Telehealth Providers of the Future

Telemedicine and eHealth refer to the use of information and communication technology (ICT) embedded in software programs with highspeed telecommunications systems for delivery, management, and monitoring of healthcare services. Application of telemedicine have become timely while providing great potentials to protect both medical practitioners and patients, as well as limit social mobility of patients contributing to reduce the spread of the virus. This study employs data from the existing literature to describe the application of telemedicine and eHealth as a proactive measure to improve clinical care. Findings from this study present the significance of telemedicine and current applications adopted during the pandemic. More importantly, the findings present practical application of telemedicine and eHealth for clinical services. Also, polices initiated across the world to promote management of COVID-19 are discussed. Respectively, this study suggests that telemedicine and eHealth can be adopted in times of health emergency, as a convenient, safe, scalable, effective, and green method of providing clinical care.

As health care has shifted to increasingly rely on digital tools for patient care, digital inclusion has become critical to promoting health care equity. The recently enacted Infrastructure Investment and Jobs Act (IIJA) makes investments that could foster sustainable digital inclusion. Although the law isn’t focused on health care, it addresses long-standing drivers of digital health disparities, presents new opportunities for community-based digital inclusion, and could be a critical lever for improving access to care. We believe it’s important for health care organizations to understand the opportunities the law presents, to advocate for its effective and equitable implementation, and to take advantage of improvements to digital infrastructure.

Telerehabilitation is an evolving modality for the delivery of rehabilitation care. It allows for innovative approaches for delivery of care in different locations and using different technology based on the patient’s needs, clinical judgment of the provider, access to technology, and existing infrastructure of the health care system. Technology continues to evolve to expand the scope of care that can be provided over telerehabilitation, particularly to home. The COVID-19 pandemic has led to accelerated adoption of telerehabilitation with potential to expand access, improve interdisciplinary collaboration, and customize patient-centered care to an unprecedented degree.

This chapter explores the specific technologies that enable telehealth services in the areas of evaluation, monitoring, consultation, treatment, and care coordination. Historical, current, and future state applications are explored through case examples as a way to demonstrate technical functionality and capabilities. The foundational underpinning of broadband networks and the technological processes supported through telehealth vendors are presented. Additional discussions present examples of established systems, areas where interoperability is functional and the need for advancements in HIT technologies to better address security protocols and validate health analytics.

In response to the emerging COVID-19 public health emergency in March 2020, the Medical University of South Carolina rapidly implemented an analytics-enhanced remote patient monitoring (RPM) program with state-wide reach for SARS-CoV-2-positive patients. Patient-reported data and other analytics were used to prioritize the sickest patients for contact by RPM nurses, enabling a small cadre of RPM nurses, with the support of ambulatory providers and urgent care video visits, to oversee 1234 patients, many of whom were older, from underserved populations, or at high risk of serious complications. Care was escalated based on prespecified criteria to primary care provider or emergency department visit, with 89% of moderate- to high-risk patients treated solely at home. The RPM nurses facilitated the continuity of care during escalation or de-escalation of care, provided much-needed emotional support to patients quarantining at home and helped find medical homes for patients with tenuous ties to health care.

MUSC Pediatric Critical Care Specialist, Dr. David McSwain, talks about the telemedicine program MUSC has with three of the rural hospitals in S.C.

The Federal Communications Commission is looking to use technology to connect rural hospitals and patients to the high quality care they need, while keeping them in their communities

We describe a telemedicine weight management programme, Wellness Connect, developed through a partnership of academic clinicians and rural primary care providers in South Carolina, and present utilisation and weight outcomes from seven patient cohorts.

There are high rates of maternal and newborn morbidity and mortality associated with opioid use disorder (OUD). Integrating OUD treatment in obstetric practices for pregnant and postpartum women via telemedicine can increase access to care and reduce the consequences of OUD. Evaluation of this care delivery model, however, is needed before widespread adoption.

