborhood” model.
Methods: Volunteer training materials were integrated from the nonprofit Health Leads and various “train the trainer” models (e.g. project ECHO). The RE‐AIM model was used for evaluation as follows: number of patients reached (R), the proportion of encounters resulting in resource connections (E), utilization rates of the BMC patient portal and incidence of technical errors (A), and self‐sustaining volunteer recruitment and service provision after two years (IM). Data was collected March‐2020 to March‐2022.
Outcomes: Results support a volunteer‐based training and delivery model for improving telehealth access in patient populations facing complex barriers and health needs. Social ecological interventions have an important role in the future of telehealth. Further studies should investigate how effectively volunteer curriculum can prepare student health professionals for patient interactions, and how navigation services influence patients' experiences of care.
Classification of Research: Access to Care
Method: Implementation Science
Results: Researchers developed a novel, self‐sustaining system of 20 volunteers “trained as trainers” in empathic inquiry, trauma‐informed care, implicit bias, cultural humility, and resource navigation. Recruitment and training procedures were repeated quarterly. Volunteers provided telehealth tutorials and screened 40% of BMC's pediatric neurology patients for social health factors (n = 436 reached, n = 19 refused, and n = 386 confirmed unique IDs). Over 60% of patients were connected to local resources for unmet needs, and fewer than 6% of telehealth appointments reported technical difficulties. Access to the hospital's patient portal also increased by 40% in Spanish‐speaking epilepsy patients.
Conclusions: The “health neighborhood” model is increasingly recognized as a benchmark in preventive care for youth with complex healthcare needs. Our volunteer model facilitated a virtual health neighborhood and remains sustainable due to: strong partnerships with diverse health‐professional groups; our virtual learning collaborative model; and researchers' engagement with clinic leaders. Resource‐limited hospital systems may benefit from implementing similar models to ensure that telehealth services develop inclusively and in partnership with multilingual patient communities.


Misty McDowell, APRN, CPMHNP, CFNP
University of Cincinnati
Description: An outpatient mental health clinic is using telepsychiatry services and wants to know patients' perspective on telepsychiatry services. Telepsychiatry has proven to be beneficial in treating mental health disorders. However, studies have reported telepsychiatry barriers. A needs assessment would assess satisfaction, identify barriers and resources needed to improve telepsychiatry services.
Abstract: Telepsychiatry is effective in treating mental health disorders and improves access to services. It is currently being used in a variety of healthcare settings (Chan, et al., 2015). Telepsychiatry services are becoming more common place and due to the increased use of the internet, social media, cellphones, and computers by patients. Literature reports that patients are highly satisfied with telepsychiatry services, having a similar satisfaction rating to in‐person visits (Chan, et al., 2015). However, there are reported patient barriers to using telepsychiatry services (Cowan, et al., 2019). Patient perspectives on barriers with telepsychiatry is underrepresented. A needs assessment can identify specific barriers that can be addressed and increase the use of telepsychiatry.
Classification of Research: Clinician Experience; Information Technology
Method: Survey / Qualitative
Results: A needs assessment occurred at an outpatient mental health clinic, located in southern Ohio. A client survey consisted of fourteen questions, open ended questions, and a five‐point Likert scale was used to solicit patient opinions about their telepsychiatry experiences over a five‐week period. There were 112 participants who completed the survey questionnaire, yielding a 37% return rate. The participants reported higher satisfaction with telephone visits when compared to in‐person visits. The barriers reported included poor audio sound and dropped telephone connections.
Conclusions: Patients were in favor of telepsychiatry services and preferred telephone visits over in‐person visits. Telepsychiatry is effective treatment for patients with a wide range of mental disorders and improves access to care. Patients at this clinic were offered telephone visits by the providers which improves telepsychiatry utilization and patient access to treatment services. Additionally, participants suggested shorter wait times to see clinician, longer appointment times and a pamphlet to improve telepsychiatry services.
Telepsychiatry shows promise for this outpatient mental health clinic. Further research is needed to determine clinician experience, clinician preference for telepsychiatry and barriers for providers offering telepsychiatry services.


Samantha McColley, MHA, Sarah Harper, MA, MBA, Brittany Johnson, Justin Smith, APRN, CNS, CNP, Cynthia Alvarado, RN
Mayo Clinic
Description: Ensuring access to quality obstetric care became more critical with the onset of the coronavirus pandemic. Pregnant patients who tested positive for COVID‐19 faced unique risks in accessing safe, quality care. This study describes the design, deployment, and evaluation of a digital health intervention for COVID‐19 positive obstetric patients.
Abstract: Pregnant patients are at higher risk of COVID‐19 complications and face greater barriers to access in‐person care. During the initial wave of the pandemic, Mayo Clinic's COVID‐19 Remote Patient Monitoring program experienced record enrollments (daily census peak of 893 on November 20, 2020), and pregnant patients without severe symptoms were not eligible due to limited resources. Symptomatic obstetric patients required daily monitoring to detect decompensation and enable early intervention to improve outcomes. In 21 days, a team of clinicians and Information Technology personnel designed, built, and implemented a 14‐day Interactive Care Plan (ICP) to deliver self‐management education, daily vitals, and symptom tracking tools to a patient's mobile device.
Providers enrolled patients during a video visit using an order in the electronic health record (EHR). The order sent a welcome message through the patient portal and notified an internal operations team to ship a home monitoring kit. The kits included a blood pressure cuff, thermometer, fetal doppler, and pulse oximeter and were shipped in an average of 1.1 days from enrollment.
Patients recorded vitals and symptoms twice daily using the Mayo Clinic app. Care teams monitored alerts in the EHR for vitals out of range, worsening symptoms, or missed patient tasks.
Classification of Research: Access to Care
Method: Descriptive
Results: 249 patients were enrolled between 12/4/2020 and 06/04/2022. 47% (n = 116) lived >25 miles from Rochester, an average of 46.3 miles from Mayo Clinic. 19% had a documented or unknown transportation barrier in their medical record.
An average of 13.2 alerts per patient were generated. 60% related to missed tasks; 25% to vitals or symptoms. ICP patients accounted for 5% of non‐visit care (NVC) volume (n = 117). Patients eligible but never enrolled generated 95% of NVC volume.
Patients were surveyed about their experience. 86% of respondents (N = 23) agreed or strongly agreed that ICP “helped me communicate with my care team.”
Conclusions: A structured design and implementation process proved essential to rapidly deploying asynchronous obstetrical care during the COVID‐19 global pandemic. Leveraging Epic Systems Incorporated Care Companion® tools, as well as an existing logistics system, a low‐touch, high‐value virtual obstetrical care extension was achieved.


Andrew Talal, MD, Suzanne Dickerson, PhD, RN, Arphan Dharia, MD, SUNY
University at Buffalo
Description: We interviewed 25 participants, 6‐40 months after achieving an HCV cure through facilitated telemedicine integrated into opioid treatment programs, to understand their experiences of telemedicine for HCV treatment. Participants' meanings of facilitated telemedicine provide insight into its contribution to expansion of healthcare access points for people with opioid use disorder.
Abstract: People with opioid use disorder (OUD) are often infected with hepatitis C virus (HCV) due to injection drug use. Despite the availability of efficacious HCV treatment, HCV prevalence and incidence continue to increase, while HCV treatment initiation rates remain low. HCV treatment access is a challenge for people with OUD, due to a variety of competing priorities and an aversion to seeing physicians in person. We are completing an efficacy study of facilitated telemedicine for HCV treatment integrated into opioid treatment programs (OTPs). OTPs provide OUD treatment consisting of medication combined with behavioral therapy. People with OUD consider OTPs “safe spaces”, where respect and trust are promoted between patients and staff versus traditional healthcare settings. OTPs destigmatizing environments provides a convenient venue for HCV treatment access through facilitated telemedicine that expands healthcare access points for people with OUD. For this study, we interviewed 25 participants 6‐40 months after achieving an HCV cure to elucidate their experiences of facilitated telemedicine. We utilized hermeneutic phenomenology to interpret and explicate common meanings and shared practices of participants' experiences of facilitated telemedicine for HCV treatment. The results provide insights to inform policies about healthcare access expansion through telemedicine for vulnerable populations.
Classification of Research: Patient Experience
Method: Survey / Qualitative
Results: Participants illuminated their experiences of addiction and committing to the OTP. They viewed OTPs as destigmatizing environments that provide treatment for addiction and behavioral issues (Theme 1). Participants conveyed facing self‐perceptions of addiction shame, confronting poor reactions from external healthcare providers, and enduring negative perceptions of addiction in society (Theme 2). Participants embraced facilitated telemedicine integrated into the OTP as it delivered patient‐centered care and mitigated several HCV treatment pursuit challenges (Theme 3). Participants consider the HCV cure as a victory over a lethal disease, promoting self‐confidence, enabling them to improve their health and their lives (Theme 4).
Conclusions: Participants perceived their addiction and HCV diagnosis as shameful, limiting their engagement in HCV treatment and healthcare overall. Participants described how OTP staff promoted respect and trust, giving them a sense of comfort and familiarity. Integrating facilitated telemedicine within the OTP enabled virtual provider‐patient encounters to occur while concurrently administering HCV medications with OUD treatment, mitigating HCV treatment access challenges. Additionally, participants valued the convenience of seeking HCV treatment integrated within the OTP. Facilitated telemedicine can be utilized as a healthcare delivery model to remove healthcare access barriers and integrate healthcare services, especially for vulnerable populations.


Rohit Nayak, Abby McInturf
Band Connect, Inc.
Description: While telemedicine has delivered tangible value across many areas of healthcare, the notion of telerehab specifically purposed to augment the PT‐Patient experience for musculoskeletal‐rehab is still in a nascent stage of evolution. The situational need for telerehab with the onset of the pandemic highlighted some limitations of available technology approaches.
Abstract: The pandemic highlighted why traditional telemedicine approaches can be insufficient for effective MSK telerehab. This report explores the viability of available tech‐enabled telerehab solutions while recommending opportunities for innovation and advancement of MSK‐specific telerehab. This report provides a snapshot of the various tech‐enabled telerehab solutions and also explores the barriers and opportunities for viable and clinically focused telerehab solutions aligned with remote therapeutic monitoring, while highlighting the personalized care protocols leveraged by PTs.
Classification of Research: Clinician Experience
Method: Observational
Results: This report serves as an information resource for PTs and PT Clinic managers as they evaluate approaches for telerehab and remote therapeutic monitoring (RTM).
Conclusions: Although telehealth, and particularly telerehabilitation, has evolved significantly due to the pandemic, it has also highlighted the numerous opportunities for further evolution and progress. It is anticipated that many of the telehealth innovations are likely to be retained in a post‐COVID world, but it is likely that rehabilitation services will adapt to a hybrid combination of remote and in‐person therapy. Most telerehabilitation studies to date have addressed the outcomes of synchronous, real‐time time rehabilitation, but there is emerging evidence that asynchronous telemedicine can also be effective for specific patient populations, such as those undergoing postoperative rehabilitation following total joint replacement.


Tochi Iroku‐Malize, MD, MPH, MBA, Aditya Bissoonauth, MPH, MBA, Lillian Cargill‐deSilva, MHA, Barbara Keber, MD, Amanda Inga
Northwell Health & Zucker School of Medicine
Description: In 2022 the family medicine service line piloted a program to increase recruitment of physicians to a low access area. With the partnership of stakeholders, an innovative schedule was created to allow for physicians to work a hybrid schedule of alternating weeks of live clinical care and virtual telehealth.
Abstract: Recent data for physicians in the East End shows 98 Primary Care Physicians across 61 locations. Of the 98 physicians, 54 (55%) are Family Medicine. An adult primary care physician supply/demand analysis that was completed in April 2021 showed there is an undersupply of primary care physicians in the overall East End market. Primary Care E&M visits from 2020 were divided by the MGMA benchmark (1,047,468/4,330), which identified a demand for 242 Primary Care Physicians. Therefore, there is an undersupply. Aggravating this problem is the crisis seen by healthcare workers with regards to burnout, especially those newly into the profession, who are looking for a better life‐work balance. The family medicine service line partnered with the Peconic Bay Medical Center senior leadership, the eastern region health system leadership, and the physician recruitment office to create an opportunity for physicians to sign on for an alternating schedule. They would see patients for live visits in the office the first week and then do telehealth visits the following week. This would allow for expanded access for patients as well as some lifestyle modification for the physician.
Classification of Research: Access to Care, Patient Experience, Clinician Experience
Method: Observational, Descriptive, Implementation Science
Results: The recruitment program began in August 2022. Family medicine residents from across the region were invited to visit the sites in the East End with a networking opportunity to meet other practicing physicians in the area. The various stakeholders were in attendance to show their support for the initiative and the innovative scheduling that would incorporate telehealth visits as 50% of the FTE. Within a week, several residents have expressed interest and have interviewed for the positions. We are currently collecting data on how many will sign contracts and then work in the area.
Conclusions: Creating a work environment that allows for physicians to have a variable schedule that allows for telehealth as a block of service is a mechanism for physician satisfaction and improved recruitment in the primary care arena. A modified telehealth schedule is of interest for physicians seeking an alternative to full live visits in an ambulatory practice. The offerings for 50/50 telehealth live visits in the ambulatory setting are being reviewed to determine the feasibility in the hospitalist setting.


Maria Buquicchio, MSN, RN, PCCN, CCRN‐K, Kara Benneche, MSN, RN, PCCN
Northwell Health Telehealth Program
Description: The COVID‐19 pandemic exacerbated an existing nursing shortage across the country. This resulted in inadequate staffing in hospitals leading to a increased volume and length of stay of critically ill patients in the Emergency Departments. Many health systems turned to technology to provide a rapid solution.
Abstract: A rapid implementation of a virtual critical care nursing project staffed by out of state Tele ICU critical care nurses was created to support the bedside nursing team involved the care of critically ill patients boarding in the ED of a busy academic medical center. The process was started by aligning key stakeholders between 2 health systems (administration, nursing ED leadership, Tele ICU, and bedside team members). 10 rooms in the ED were equipped with hardwired equipment for Audio‐Video Telehealth visits and 2 mobile carts. EMR access and external vendor portal were provided to the Tele ICU team to connect to the equipment. The nursing leadership between the 2 health systems worked collaboratively to understand the need to develop a targeted workflow that focused on hourly rounding on critically ill patients, documentation in the EMR and mentoring and support to bedside nurses.
Classification of Research: Clinical Outcomes
Method: Descriptive
Results: The virtual nursing project ran approximately 30 days. The 24/7 monitoring program resulted in 1840 video encounters on approximately 250 unique critically ill patients boarding in the ED. A weekly list compiled by the Tele‐ICU team was shared with the nursing leadership that demonstrated the value of the remote team in addressing patient concerns, responding to bedside nursing requests for support, and communicating any changes in status of the patients to the bedside team. The duration of the pilot was limited by the temporary state licensure therefore, overall impact on patient outcomes and ED throughput were unable to be determine.
Conclusions: In this proof of concept model we have demonstrated that Telehealth technology can be leveraged to support bedside nursing teams taking care of complex critically ill patients by out of state experienced critical care Tele‐ICU RNs. Lack of interoperability between disparate EMRs, lack of reimbursement for virtual nursing care and lack of participation in the Nursing licensure compact by all states remain barriers to widespread use of technology to offset the existing nursing shortage.


Rika Bajra, MD
Stanford School of Medicine
Description: The rapid adoption of telemedicine calls to expand attention beyond feasibility and satisfaction to the quality and safety of clinical care delivery. Using Stanford's EMR encounter data and a custom dashboard to monitor quality measures, we compared ED visit rates following telemedicine and in‐person visits.
Abstract: Despite the widespread adoption of telemedicine in the ambulatory setting, there is limited research on telemedicine safety.1 Patient safety outcomes data are needed to minimize patient risk and develop evidence‐based best practices.2 The study objective was to examine the rate of emergency department (ED) visits within 7 days of an anchoring visit between June 2021 and May 2022 at primary care clinics of a large academic medical center. Emergency department (ED) visits included visits to the ED and urgent care clinic. We selected the 12‐month study period to ensure recency and reasonable visit volumes to compare the two modalities. Telemedicine visits were video and phone visits, and clinic types included general primary care, employer‐based clinics, and senior‐care clinics. We classified encounters by visit type (in‐person or telemedicine) and matched them with subsequent ED visits occurring within seven days of an anchoring or baseline visit. Of all visit encounters (N = 110,826), we identified 47.9% of telemedicine and 52% of in‐person office visits and matched them with subsequent ED visits. Statistical analyses were conducted using EXCEL (Microsoft Corp). Unpaired two‐tailed t‐tests were used to compare changes between cohorts. P‐value <.05 was deemed statistically significant.
Classification of Research: Quality Improvement
Method: Observational
Results: The median age ranged between 40‐49 years, and 57.4% identified as female, 42.7% as male, and 0.01% identified as non‐binary/unknown. Additionally, 81.7% were non‐Hispanic Latino, and 93% spoke English. Across all clinics, 2.4% (1292/53091) telemedicine visits were followed by an ED visit within seven days, compared to 1.1% (638/57735) in‐person visits. Furthermore, senior care clinics demonstrated the highest percent difference in seven‐day ED visit rate, 1.68% (p < 0.001), compared to in‐person visits. In contrast, employer‐based clinics showed the least percent difference of 0.31% (p < 0.001), while general primary care clinics demonstrated 1.42% higher ED rates (p < 0.001) compared to in‐person visits.
Conclusions: As telemedicine continues to integrate into health care delivery, patient outcomes in safety and quality are needed to help guide appropriate uses and best practices. Our study assessed the rate of ED visits following telemedicine and in‐person visits. For all primary care clinics (general primary care, employer‐based clinics, and Senior Care clinic), telemedicine visits were associated with higher ED visits within seven days compared to in‐person office visits. Therefore, further investigation into potentially contributing factors, such as scheduling processes, clinical appropriateness, and patient characteristics, is needed to elucidate safety in telemedicine visits.