PURPOSE: A telehealth oncology practice was created to care for patients in rural communities to improve access to health care, decrease financial burdens, and save time. PATIENTS AND METHODS: Patients with cancer at Sevier Valley Hospital in Richfield, Utah, were treated with a real-time video-based telehealth program under the care of an oncologist at a tertiary medical center. Data on financial savings, travel hours, mileage avoided, carbon emissions reduced, and revenue retained by Sevier Valley Hospital were collected from 2015 to 2018. RESULTS: From 2015 to 2018, 119 patients with cancer in Richfield, Utah, were treated with telehealth for oncology visits, accounting for 1,025 patient encounters. On average, patients saved 4 hours and 40 minutes and 332 miles roundtrip per encounter. In total, patients’ savings were estimated to be $333,074. Carbon emissions were reduced by approximately 150,000 kg. Of new patient referrals, 59% were for solid tumors (70 of 119 referrals; 42 metastatic and 28 nonmetastatic cancers), and 41% were hematology consultations (49 of 119 referrals; 28 classical and 21 malignant hematologic conditions). We estimate that Sevier Valley Hospital retained $3,605,500 in revenue over this 4-year period.

In 2020, the Centers for Medicare & Medicaid Services reimbursement structure was relaxed to aid in the rapid adoption nationally of telemedicine during the COVID-19 pandemic. Due to limited access to internet service, cellular phone data, and appropriate devices, many patients may be excluded from telemedicine services. In this study, we present the findings of a survey of patients at an urban primary care clinic regarding their access to the tools needed for telemedicine before and after the COVID-19 pandemic. Patients provided information about their access to internet services, phone and data plans, and their perceived access to and interest in telemedicine. The survey was conducted in 2019 and then again in September of 2020 after expansion of telemedicine services. In 2019, 168 patients were surveyed; and in 2020, 99 patients participated. In both surveys, 30% of respondents had limited phone data, no data, or no phone at all. In 2019, the patient responses showed a statistically significant difference in phone plan types between patients with different insurance plans (p < 0.10), with a higher proportion (39%) of patients with Medicaid or Medicaid waiver having a prepaid phone or no phone at all compared with patients with commercial insurance (26%). The overall awareness rate increased from 17% to 43% in the 2020 survey. This survey illustrated that not all patients had access to devices, cellular data, and internet service, which are all needed to conduct telemedicine. In this survey, patients with Medicaid or Medicaid waiver insurance were less likely to have these tools than those with a commercial payor. Finally, patients' access to these telemedicine tools correlated with their interest in using telemedicine visits. Providing equitable telemedicine care requires attention to and mitigation strategies for these gaps in access.

Despite widespread interest in the use of virtual (ie, telephone and video) visits for ambulatory patient care during the COVID-19 pandemic, studies examining their adoption during the pandemic by race, sex, age, or insurance are lacking. Moreover, there have been limited evaluations to date of the impact of these sociodemographic factors on the use of telephone versus video visits. Such assessments are crucial to identify, understand, and address differences in care delivery across patient populations, particularly those that could affect access to or quality of care.

The growth and evolution of telehealth are opening new avenues for efficient, effective, and affordable pediatric health care services in the United States and around the world. However, there remain several barriers to the integration of telehealth into current practice. Establishing the necessary technical, administrative, and operational infrastructure can be challenging, and there is a relative lack of rigorous research data to demonstrate that telehealth is indeed delivering on its promise. That being said, a knowledge of the current state of pediatric telehealth can overcome many of these barriers, and programs are beginning to collaborate through a new pediatric telehealth research network called Supporting Pediatric Research on Outcomes and Utilization of Telehealth (SPROUT). In this report, we provide an update on the landscape of pediatric telehealth and summarize the findings of a recent SPROUT study in which researchers assessed pediatric telehealth programs across the United States. There were >50 programs representing 30 states that provided data on their implementation barriers, staffing resources, operational processes, technology, and funding sources to establish a base understanding of pediatric telehealth infrastructure on a national level. Moving forward, the database created from the SPROUT study will also serve as a foundation on which multicenter studies will be developed and facilitated in an ongoing effort to firmly establish the value of telehealth in pediatric health care.