Bella Siangonya, MPH
Morehouse School of Medicine
Using Software‐defined Networking and Post the COVID‐19 Era: Lessons Learned from Zambia
Description: The adoption of telemedicine in sub‐Saharan Africa has historically been low due to policy issues, cost of broadband internet, and cost of information and communication technology (ICT). To overcome these historical challenges, the Morehouse School of Medicine and its partners implemented a Software‐Defined Networking (SDN) based telemedicine architecture in Zambia.
Abstract: To minimize the spread of COVID‐19, policy makers in Zambia began providing multi‐month supply of anti‐retroviral treatment (ART as a key strategy to protect people living with HIV (PLHIV) and health care workers. To further this prevention strategy, the Morehouse School of Medicine collaborated with the Ministry of Health and Digital Safe Limited to implement a hub and spoke telemedicine program in June 2021 in Lusaka district to ensure continuity of care for PLHIV.
Conventional Internet Protocol‐based protocols make implementing telemedicine make it challenging to provide high quality of services through telemedicine due to issues arising from costs to setup such networks and network congestion. To overcome these historical telemedicine implementation limitations, the MSM and its implementing partners designed a Software‐Defined Networking (SDN) based telemedicine architecture to provide high quality services during telemedicine health consultations. The telemedicine program was launched in June 2021 in four general hospitals serving as hubs and nine primary health centers services as spokes. The government of the republic of Zambia has been very supportive of integrating telemedicine services into the healthcare system. A total of 1,421 PLHIV have been seen via the telemedicine program in Lusaka district since June 2021.
Classification of Research: Information Technology
Method: Implementation Science
Results: Organizations seeking to implement telemedicine services in low‐resource settings need to consider supply chain challenges caused by the COVID‐19 pandemic to procure the required equipment. SDN allowed the Morehouse School of Medicine telemedicine program to add additional telemedicine sites at reduced cost than what would have been possible with conventional IP‐based protocols. Stakeholder engagement is critical in the design and implementation of telemedicine networks in low‐resources settings.
Conclusions: Regulatory support for telemedicine services has been critical for the successful expansion of this service in Lusaka district. The SDN deployed by the MSM program enhanced capabilities of telemedicine services in health centers and represents an opportunity to provide scalable and reliable infrastructures to embed within normal clinical operations well after the COVID‐19 pandemic ends that improve service delivery for PLHIV.


Thomas Cronin Ankur Gupta
Geisinger Commonwealth School of Medicine
Description: A novel stereoscopic slit lamp camera was tested for its ability to capture images that can be used for remote assessment of the limbal anterior chamber, specifically whether the limbal anterior chamber depth was shallow or deep.
Abstract: Limbal anterior chamber depth is typically assessed during most ophthalmic examinations, as a shallow limbal anterior chamber can correlate with risk of angle closure glaucoma or the risk of angle closure due to pharmacologic dilation. There are a variety of in‐person techniques to assess limbal anterior chamber depth, with gonioscopy remaining the clinical gold standard. We hypothesized that limbal anterior chamber depth assessment can be evaluated remotely using a prototype telemedicine slit lamp device capable of recording and transmitting stereoscopic videos to remote clinicians. This pilot proof‐of‐concept study aimed to understand if this telemedicine modality can be used to reliably appreciate limbal anterior chamber depth in digitally captured stereoscopic slit lamp images.
Classification of Research: Clinician Experience
Method: Implementation Science
Results: The reliability of assessments made by 5 remote graders for 39 eyes was found to be moderate (Fleiss Kappa = 0.476). The reliability of assessments made in‐person and remotely by the same grader was found to be fair (Cohen Kappa = 0.242). Remote graders were scored based on percent of eyes correctly assessed as being shallow or deep with shallow eyes being defined as having an AOD of 300um or less (In‐person grader: 72%. Remote grader 1: 65%, 2: 67%, 3: 82%, 4: 75%, 5: 67%).
Conclusions: This study suggests that evaluation of limbal anterior chamber depth with stereoscopic slit lamp images is reproducible by remote ophthalmologists. These findings suggest this form of ophthalmologic telemedicine holds the potential to significantly increase access to eye care and reduce healthcare costs. Future studies will gauge the diagnostic accuracy obtainable remotely using stereoscopic images by matching them to anterior segment OCT images. Future studies should assess this technology for its ability to evaluate the entire limbal anterior chamber depth. This study is the first step in validating whether remote stereoscopic slit lamps could be incorporated into telemedical assessments.


Aaron Nye
Connect America/100 Plus
Description: Leveraging telehealth, remote patient monitoring (RPM) comprises a digital technology solution that captures physiologic and disease‐related data from a user's home and delivers them to healthcare providers. An analysis of 18,555 patients revealed that RPM provides measurable improvements in patient health outcomes across various conditions, including hypertension, obesity, and diabetes.
Abstract: As adoption of RPM has continued to expand across healthcare, Connect America's 100Plus team performed a quality analysis to, first, determine the impact of its RPM system on key health metrics and, second, evaluate healthcare provider perspectives on how RPM has affected care delivery. The research involved 344 practices across 43 states, accounting for 18,555 patients and focused on three key metrics: blood pressure control, blood glucose control in diabetic patients, and weight loss in patients who weighed between 220 and 286 pounds.
A key component of the RPM system is an artificial intelligence (AI)‐enabled virtual medical assistant that engages with patients via text message to answer questions, deliver positive reinforcement, and remind them to take readings of their vital signs. This engagement, the perception of being observed, as well as reminders and feedback from the virtual medical assistant, creates a sense of accountability for patients. For providers, the data generated by RPM provides a means of earlier intervention to get a head of common clinical problems such as the need for therapy escalation, change in therapy, or addressing barriers to improve medication adherence and refill compliance.
Classification of Research: Clinical Outcomes
Method: Survey / Qualitative
Results: Upon completion, the study revealed that Connect America's 100Plus RPM technology delivered the following impactful results for patients with chronic conditions:
• Hypertensive patients saw a clinically meaningful average decrease of 4.7 mmHg in blood pressure at 180 days.
• Diabetic patients saw a clinically meaningful decrease of 7.5 mg/dL in blood glucose within the 180‐day period.
• Patients who started at greater than 286 pounds lost a clinically meaningful 8.2 pounds in 90 days. After a three‐month period, the weight reductions were sustained.
Conclusions: This non‐randomized, intervention‐only, quality improvement analysis found that AI‐enabled RPM drove statistically significant and clinically meaningful reductions in weight, blood pressure, and blood glucose. Most healthcare providers reported the Connect America's 100Plus RPM technology improved or greatly improved their ability to manage these metrics. Most importantly to patients and their physicians, 69% of clinical and provider customers asserted that the technology reduced or greatly reduced the incidence of hospitalizations and other forms of high acuity care for their patients. These findings could have major health and cost implications for healthcare systems and further underline the growing role of AI‐enabled RPM.


Sandeep Pulim, MD
Description: Within a remote hospital at home program, a retrospective study evaluating how digital communication (text, phone, video) impacts the patient care experience. Data on communication path, frequency, and duration yield insights on how remote communication may improve engagement and impact outcomes in remote care programs.
Abstract: Operating an AHCAH program requires delivering essential elements of inpatient hospital care to qualified patients in their home. Technology is a key to helping with the expansion of hospital at home programs. Understanding how digital communication tools are being utilized will improve adoption and access to care for patients.
Retrospective analysis of utilization of digital communication between patients receiving acute care in the home and their remote care teams. Communication data from multiple AHCAH programs across the country over a four‐month period was analyzed for the following metrics: call initiation, call duration, call type, and use of digital communication.
Classification of Research: Patient Experience
Method: Observational
Results:51% of total patients (N = 238) had a digital communication encounter. There was a total of 462 digital encounters of which 59% were initiated by the care provider and 41% were initiated by the patient. 79% of the encounters were via video and 21% of the encounters were via audio. Average duration of patient‐initiated video encounter was 5.1 minutes, and audio encounter was 3.8 minutes. Average duration of care provider‐initiated video encounter was 4.0 minutes, and audio encounter was 2.2 minutes.
Conclusions: Utilization of digital encounters in AHCAH programs during a four‐month period was seen by 51% of patients and care team providers. We identified a 27.5% increase in the duration of video encounters initiated by patients and 72.7% increase in the duration of audio encounter when initiated by patients. Care team provider‐initiated audio and video encounters had the shortest duration. Care team provider‐initiated encounters seem to be a more efficient means of communication with AHCAH patients.


Nikki Trupiano
University of Michigan Medical School
Description: Specific patient demographics (single, younger age, and private insurance) and visit diagnoses (isotretinoin) were associated with a higher likelihood of successful completion of an e‐visit, or asynchronous direct to patient teledermatology, compared to unsuccessful completion during the COVID‐10 pandemic.
Abstract: Importance: During the COVID‐19 pandemic, the Centers for Medicare and Medicaid Services (CMS) released a 1135 waiver providing improved reimbursement and less strict access requirements to make teledermatology more feasible and reduce viral spread. As it continues to remain an effective and popular mode of delivery, it is likely to become a permanent aspect of dermatologic care.
Objective: Determining the most appropriate use criteria for asynchronous teledermatology, specifically the diagnoses and patient demographics.
Design: This is a retrospective study of submitted asynchronous telehealth visits from September 1, 2020 to March 31, 2021.
Setting: This study takes place at a single, large academic institution.
Participants: 1,446 encounters of submitted e‐visits during the study time frame. Exclusion criteria include erroneous encounters.
Classification of Research: Clinical Outcomes
Method: Retrospective chart review
Results: The number of e‐visits completed was significantly associated with the diagnosis sub‐type (P < .001). Compared to a visit for rash, the odds of completing a visit for isotretinoin were significantly higher (OR = 5.55, P < .01) and lower for completing a visit for skin lesion (OR = 0.67, P = .02). Compared to those patients that were divorced, those that had a significant other (OR = 4.51, P = .02) or were single (OR = 4.11, P = .02) had a higher odds of completing their visits. Compared to those with government insurance, those with private insurance (OR = 1.98, P < .01) were more likely to complete their visits.
Conclusions: Certain dermatologic conditions, such as acne, warts, and arthropod bites, and patients being treated with isotretinoin may be better suited to asynchronous teledermatology visits given their higher completion rates. E‐visits for general skin lesions were frequently not completed given the likely need for a biopsy. Patients who were a new patient, single, a student, under the age of 35, or had private insurance had higher rates of completing e‐visits, which suggests that these may be optimal targets for offering e‐visits to in the future.


Tochi Iroku‐Malize, MD MPH MBA, Aditya Bissoonauth, MPH MBA, Lillian Cargill‐deSilva, MHA, Barbara Keber, MD, Amanda Inga
Northwell Health & Zucker School of Medicine
Description: In 2021 the family medicine service line signed up to pilot a program being implemented at Northwell Health whereby patients could choose a telehealth appointment with their family physician. The service line clinical leaders created a database of appointment types: either live, virtual or both which allowed appropriate scheduling.
Abstract: The pandemic allowed for the acceleration of telehealth within the family medicine service line to allow for broader access and convenience for patients and clinicians trying to manage acute, chronic and preventive care. In 2021 the division of patient access requested collaboration to embark on a new program whereby patients could schedule their own appointments as well as the type of appointment. Family Medicine clinical leadership reviewed the data showing all visit types of family physicians and then classifying whether each visit could be done live, virtually or both ways. Duplicate visit types with different nomenclature were resolved and a literature review and consultation with other family physicians across the country was done to ensure the correct classifications. Also taken into consideration were future technology that could potentially allow for virtual visits that were not currently in place. Each family physician was allowed to accept the virtual visits they were most comfortable performing. This was cross linked with the database so that patients would be able to sign up for virtual visits only for types that were available by the physician. The roll out occurred at 4 sites in May 2022 and in 103 days we have had 238 visits.
Classification of Research: Access to Care, Patient Experience, Clinician Experience
Method: Implementation Science, Observational, Descriptive, Implementation Science
Results: The virtual capable utilization was divided into activity types – (a) total virtual specific visits (acute patient, new patient, return patient, hospital follow up, medical clearance (b) telehealth billable (TEB) and nonbillable. Our pre go‐live TEB usage from January to May 2022 (130 days) was 273. Our post go‐live virtual appointments from May 2022‐August 2022 (103 days) was 163 with TEB usage at nine. 50 were “cancelled/no show”. On review with patients, these were due to lack of capability to carry out the virtual visit or the need to be seen urgently via a live visit prior to scheduled appointment.
Conclusions: Creating a platform that allows for patients to self‐select appointments based on their preferences and ability and allowing for physicians to have a variety of options by which to care for their patients, is a mechanism for better access as well as patient/physician satisfaction. What should be taken into consideration is the capability of patients to have access to equipment and internet to carry out the virtual visit. Better communication on what virtual visits entail. Also, a better screening tool and algorithm for patients to ensure they have the resources to escalate the visit to a live visit as needed.


Therese Chan Tack, DO MPH
University of California
Description: The COVID‐19 pandemic created opportunities to improve healthcare delivery while heightening preexisting digital disparities. The Telehealth Training for Older Patients Program is the first program of its kind at UCSF to partner with a community based organization to actively address the digital divide amongst older and Limited English Proficiency patients.
Abstract: Digital health is an expanding aspect of healthcare with the potential to improve care access, continuity, and chronic disease management. Today's smartphone/tablets and commonly available broadband, WiFi or mobile connectivity have enabled a higher level of collaboration among patients, doctors and staff. According to a 2017 Pew Research Center study, 67% of 65+ year olds access the internet, with 51% using home broadband. Moreover, 42% have smartphones while 32% use tablets. The adoption is non‐uniform with large variances due to age, socioeconomic and digital divide factors.
The COVID‐19 pandemic created opportunities to improve healthcare delivery while heightening preexisting digital disparities. This study describes the development and iterative data‐driven approaches taken by the Telehealth Training for Older Patients Program (TTOP) to a) improve patient education and training to integrate telehealth into their medical care, b) identify and address digital health entry barriers, and c) increase the percentage of successful video visits completed by target group.
Classification of Research: Access to Care, Quality Improvement, Patient Experience, Clinical Outcomes
Method: Implementation Science
Results: TTOP performed educational outreach to ∼3,000 50y+ patients, contacted 1,100 (18% Limited English Proficiency (LEP) and 46% with state insurance). 410+ patients received telehealth education with TTOP, of which 92% subsequently conducted video visits. Both Press Ganey and CGHAPS Patient Experience surveys reported higher ratings with video visits in comparison to in‐office visits. The largest, positive differences were seen in physician communication (96.2% vs 92.8%) and moving through the visit (96% vs 90%).
Conclusions: TTOP is a unique program which demonstrates the ongoing importance of bridging the digital divide and improving health inequities. Partnerships across academic and community based organizations bring complementary skills and perspectives which identify, tailor and elevate healthcare delivery. The challenges, iterations, and key learnings presented herein may serve as an example for other organizations.


Akshay Swaminathan
Stanford Medicine
Description: In the wake of civilian displacement in Ukraine following the Russian invasion, a team of medical students initiated a telehealth solution to connect Ukrainians to US and Ukraine‐based physicians. Over 90 clinicians volunteered to conduct telehealth visits via a HIPAA‐compliant video platform with support from a team of medical interpreters.
Abstract: In the wake of civilian displacement in Ukraine following the Russian invasion, a team of medical students initiated a telehealth solution, TeleHelp Ukraine, to connect Ukrainians to US and Ukraine‐based physicians. From 04/22/22 to 09/03/22, 124 patients were seen by licensed medical professionals (223 total appointments, 29.5% PCP, 44% mental health, 26% specialists). Specialty services offered included psychiatry, cardiology, rheumatology, pediatrics, and women's health, among others. Overall patient satisfaction was 4.9/5 and 93% reported that their concerns were partially or completely addressed during their appointment (57 responses; 24 fully; 29 partially). A key component of provider satisfaction was flexible scheduling and seamless interpreter integration, enabled by clinical practice management software, Cliniko. Our telehealth model to support Ukrainian citizens with limited access to healthcare proved feasible to implement and addressed patients' needs. Key team members include volunteer providers, interpreters, clinical support staff, Ukrainian‐speaking case managers, and a patient outreach team. This effort serves as a case study in interpreter integration into telemedical care, the establishment of partnerships with technology platforms, and international healthcare delivery. Future work includes further automation of scheduling, streamlining document sharing and translation, expanding services provided, and establishing a teaching program.
Classification of Research: Access to Care
Method: Implementation Science
Results: From 04/22/22 to 09/03/22, 124 patients were seen by licensed medical professionals (223 total appointments, 29.5% PCP, 44% mental health, 26% specialists). Specialty services offered included psychiatry, cardiology, rheumatology, pediatrics, and women's health, among others. Overall patient satisfaction was 4.9/5 and 93% reported that their concerns were partially or completely addressed during their appointment (57 responses; 24 fully; 29 partially). A key component of provider satisfaction was flexible scheduling and seamless interpreter integration, enabled by clinical practice management software, Cliniko.
Conclusions: Our telehealth model to support Ukrainian citizens with limited access to healthcare proved feasible to implement and addressed patients' needs. Key team members include volunteer providers, interpreters, clinical support staff, Ukrainian‐speaking case managers, and a patient outreach team. This effort serves as a case study in interpreter integration into telemedical care, the establishment of partnerships with technology platforms, and international healthcare delivery. Future work includes further automation of scheduling, streamlining document sharing and translation, expanding services provided, and establishing a teaching program.