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Informed consent is among the biggest challenges in recruiting participants for clinical research studies. Researchers face many challenges in conducting clinical trials, some of which include budgetary restrictions, lack of trained personnel, and difficulty recruiting study participants—particularly minorities and participants from rural communities.

As advancements in technology and telecommunications provide us with infinite ways to close the distance between people, it has also led to the development of telemedicine and tech- nologies to give greater health care access to patients in remote areas. Similarly, telesurgery has offered surgeons opportunities to collaborate and mentor trainees without restrictions of ge- ography. Sophisticated technologies such as virtual reality learning systems, augmented reality technology, and haptic feedback have also emerged as promising methods of surgical training that are becoming increasingly more common in surgical training. In this review, we explore the topic of telesurgery, telementoring, and telemedicine, and dis- cuss the recent advancements of engineering and technology in this fast-growing field.

This chapter explores the specific technologies that enable telehealth services in the areas of evaluation, monitoring, consultation, treatment, and care coordination. Historical, current, and future state applications are explored through case examples as a way to demonstrate technical functionality and capabilities. The foundational underpinning of broadband networks and the technological processes supported through telehealth vendors are presented. Additional discussions present examples of established systems, areas where interoperability is functional and the need for advancements in HIT technologies to better address security protocols and validate health analytics.

Background. Artificial intelligence (AI) intends to support clinicians’ patient diagnosis decisions by processing and identifying insights from multimedia patient information. Objective. We explored clinicians’ current decision-making patterns using multimedia patient information (MPI) provided by AI algorithms and identified areas where AI can support clinicians in diagnostic decision-making. Design. We recruited 87 advanced practice nursing (APN) students who had experience making diagnostic decisions using AI algorithms under various care contexts, including telehealth and other healthcare modalities. The participants described their diagnostic decision-making experiences using videos, images, and audio-based MPI. Results. Clinicians processed multimedia patient information differentially such that their focus, selection, and utilization of MPI influence diagnosis and satisfaction levels. Conclusions and implications. To streamline collaboration between AI and clinicians across healthcare contexts, AI should understand clinicians’ patterns of MPI processing under various care environments and provide them with interpretable analytic results for them. Furthermore, clinicians must be trained with the interface and contents of AI technology and analytic assistance.

COVID-19 has had a significant effect on healthcare resources worldwide, with our knowledge of the natural progression of the disease evolving for the individual patient. To allow for early detection of worsening clinical status, protect hospital capacity and provide extended access for vulnerable patients, our emergency department developed a remote patient monitoring programme for discharged patients with COVID-19. The programme uses a daily emailed secure link to a survey in which patients submit biometric and symptoms data for monitoring. Patients’ meeting criteria are escalated to a physician for a phone or video visit. Here, we describe the development, implementation and preliminary analysis of utilisation of the programme.

The release of final rules from the Office of the National Coordinator for Health Information Technology’s (ONC) Cures Act in March 2020 places a new focus on patients’ access to their health data.1 The ONC rules make “health data more computable and [give] patients more control of their medical record.”1 Hopefully, patients will be able to interact more easily with their data through patient portals and mobile health apps, and “shop for care by comparing costs, understanding possible treatments, and expected health outcomes.”1 The new rules intend to increase the pace of innovation and investment in patient-facing tools. Building on more than 300 000 health apps and $7.4 billion in digital health investments in 2019 alone, this policy environment may significantly transform the ways patients access care.2

The COVID-19 pandemic forced most U.S. healthcare systems to quickly pivot to virtual care. However, since peaking in late April, care has largely shifted back to in-person. Health systems are now challenged to further develop and integrate useful, usable, and sustainable virtual care tools into their broader care model in ways that benefit their organizations and the communities they serve.

South Carolina Governor, Nikki Haley signed the South Carolina Telemedicine Act (S.B. 1035) into law, on June 3, 2016, establishing new telemedicine practice standards in the Palmetto State.

A Practice Agreement is a written agreement between an APRN and a physician or medical staff physicians that outlines the scope of medical acts the APRN will perform pursuant to the agreement, including prescribing of medications. Practice Agreements must also include mechanisms for the physician to maintain responsibility for the quality of care and patient safety.

The Centers for Medicare and Medicaid Services (CMS) and the Medicare program have greatly set the standard for the federal government’s approach to telehealth reimbursement. Among other things, Medicare has maintained narrow restrictions that limit the type of services that can be reimbursed, and the geographic location where services can take place.

Anticipating a growing need for health care during the COVID-19 pandemic, the Centers for Medicare and Medicaid Services expanded telemedicine coverage in the United States on March 6, 2020. In this study we used roughly thirty million Medicare fee-for-service claims to quantify outpatient telemedicine use before and after the Medicare telemedicine coverage waiver and to examine the association of telemedicine use with the Area Deprivation Index, a comprehensive measure of neighborhood socioeconomic disadvantage. Before the waiver, 0.42 percent of patients had at least one outpatient telemedicine visit, with no significant differences between people residing in the most versus the least disadvantaged neighborhoods. With the waiver, 9.97 percent of patients had at least one outpatient telemedicine visit, with the highest odds of utilization seen for people residing in the most disadvantaged neighborhoods. After adjustment, our data suggest that the coverage waiver increased access to telemedicine for all Medicare populations, including people residing in the most disadvantaged neighborhoods, although the odds of use were persistently lower with increasing age. Overall, these findings are encouraging, but they illuminate a need for targeted interventions to improve telemedicine access further.

Telemedicine use has exploded during the past two years, but it has done so without sufficient attention to disparities by payer, age, race and ethnicity, income, English language proficiency, and geography. The process of designing permanent, postpandemic telehealth policies must center on equity. Current conversations on equity have focused on broadband access and payment parity between telemedicine modalities (audio only and audiovisual) and in-person care. However, creating telehealth policies that ensure equity will require a more comprehensive, cautious approach that acknowledges the unknowns about how to implement telemedicine to improve health, addresses the multilevel barriers to equity, and reconsiders the purpose and value of telemedicine.

We undertook a qualitative study to examine and compare the experience of ethical principles by telehealth practitioners and patients in relation to service delivery theory. The study was conducted prior to and during the recent global increase in the use of telehealth services due to the COVID-19 pandemic. We conducted semi-structured interviews with 20 telehealth practitioners and patients using constructionist grounded theory methods to collect and analyse data. Twenty-five axial coded data categories were then unified and aligned through selective coding with the Beauchamp and Childress (2013) framework of biomedical ethics. The groups were then compared. Thirteen categories aligned to the ethical framework were identified for practitioners and 12 for patients. Variance existed between the groups. Practitioner results were non-maleficence 4/13 or (31%), beneficence 4/13 (31%), professional-patient relationships 3/12 (22%), autonomy 1/13 (8%) and justice 1/13 (8%). Patient data results were non-maleficence 4/12 (33%), professional-patient relationships 3/12 (33%), autonomy 2/12 (18%), beneficence 1/12 (8%) and justice 1/12 (8%). Ethical principles are experienced differently between telehealth practitioners and patients. These differences can impact the quality and safety of care. Practitioners feel telehealth provides better care overall than patients do. Patients felt telehealth may force a greater share of costs and burdens onto them and reduce equity. Both patients and practitioners felt telehealth can be more harmful than face-to-face service delivery when it creates new or increased risk of harms. Building sufficient trust and mutual understanding are equally important to patients as privacy and confidentiality.

Introduction: Healthcare is experiencing significant disruptive innovation with the use of technology, including telemedicine and virtual modalities to deliver care. These new models can dramatically improve access to care and reduce healthcare disparities for patients, especially in underserved and vulnerable populations like children. Problem: To assure diffusions and retention of new approaches they must be assessed for economic value. However, measuring telehealth programs using only an institutional financial viewpoint fails to convey all the societal value of such interventions, so economic studies of telehealth are needed but complex to design. Methods: We reviewed economic study guidelines, details from telehealth study research protocols, IRB submission questions, and telehealth study design literature. We then used an iterative consensus process to develop a framework for measuring value of virtual care at the societal level. Results: The work produced a set of tools that are useful for designing studies for measuring value of virtual care at the societal level. The framework and tools are presented in this report. Conclusion: The conceptual framework for economic evaluation was feasible for use when applied to measure pediatric telehealth value.