Sinan Turnacioglu, MD
Floreo, Inc.
Description: Individuals with autism spectrum disorder (ASD) have difficulty managing challenging social situations. This study describes the implementation via teletherapy of a novel virtual reality (VR) intervention, the Floreo Police Safety Module (PSM), aimed at teaching autistic individuals the appropriate behaviors to successfully navigate interactions with law enforcement.
Abstract: A diagnosis of autism spectrum disorder (ASD) is associated with significant challenges in navigating social encounters, particularly high‐intensity and novel interactions such as those with law enforcement officers. Approximately one‐fifth of adolescents with ASD will be stopped and questioned by a police officer before their early twenties. Police interactions are challenging, unexpected, include unusual sensory stimulation, require novel problem solving, and necessitate rapidly processing social situations in real time. The consequences of engaging in behaviors that might be perceived as suspicious or threatening by law enforcement officers can be devastating for an autistic individual. It is difficult to prepare for such scenarios in traditional therapeutic settings. VR can be a useful tool as it provides individuals with the opportunity to practice interacting with police officers in a safe, simulated environment. Previous research indicated that there were significant improvements in autistic individuals' overall behavior, appropriateness of response, and fidgeting activity in those who received training with the VR Police Safety Module (PSM) as compared to a video‐modeling police encounter training program. Although the COVID‐19 pandemic has rendered it near‐impossible to safely implement in‐person behavioral interventions, but a teletherapy system for delivering the PSM intervention has been found to be feasible.
Classification of Research: Information Technology
Method: feasibility study
Results: To date, 51 verbally fluent adolescents and adults with ASD have been randomized to either Floreo or treatment as usual. Groups are stratified by age, sex, IQ, and autism symptom severity as measured by Social Communication Questionnaire (SCQ). The study population is geographically diverse with participants from different regions of the United States. Technological issues related to implementation of the teletherapy intervention have included data loss due to internet connection issues or technological difficulties, video export errors, video recording errors, and poor internet connection. Participants have contributed valuable feedback on both the intervention and the video conference format.
Conclusions: In this study that builds on the results of initial research on the safety, usability, and efficacy of a virtual reality (VR) intervention for teaching police safety skills to autistic adolescents and adults, the VR intervention was modified for teletherapy delivery in order to address access issues related both to the COVID‐19 pandemic and to autism intervention in general. These results describe So far results indicate that such a teletherapy approach to intervention is feasible. Remote intervention administration reached a geographically diverse group, and collected usable, rich data on intervention.


Nicole Zahradka, PhD
Current Health
Description: Staffing a virtual care program requires anticipating workload as the program scales. Nursing workload includes admitting and discharging patients and responding to alarms. We mapped these activities to typical shift patterns (day/night, weekday/weekend) in a cohort of 932 patients remotely monitored by four American healthcare organizations.
Abstract: Staffing a virtual care program requires anticipating workload as the program scales. Nursing workload includes admitting and discharging patients and responding to alarms. We mapped these activities to typical shift patterns (day/night, weekday/weekend) in 1,025 admissions of 932 patients, remotely monitored by four American healthcare organizations using the Current Health platform. Median age was 69 (IQR 57‐79) years. Patients were monitored for 8 (4‐15) days, transmitting 228,487 hours of data between 8/1/21 and 8/1/22. 80% were admitted and 79% discharged on weekdays between 8am‐8pm. Patient numbers increased Monday to Thursday, with most discharged on Fridays, and significantly fewer monitored on weekends. Wearable adherence was 90 (73‐96)%, highest on day 1, lowest on day 7. 79% of patients triggered 29,280 alarms (74% vital sign, 26% adherence). There were significantly more vital sign alarms during the day and significantly more technical adherence alarms overnight. 10% of patients contributed 53% of vital sign and 46% of adherence alarms. Highest RPM clinical workload is weekdays ‘in hours’. The 10% of patients who generated half the alarms should be identified early for additional support. Alarm thresholds should accommodate activities of daily living, and patients should be prompted for adherence overnight and on day 6.
Classification of Research: Virtual Care Program workflow, staffing and implementation
Method: Descriptive
Results: Patients were monitored for median 8 (IQR 4‐15) days, transmitting 228,487 hours of data between 8/1/21 and 8/1/22. 80% were admitted and 79% discharged on weekdays between 8am‐8pm. Patient numbers increased Monday to Thursday, with most discharged on Fridays, and significantly fewer monitored on weekends. Wearable adherence was 90 (73‐96)%, highest on day 1, lowest on day 7. 79% of patients triggered 29,280 alarms (74% vital sign, 26% adherence). There were significantly more vital sign alarms during the day and significantly more technical adherence alarms overnight. 10% of patients contributed 53% of vital sign and 46% of adherence alarms.
Conclusions: The highest clinical workload is weekdays, ‘in hours’, and RPM programs should be staffed accordingly. The 10% of patients who generated half the alarms should be identified early for additional support. Alarm thresholds should be set to accommodate the physiological challenges of activities of daily living. Wearable adherence was high, but prompting patients in the afternoons, and on day 6, to charge their wearable and wear it overnight will improve data quality and reduce the number of adherence alarms. Future research should focus on understanding and predicting patient trends by clinical condition, demographics and program goals.


Maria Buquicchio, MSN, RN, PCCN, CCRN‐K, Alice Cheng, MSN, RN, FNP‐C, CCRN
Northwell Health Telehealth Program
Description: New medications prescribed post percutaneous coronary intervention (PCI) are universal among hospitalized patients. Compliance and knowledge of medications are essential for positive patient outcomes. Facilities face challenges with patient education and may seek additional nursing support via telemedicine to narrow the disparity for the post‐PCI patient population.
Abstract: A review was made of the post‐PCI unit utilizing HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores, which also includes verbatim patient feedback. The HCAHPS survey is a standardized nation survey of patients' perceived experience with their hospital care. Understanding of new medications at discharge is one of the questions assessed on the survey.
A community hospital intensive care unit and the Tele ICU from the same health system formed a partnership to identify the post‐PCI patients ready for discharge each day. Once the post PCI patient is identified, a timeframe for the medication education was established by the bedside nurse and the Tele ICU nurse. Utilizing A‐V technology, the Tele‐ICU reviews the new medications prescribed with the patient and/or families. Utilizing the HCAHPS questions regarding communication about medicines, the Tele ICU nurse presents a comprehensive education process via telemedicine technology. The elements of the new prescribed medication education are; indication, onset, side effects, contraindications, and when to seek help. It is essential that these elements remain consistent for all patients included in the project. The Tele ICU nurse will then use the teach‐back method to assess the patient's understanding and effectiveness of the education.
Classification of Research: Patient Experience
Classification of Research ‐ Other (if different from options above):
Method: Descriptive
Results: HCHAPS scores for the survey question about medicine explanation increased 35.7% from 2021 to year‐to‐date 2022. Conversely, the survey question regarding explanation of side effects decreased 10.9% from 2021 to year‐to‐date 2022. Upon evaluation of the results, the Tele‐ICU will continue the education for the PCI patients as it is having a positive impact and ensure that side effects of medications are addressed.
Conclusions: TeleICU will continue the education for the PCI patients as it is having a positive impact and ensure that side effects of medications are addressed. The Tele‐ICU nurse will continue to evaluate the patient's understanding of their new medication via the teach‐back method. Delivering adequate medication education is essential in preventing post‐discharge complications, and telemedicine can bridge the gap to improve national patient outcomes. Utilizing telemedicine for discharge medication education may have a significant effect on patient outcomes.


Lauren Broffman
Description: Direct‐to‐patient (DTP) healthcare platforms have an opportunity to incorporate the collection and analysis of patient health outcomes data to help improve both individual patient and population health. This study represents the first large‐scale, systematic attempt to explore the efficacy of ED treatment in the DTP space.
Abstract: Introduction: Collecting patient health outcomes (PHO) is a pillar of patient‐centered care. Direct‐to‐patient (DTP) healthcare platforms have an opportunity to invest in collection and analysis of PHO data to improve patient and population health. This study represents the first large‐scale, systematic attempt to collect PHO in a DTP setting. Methods: A cross‐functional team at a large DTP company identified clinically‐validated and in‐house developed measures to capture outcomes for erectile dysfunction (ED). PHO measures were added to initial asynchronous onboarding visits and an optional treatment check‐in 1‐month later. The team analyzed PHOs for 4,084 patients in 2022.
Results: Most patients improved in individual erectile function measures (>85%), personal (82%) and partner sex life satisfaction (80%), and an increase in self confidence and positive body perceptions (78% and 60%). Comparison of composite scores found that over 90% of patients experienced improvement in overall erectile function, 86% in overall sex life satisfaction, and 81% in quality of life.
Conclusions: Results suggest treatment efficacy was high. Given the well‐documented safety and efficacy profile of ED prescriptions, these findings are unsurprising; nonetheless, this is one of the first studies to demonstrate that DTP platforms can collect PHO at scale and treat patients effectively.
Classification of Research: Clinical Outcomes
Method: Observational
Results: Most patients improved in individual erectile function measures (>85%), personal (82%) and partner sex life satisfaction (80%), and an increase in self confidence and positive body perceptions (78% and 60%). Comparison of composite scores found that over 90% of patients experienced improvement in overall erectile function, 86% in overall sex life satisfaction, and 81% in quality of life.
Conclusions: Results suggest treatment efficacy was high. Given the well‐documented safety and efficacy profile of ED prescriptions, these findings are unsurprising; nonetheless, this is one of the first studies to demonstrate that DTP platforms can collect PHO at scale and treat patients effectively.


Arianna Milicia
MedStar Health National Center for Human Factors in Healthcare
Description: We conducted interviews with both primary care providers and primary care patients from various healthcare systems across the United States to understand barriers and facilitators to telehealth use and suggested practical strategies for integrating and improving telehealth in primary care.
Abstract: While telehealth is recognized by many as essential to a high‐quality primary care, few studies have characterized how variations in telehealth implementation either pose barriers or facilitate telehealth use among primary care providers and patients. We conducted semi‐structured interviews with fifteen physicians and eight patients from various healthcare systems across the U.S. We qualitatively analyzed these interviews to identify themes about telehealth use in primary care and applied human factors principles to suggest strategies for improving telehealth experience. Interviews with primary care physicians and patients indicated general acceptance of telehealth technology, processes, and care across healthcare systems. Barriers to telehealth use ranged from pre‐ and post‐visit workflow to technology, usability, and clinical concerns. Suggestions for improvement included clarification around pre‐ and post‐ visit tasks, technology training and support, and patient safety concerns including patient identification, care quality, and delays in care. Successful long‐term integration of telehealth to support high‐quality primary care will require a collaborative approach with multiple stakeholders to improve both providers' and patients' experience.
Classification of Research: Patient Experience
Method: Survey / Qualitative
Results: Across multiple healthcare systems, physicians and patients accepted telehealth as a care modality during the pandemic and felt the care provided was appropriate. Most participants interviewed noted that telehealth increased access to care and felt that telehealth was often more efficient than in person visits. Important concerns highlighted were issues with telehealth workflow, technology, usability, and quality and safety. The most frequent opportunity for improvement included clarification around pre‐ and post‐ visit, training and support around technology, usability for patients with disabilities, and patient safety concerns including patient identification, care quality, and delays in care.
Conclusions: Interviews with primary care physicians and patients indicated general acceptance of telehealth as a care modality during the pandemic. However, there are gaps in the system and workflow that need to be addressed to provide all patients with accessible, high quality, safe, and appropriate care. Areas for telehealth improvement include optimizing workflow, addressing usability concerns, providing technology support, and addressing quality and safety concerns. Overall, patient and physician experiences with telehealth documented in this study suggest practical strategies that can be used as a starting point for integrating telehealth into a high‐quality primary care system.


Dawn Kempa, Linda Stopsky
Northwell Health System
Description: Northwell Health provides remote lactation consultations via audio visual technology to support post‐partum mothers. Breastfeeding difficulties are addressed in the critical first days and weeks after discharge when breastfeeding failure and breast milk production are most at risk. This has resulted in increased duration and exclusive breastfeeding rates.
Abstract: By age 6 months only one half of all infants born in the US receive any breast milk and only 22% are breastfed exclusively as recommended by the American Academy of Pediatrics.
US Preventative Services Task Force found that breastfeeding support increases the likelihood that mothers will breastfeed exclusively for at least 6 months by an average of 16% compared with usual care. During the Public Health Emergency, a need for telelactation services was identified at Northwell Health. The program was started with referrals from hospital based lactation consultants. A telelactation script and workflows were created. Since inception, Northwell Telehealth Lactation Program has expanded to 10 hospitals. Our team of 6 RN, IBCLCs have completed 5,900 consultations.
Northwell Health uses audio‐visual technology as an effective method of providing education, assessment, and support to breastfeeding moms in the comfort of their own homes. Telelactation offers a service that rivals in‐person care and is often more convenient for the mother, less costly, and encourages self‐efficacy. Breastfeeding difficulties are addressed in the critical first days and weeks after discharge when breastfeeding failure and breast milk production are most at risk. This has resulted increased duration and exclusive breastfeeding rates.
Classification of Research: Quality Improvement
Method: Survey / Qualitative, Patient satisfaction scores and continued breastfeeding/breastfeeding exclusivity percentages were used as key performance indicators (KPIs). Measurement of patient satisfaction scores were performed. Mothers were sent a survey after their initial telelactation visit asking about their virtual experience. Another survey was sent again at 6 weeks, at 3 months, and 6 months following their first telelactation visit asking them about their breastfeeding exclusivity and success.
Results: KPI results from 10/26/20 to 9/1/2022:
• 99% of patients felt the Northwell telelactation support call was helpful and educational.
• At 6 weeks; 46% of mothers that received a telelactation visit were exclusively nursing their newborn, 44% were breastfeeding with formula supplementation, and 10% were formula feeding.
• At 3 months; 42% of mothers that received a telelactation visit were exclusively nursing their newborn, 42% were breastfeeding with formula supplementation, and 16% were formula feeding.
• At 6 months; 40% of mothers that received a telelactation visit were exclusively nursing their newborn, 29% were breastfeeding with formula supplementation, and 31% were formula feeding.
Conclusions: By age 6 months, only 50% of all infants born in the US receive any breast milk. By 6 months, 69% of infants who's mothers received a telelactation visit were still receiving some breast milk.
The mothers that received a telelactation for breastfeeding education increased breastfeeding duration by 19%. 22% of mothers in the US breastfeed exclusively for 6 months. 40% of the mothers that received a telelactation consultation were still breastfeeding exclusively at 6 months.
The mothers that received a telelactation for breastfeeding support increased the likelihood that they will breastfeed exclusively for at least 6 months by 12%.


Kathleen Daly Stuart, MA, Brent A. Warndahl, BS RT(R)(MR), Ryan Karshen, MBA, R.D.M.S., RVT., RT(R)
Mayo Clinic
Description: The goal of this project was to develop a technology solution to remotely monitor sonographers‐in‐training without impeding their clinical learning and skill development.
Abstract: Ultrasonography is an operator dependent imaging modality that requires image acquisition training paired with mentoring. The ability for mentors and radiologists to physically observe and guide trainees is time consuming and sometimes impractical in geographically dispersed healthcare organizations. Additionally, having mentors in the room can impede the trainee's ability to learn to work autonomously. Off the shelf telemonitoring products can be an effective tool in sonographer training but may be expensive, bulky, and often require some level of set‐up and operation. To address these constraints, we launched a formal project to analyze the regulatory, business, functional and end user requirements for developing a custom telemonitoring solution. The plan resulted in a client‐server architecture model using a small, IP based video encoder for the capture and streaming, the existing hospital network for transmission and open‐sourced software for viewing and content management. The team used a proof‐of‐concept model approach to test the device's performance and to determine if it was adaptable to the sonographer's workflow. For a period of two weeks, the devices ran from two Vascular‐Ultrasound exam rooms. The video stream's imaging quality was routinely monitored and evaluated by the radiologist project proponent and technologist leads.
Classification of Research: Information Technology
Method: Observation with Proof of Concept
Results: This solution proved to meet all the project requirements. The devices were secure, reliable, and consistently delivered high quality imaging with no set up or operation. The content management software was easy to install and configure, and the user interface intuitive. Mentors and radiologists were able to view the video streams in real time from their desktops and provide guidance if needed. The project took approximately ten months from start to finish and resulted in thirty‐one rooms being outfitted for a total cost of $55,000. The project is now expanding to include an additional 46 rooms across the organization.
Conclusions: Our simplistic real‐time telemonitoring solution met the individualistic needs of our staff, practice and sonographer trainees because it reduced physical barriers, allowed for autonomy in learning and did not burden the end users with complex equipment and technology. In an ever‐increasing complex world, sometimes the best solution is the simplest one.