The novel coronavirus disease 2019 infection poses serious challenges to the healthcare system that are being addressed through the creation of new unique and advanced systems of care with disjointed care processes (eg, telehealth screening, drive-through specimen collection, remote testing, telehealth management). However, our current regulations on the flows of information for clinical care and research are antiquated and often conflict at the state and federal levels. We discuss proposed changes to privacy regulations such as the Health Insurance Portability and Accountability Act designed to let health information seamlessly and frictionlessly flow among the health entities that need to collaborate on treatment of patients and, also, allow it to flow to researchers trying to understand how to limit its impacts.

Despite the availability of a streamlined telehealth credentialing method called Credentialing by Proxy (CBP), a significant number of hospitals still opt for traditional credentialing. This project seeks to better understand the barriers and benefits to CBP.

Telemedicine diagnoses and treats patients remotely via telecommunications technology all over the world. Telemedicine becomes more prevalent as providers recognize the benefits, patients receive increased access and payers see the reduction in cost of care. Telemedicine studies have shown success in limiting geographical constraints, time spent, and costs incurred by patients with positive health outcomes across medical specialties. The aim of this review is to evaluate the implications of telemedicine and health policies. An assessment of the literature in four databases was made on content germane to health policy implications of telemedicine. From the results of the search, 48 publications were kept for analysis. The fifteen facilitators mentioned most often were increased access, increased convenience, improved population health, care enabled through mobile technology, self-efficacy, increased patient-to-provider communication, cost advantages, efficacy of modality, increased health outcomes, reaches developing countries, increased quality, a positive previous experience, and a secure means of care. The twelve barriers mentioned most often were the increased cost to providers, patient privacy, technical literacy, state licensing, data security, socioeconomics, limited reimbursements, issues of interoperability, patient safety, less personal means of care, misaligned incentives, and ethical concerns. Telemedicine has the potential for growth and adoption, however, there are several implications and barriers of health policy surrounding telemedicine that make it difficult to adopt. Policies will likely encourage and incentivize its spread and use. Future research should focus on standardization of telemedicine and new policies and incentives that encourage its use.

The purpose of this article is to present a training program that prepares students with the unique skill set necessary to conduct telehealth visits.

To describe the development, implementation, and assessment of simulated interprofes- sional education (IPE) telehealth case activities.

In this descriptive, qualitative study, we conducted eight focus groups with diverse informal and formal caregivers to explore their experiences/challenges with nursing home (NH) to emergency department (ED) transfers and whether telehealth might be able to mitigate some of those concerns.

Considerable efforts over the last decade have been placed on harnessing technology to improve access to behavioral health services. These efforts have exponentially risen since the outbreak of the Coronavirus disease 2019 (COVID-19), which has prompted a move to novel systems of care, largely based on telehealth delivery. This article aims to provide a broad review of evidence for telehealth assessment and treatment of externalizing disorders and internalizing disorders in children and discuss practice considerations and established guidelines for telehealth delivery. Existing literature supports the promise of behavioral health interventions including behavioral parent training and combination approaches for externalizing disorders as well as cognitive-behavioral based interventions for internalizing disorders. There is a scarcity of work on assessment via telehealth compared with the available treatment literature. While treatment may be most pressing given the COVID-19 circumstances to continue delivery of care, movement toward establishing evidence-based assessment via telehealth will be of increased importance. Lastly, practice guidelines have been set forth by national associations, professional societies, and supported by the development of national Telehealth Centers of Excellence. These guidelines and practice considerations are discussed within the context of COVID-19.