Seethal Jacob, MD, MS,1 Julia LaMotte, PhD,1 Aaron Carroll, MD, MS,1Jillian Bouck, B.A.,2 Roua Daas,2
1Indiana University School of Medicine
2Indiana University
Description: Few have explored barriers which affect the pediatric Sickle Cell Disease population in areas such as the Midwest, wherein the geographical landscape can prohibit healthcare access. Furthermore, few studies have established acceptability of telemedicine among caregivers of patients with SCD. This study sought to increase this understanding.
Abstract: Sickle cell disease (SCD) is associated with a wide range of complications. However, a multitude of barriers prevent SCD patients from receiving adequate healthcare, including difficulties with transportation and lack of provider knowledge about disease sequelae. Importantly, studies have demonstrated the benefits of telemedicine in addressing barriers to healthcare in chronic disease populations. The objective of this study was to increase understanding of barriers to care and perceptions of telemedicine by caregivers of pediatric SCD patients.
An 88‐item statewide survey was distributed to caregivers of children with SCD cared for at Riley Hospital for Children in Indianapolis, IN. Caregivers were contacted by the research team via secure text messaging or in‐person. Questions for the survey were developed based on previously performed semi‐structured interviews with caregivers and the validated Barriers to Care Questionnaire (BCQ). The survey included questions regarding their experience accessing care, including barriers and facilitators of care, as well as their perspective on the use of telemedicine in SCD. Responses were analyzed using t‐tests or chi square tests where appropriate.
Classification of Research: Access to Care
Method: Survey / Qualitative
Results: Of the 300 caregivers contacted, 101 completed the survey, resulting in a response rate of 34%. Forty percent of caregivers had participated in some form of telemedicine, the majority being direct‐to‐consumer. Eighty‐one percent were willing to participate in telemedicine visits sometimes or always. However, nearly half felt the lack of a physical exam was a negative for telemedicine, and about 25% stated it was harder to build trust via telemedicine. Willingness to participate in telemedicine was not associated with prior telemedicine use, perceived positives/negatives of telemedicine, caregiver worry about others caring for their child, or distance from SCD center.
Conclusions: The experiences of caregivers accessing healthcare for their child with SCD suggests caregiver burden and barriers to care that may be unique to patients with SCD. Additionally, while the majority are willing to participate in telemedicine for future sickle cell care, the negatives of telemedicine that caregivers reported are significant. Future studies should evaluate models of telemedicine care adapted for this specific population.


Cynthia Zettler‐Greeley, PhD, Susan Voltz, MBA, PMP, Patrick Barth, MD, FACS, Heather Nardone, MD
Nemours Children's Health
Description: “Chatbots,” or automated virtual technologies, are increasingly being utilized to deliver health communications, provide educational content, and offer support for patients without the need for direct interaction with a provider. We examined impacts of patient‐family engagement in chats on scheduled, pediatric telehealth visit “no shows” and on pediatric tonsillectomy.
Abstract: Chatbots offer patients an opportunity to obtain educational content and express commonly experienced health concerns via secure, automated technology. Chats may serve as visit reminders for upcoming appointments, with notifications sent at regular intervals in advance of a scheduled telehealth visit, reducing the occurrence of costly patient no‐shows. Likewise, automated “check‐ins” with surgery patients may alleviate patient anxiety and reduce the need for more expensive follow up emergency care by soliciting patient status updates and providing targeted educational content to patient‐families to ensure preparation and recovery is proceeding as expected, without the need for the surgeon's direct involvement. In this study, we incorporated chatbots into an existing telehealth infrastructure across two clinical pediatric settings. We examined engagement in chats among patient‐families with scheduled primary or specialty care telehealth visits through visit reminders sent 1, 3, and 7 days in advance of a telehealth appointment. Additionally, we offered educational content to patient‐families via chats preceding and following pediatric tonsillectomy as an opportunity to provide essential educational content regarding the surgical procedure itself and to help mitigate several common pre‐ and post‐surgical concerns, including anesthesia, fever, and dehydration. Program outcomes between chat users versus non‐users will be compared.
Classification of Research: Patient Experience
Method: Descriptive
Results: To date, 21,407 Video Visit Preparation (VVP) chats and 1806 Tonsillectomy chats have been completed, with 75,703 VVP and 18,282 Tonsillectomy questions answered. Patients engaging in 2+ chats (i.e., “engaged patients”) included 5,223 (19%) VVP patients and 344 (57%) Tonsillectomy patients. Over 72% of VVP and 85% of Tonsillectomy patients were satisfied with the chat. Analysis is underway to investigate relationships between chat engagement and number of no‐show visits following VVP, as well as relationships between chat engagement and emergency department recidivism and 30‐day hospital readmissions following tonsillectomy, relative to matched samples of patients who did not use the technology.
Conclusions: Chatbots are an effective means of communicating health information and education to patients for a variety of purposes and can serve multiple clinical domains. Appointment reminders, embedded in chatbots, can help to alleviate no shows, an undue and costly burden on health care systems. Likewise, commonly experienced patient health updates and concerns can be communicated without intervention from a healthcare provider. Satisfaction with chats is high, regardless of program. Willingness to engage in chats may be somewhat dependent on factors related to patient risk. Pursuit of opportunities to increase patient engagement in chats may further benefit desired outcomes.


Mateo Rutherford‐Rojas, MA, MATI, CHI (Spanish),1; Jeff Cordell, BS2
1UCSF Health
2LanguageLine Solutions
Description: One of the top hospitals in the nation, UCSF Health, will share their findings on how the San Francisco‐based system successfully worked to reduce barriers and increase access to telehealth for their linguistically diverse patient population.
Abstract: Since UCSF Health started engaging with quality video interpreters through a stable SIP (Session Initiation Protocol) connection, the organization has vastly increased the number of telehealth interpretation encounters, enabling the organization to improve efficiency and reduce disparities. SIP works as a bridge, connecting telehealth platforms to an on‐demand interpretation platform, allowing for immediate access to audio and video interpreters for healthcare staff and the Limited English Proficient or Deaf and Hard of Hearing patients they serve via telehealth. UCSF will share research on how the increase in utilization since the SIP integration began has resulted in reduced disparities and improved access to telehealth care. UCSF will also share findings on the impact of translated patient‐facing documentation with visual guides and other initiatives that have helped patients navigate their telehealth experience, which have been key to the success of these efforts. A technology expert will provide additional detail on how SIP is enabling healthcare organizations to bridge language barriers and improve compliance with the Americans with Disabilities Act (ADA) by making telehealth easily accessible to some of the nation's most vulnerable patient populations.
Classification of Research: Quality Improvement
Method: Descriptive
Results: Improved equity of care in telehealth for Limited English Proficient and Deaf and Hard of Hearing patient populations
Conclusions: A stable SIP connection can help healthcare organizations close the equity gap in telehealth for Limited English Proficient and Deaf and Hard of Hearing populations.