Since 2003, the University of Mississippi Medical Center has operated a robust telehealth emergency department (ED) network, TelEmergency, which enhances access to emergency medicine-trained physicians at participating rural hospitals. TelEmergency was developed as a cost-control measure for financially constrained rural hospitals to improve access to quality, emergency care. However, the literature remains unclear as to whether ED telehealth services can be provided at lower costs compared with traditional in-person ED services. Our objective was to empirically determine whether TelEmergency was associated with lower ED costs at rural hospitals when compared with similar hospitals without TelEmergency between 2010 and 2017. A panel of data for 2010–2017 was constructed at the hospital level. Hospitals with TelEmergency (n = 14 hospitals; 112 hospital-years) were compared with similar hospitals that did not use TelEmergency from Arkansas, Georgia, Mississippi, and South Carolina (n = 102; 766 hospital-years), matched using Coarsened Exact Matching. The relationship between total ED costs and treatment (e.g., participation in TelEmergency) was predicted using generalized estimating equations with a Poisson distribution, a log link, an exchangeable error term, and robust standard errors. After controlling for ownership type, critical access hospital status, year, and size, TelEmergency was associated with an estimated 31.4% lower total annual ED costs compared with similar matched hospitals that did not provide TelEmergency. TelEmergency utilization was associated with significantly lower total annual ED costs compared with similarly matched hospitals that did not utilize TelEmergency. These findings suggest that access to quality ED care in rural communities can occur at lower costs.

Burn-injured patients must frequently travel long distances to regional burn centers, creating a burden on families and impairing clinical outcomes. Recent federal policies in response to the coronavirus pandemic have relaxed major barriers to conducting synchronous videoconference visits in the home. However, the efficacy and benefits of virtual visits relative to in-person visits remained unclear for burn patients. Accordingly, a clinical quality assurance database maintained during the coronavirus pandemic (3/3/2020 to 9/8/2020) for virtual and/or in-person visits at a comprehensive adult and pediatric burn center was queried for demographics, burn severity, visit quality, and distance data. A total of 143 patients were included in this study with 317 total outpatient encounters (61 virtual and 256 in-person). The savings associated with the average virtual visit were 130 ± 125 miles (mean ± standard deviation), 164 ± 134 travel minutes, $104 ± 99 driving costs, and $81 ± 66 foregone wage earnings. Virtual visit technical issues were experienced by 23% of patients and were significantly lower in pediatric (5%) than in adult patients (44%; P = .006). This study is the first to assess the efficacy of synchronous videoconference visits in the home setting for outpatient burn care. The findings demonstrate major financial and temporal benefits for burn patients and their families. Technical issues remain an important barrier, particularly for the adult population. A clear understanding of these and other barriers may inform future studies as healthcare systems and payors move toward improving access to burn care through remote healthcare delivery services.

INTRODUCTION The need for oral health resources in the school setting is an integral part of the overall health of students. Studies have shown that not only do school nurses encounter dental emergencies in students, but they encounter children in pain more frequently than not due to oral cavity issues. Therefore, this study sought to examine the current knowledge and accessibility of oral health resources for nurses serving school-aged children. METHODS Guided by an ecological framework, this study surveyed South Carolina school nurses (n= 42) about their access to oral health resources, knowledge of their students’ dental health status and unmet needs, and challenges associated with receiving dental care. RESULTS Two-thirds of school nurses saw urgent dental cases at least once a semester. Three quarters of the school nurses made referrals to a dentist at least once a semester. Half of the school nurses offered an annual dental screening. As a part of continuing dental care, referral completion for school-aged children was a challenge due to social determinants. DISCUSSION This study directly aligns with the forthcoming 2020 Surgeon General Report on Oral Health, which includes a section on ‘Oral Health Integration, Workforce and Practice’. This study reveals how school nurses are on the forefront of addressing children’s health needs and their ability to contribute to the integrated oral healthcare workforce. CONCLUSION Overall, a need exists to continue to elevate school nurses as interprofessional oral health practice champions to improve the oral health of children in South Carolina public schools.

Despite a robust health care system in the United States, many Americans experience health care disparities as a result of poor access to medical care. In South Carolina, 43 of its 46 counties are designated as fully or partially Medically Underserved Areas (MUAs). To address these health care disparities, an academic medical center in South Carolina created a hub-and-spoke specialty care model using telemedicine in partnership with primary care providers across community settings.