Lesli Culver, AA, BA, MSW, Hugo Padilla, B.S., Management of Computer Information Systems A.S., Criminal Justice A.S., Information Systems
Veterans Health Administration
Description: The U.S. Department of Veterans Affairs (VA) Veterans Health Administration (VHA) has implemented a 'chat by text' application (app) for Veterans to chat in‐real‐time with VA healthcare providers and staff called VA Health Chat. This presentation will describe the implementation process and highlight positive data outcomes for Veteran patient satisfaction.
Abstract: The VA is the largest integrated healthcare system in the United States and has been leading the way with virtual care innovations, such as telehealth, for many years. With the success of telehealth as an effective means to engage Veterans in high‐quality care the VA has continued efforts to implement other virtual care tools Veterans can use for greater access and ease of health care. VA has implemented a 'chat by text' application (app) called VA Health Chat. It allows Veterans to chat in‐real‐time with VA healthcare providers and staff to remove barriers to VA Health Care; divert Veterans to a single virtual point of care and to optimize VA staffing resources. Overall goals: improve Veteran access to care; reduce Veteran wait times; promote better provider‐Veteran communication; improve overall Veteran health outcomes and Veteran satisfaction. This presentation will highlight the implementation process and positive outcomes of integrating this app in the largest integrated health system in the United States.
Classification of Research: Patient Experience
Classification of Research ‐ Other (if different from options above):
Method: Implementation Science
Method ‐ Other (if different from options above):
Results: Results have dispelled certain myths about Veterans use of virtual care technology based on age and modality. We hypothesized that younger Veterans would use a mobile version of a chat by text app on a mobile device (smartphone or tablet). However, Initial data showed that Veterans aged 65 and up were the highest utilizers of this app. and were engaging by using the web version of the app on a desktop computer or laptop. Other results showed high Veteran and Provider satisfaction and high resolution of issues in one encounter.
Conclusions: VA Health Chat has facilitated greater access to healthcare and improved Veteran experience in the VA by providing a virtual care tool that is easy for both Veterans and providers to use. The Health Chat app has demonstrated high satisfaction rates among users. Data shows high resolution rates to Veteran issues in one encounter. And, Health Chat has provided a significant Veteran diversion rate to a single point of care and data shows a reduction in: veteran travel time for in‐person visits (and appointment wait times), phone Calls to VA providers, urgent Care and ER visits.


Nicole Lew, DPT, Danna Chung, MD, Matt DeBole, DPT
Crossover Health
Description: The COVID‐19 pandemic forced many physical therapists to shift their in‐person practice to the virtual setting; however, the effectiveness of virtual physical therapy compared to that of in‐person physical therapy has not been well studied.
Abstract: We aimed to compare the functional outcomes, attrition, and therapeutic alliance of virtual physical therapy to that of primarily in‐person physical therapy.
Our virtual physical therapy program included video visits with frequent asynchronous messaging check‐ins, education, and updates to exercise programming between visits. With our onsite physical therapy program, the vast majority of visits (92.8%) were in‐person visits, with the remaining being video visits.
The Patient‐Specific Functional Scale (PSFS) is an industry‐accepted and well‐validated outcome measure for musculoskeletal issues. Patients are asked to identify important activities they are having difficulty performing as a result of their musculoskeletal complaint (e.g., donning shoes, running). Efficiency of the PSFS represents the percentage of participants who had significant change in their functional scale in 6 weeks. Attrition within the PSFS represents the percentage of participants who completed an initial survey, but did not complete a follow‐up survey, indicating that they did not continue physical therapy after the first visit.
The Goodness of Fit (GoF) measure is adapted from a tool that psychologists use to measure therapeutic alliance, the cooperative working relationship between the provider and patient. The GoF is represented as a scale from 0 (no/low therapeutic alliance) to 9 (high therapeutic alliance.)
Classification of Research: Clinical Outcomes
Method: Observational
Results: A total of 436 patients participated in this study from January to June 2022. There were 105 participants in our nationwide virtual only practice group and 331 participants in our onsite health center group. The PSFS efficiency of our virtual‐only population (68.57%) was comparable to that of our primarily in‐person population (65.56%). The PSFS attrition of our virtual‐only population (13.87%) was significantly less than that of our primarily in‐person population (40.70%). The average GoF of our virtual‐only population (9/9) was greater than that of our primarily in‐person population (8.4/9).
Conclusions: We were able to demonstrate that virtual physical therapy has comparable efficacy in improving patient functional outcomes, less attrition, and improved promotion of therapeutic alliance than primarily in‐person physical therapy. We believe our virtual physical therapy program is an effective intervention for musculoskeletal concerns because of the improved accessibility with often same‐day access, frequent touch points, and flexibility to engage in care asynchronously or synchronously based on patient convenience which improves patients' engagement.


Praneetha Elugunti, MSHA, MBA, MSc
Mayo Clinic Arizona
Description: The aim of this study was to determine the feasibility of an artificial intelligence (AI) enabled text‐based communication system (chatbot) for COVID‐19 screening for patients prior to radiology appointments and to describe patient experiences with the chatbot.
Abstract: The Mayo Clinic brand is synonymous with world class healthcare guided by its unwavering commitment to patient care, education, and groundbreaking research. The foundation of this commitment is cemented in the culture of patient centric clinical care and innovation. At the onset of the COVID‐19 pandemic in 2020, the Centers for Disease Control and Prevention issued guidelines for safety measures with respect to screening high‐risk patient populations for exposure. Additionally, healthcare organizations were urged to limit in‐person contact when possible to reduce transmission rates. Multiple stakeholders were consulted including Radiology Physicians, Radiology Administrative Leadership, Center for Digital Health Administrative Leadership, Allied Health Staff, and Nursing. A multidisciplinary project team was assembled with champions from Radiology to pilot a HIPAA‐approved, IRB‐waived study implementing an AI chatbot into the clinical practice from July 6‐August 31, 2020. The team partnered with an external vendor to customize a secure AI chatbot to screen patients for COVID‐19 symptoms prior to a scheduled radiology exam. The initial pilot group consisted of patients scheduled for ultrasound exams, and then, subsequently, MRI exams in outpatient settings across all regional campuses. The SMS‐ based AI chatbot routed patients into several pathways depending on response to COVID screening survey.
Classification of Research: Quality Improvement
Method: Survey / Qualitative
Results: The chatbot COVID‐19 screening text message was sent to 4,687 patients. Of these patients, 2,722 (58.1%) responded. Of the respondents, 46 (1.7%) reported COVID‐19 symptoms; 34 (1.2%) had COVID‐19 tests scheduled or pending. Of the 1,965 nonresponders, authentication failed for 174 (8.8%), 1,496 (76.1%) did not engage with the text, and 251 (12.8%) timed out of the survey. The mean rating for the chatbot experience was 4.6. In a multivariable logistic regression model predicting response rate, English written‐language preference independently predicted response (odds ratio, 2.71 [95% CI, 1.77‐2.77]; P = .007). Age (P = .57) and sex (P = .51) did not predict response rate.
Conclusions: An AI enabled text‐based communication system is an effective mechanism to communicate with patients for COVID‐19 screenings prior to Radiology appointments. Overall, patients indicated a positive patient experience of using an AI enabled chatbot to communicate with the care team.


Anders Carlson, MD, Phillip Quintero, Julia Campbell, Lisa Ide, MD
Zipnosis by DocSquad
Description: Patients faced with the choice between an asynchronous telehealth visit and a synchronous video visit may not completely understand the differences between the two, making their decision difficult and often deferring to video visit assuming this will lead to a more one‐to‐one, personal visit with a clinician.
Abstract: Test patients (n = 12) were interviewed about various naming conventions between asynchronous visits and synchronous video visits, and why they would prefer one over the other. Patients were presented with an example health condition telemedicine visit scenario and basic visit type descriptors. Initial interview questions included “what do you expect to happen if you select this type of visit?”, “what do you think you will come away with once you've finished this visit?”, “how long do you think it would take you to complete?” and “which one would you be most likely to select and why?”. Based off these interviews, patterns emerged about what patients felt an asynchronous visit includes compared to a synchronous video visit. The main finding was concern about whether they would speak to a provider or not, as well as the time commitment to do so. Following this, the above interview findings were validated by another round of interviews after additional descriptors and explanations were added to the visit types to assess if the test patients had more clarity to the differences of asynchronous vs. synchronous visits.
Classification of Research: Patient Experience
Method: Descriptive
Results: Findings suggest that the visit time commitment was important, but the potential severity and complexity of their symptoms was the primary determining factor between asynchronous and synchronous visits. While asynchronous visits were considered the quicker option, patients felt that if their illness was severe, they may decide to wait to speak to a clinician for reassurance of a correct and immediate diagnosis. Additional emphasis on the fact that symptoms in both visit types are reviewed by a clinician made asynchronous visits more attractive and offered reassurance. Additional descriptions and clear titles also helped improve the expectations of asynchronous visits.
Conclusions: The visit descriptions presented to patients to help them select between asynchronous visits and synchronous video visits should be optimized to ensure patients expectations are being met and so they more completely understand what type of clinician interaction they will have during the visit. Time commitment to a telehealth visit is also important in making this decision. Further research into the optimal way to assist patients to distinguish asynchronous from synchronous telehealth visits is needed to understand the factors driving patient decisions around visit preferences and expectations.

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Published In

cover image Telemedicine and e-Health
Telemedicine and e-Health
Volume 29Issue Number 4April 2023
Pages: A-1 - A-43


Published online: 4 April 2023
Published in print: April 2023
Published ahead of print: 1 March 2023


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