The 50 States of Digital Health Policy Innovation: Ten Pillars of a Comprehensive Advocacy Strategy
Jess Boyle BS
Children's Hospital of Philadelphia
Primary Email:boylej4@chop.edu
Background: The rapid growth of telehealth during the COVID-19 pandemic and subsequent post-PHE (public health emergency) permanent legislation exposed disparities in state-level digital health policies, resulting in inconsistencies in access, reimbursement, and care models. While federal initiatives provided a foundation for virtual care expansion, fragmented state policies continue to hinder scalability and equity. This abstract and presentation examines trends in state-level digital health policy innovations to identify key enablers of virtual care growth. By analyzing best practices and barriers, this work presents a comprehensive advocacy strategy that emphasizes equitable access, supports diverse care models, and integrates patient-centric telehealth-enabling language into policy frameworks. This presentation aims to equip virtual care and policy leaders with actionable insights for fostering sustainable and inclusive digital health ecosystems.
Methods: A mixed-Methods: approach was used to analyze state-level digital health policy innovations since the conclusion of COVID-19-related public health emergency flexibilities. A policy innovation index assessed performance across five domains: reimbursement parity, licensure portability, geographic flexibilities, patient access and ease of use, and regulatory support for diverse virtual care models. Legislative data from all 50 states were collected and verified. Particular focus was given to provisions supporting various virtual care models, including asynchronous telehealth, remote patient monitoring, and hybrid care approaches. Additionally, semi-structured interviews with policymakers, health care executives, and patient advocates explored barriers and enablers of digital health policy adoption. Findings were synthesized into a top 10 list of policy innovations that virtual care leaders should prioritize, supported by an advocacy framework emphasizing evidence-based virtual care models, patient-centricity, reimbursement considerations, and operational scalability.
Results: The analysis revealed substantial variability in policy innovation among states. High-innovation states excelled in integrating reimbursement parity, licensure compacts, geographic flexibilities, and patient-centric telehealth-enabling language while supporting diverse care models. Moderate-innovation states progressed in areas like patient access but lacked comprehensive strategies or enabling provisions. Low-innovation states faced political complexities, insufficient provider-government collaboration, and resistance from payers. Key enablers of success included bipartisan legislative support, alignment with federal initiatives, and robust stakeholder engagement. States encountering challenges cited limited telehealth education for policymakers and competing fiscal or policy advancement priorities. Research reinforced the importance of patient-centric language, including clear coverage mandates and requirements for payment parity, as critical pillars. States with higher policy innovation scores correlated with improved access, greater virtual care adoption, enhanced clinical innovation, and broader utilization of telehealth services.
Discussion: Findings highlight the urgent need for a unified, scalable advocacy strategy to address disparities in state-level telehealth policies. The proposed framework includes four pillars: (1) evidence-based policymaking using data on telehealth’s economic & clinical benefits; (2) coalition-building to amplify advocacy across diverse stakeholders; (3) integration of patient-centric telehealth-enabling language to prioritize equitable access and engagement; and (4) inclusion of provisions supporting diverse virtual care models, such as asynchronous care, hybrid visits, and remote monitoring, with location-agnostic considerations across the care continuum. This presentation will feature a top 10 list of policy innovations that virtual care and policy leaders must advocate for, offering actionable insights to drive equity, access, and sustainability in telehealth. Attendees will gain practical tools to navigate the evolving policy landscape and champion digital health innovation in their state.
Implementation of a Virtual Nursing Program to Address Nurse Burnout in an Adult Med/Surg Unit
Briana Petty MSN RN, Bethany Smith BSN RN CMSRN, Lindsey Kuiper PhD, Yueh-Yun Lin PhD, Kristina Cherry PhD, Saurabh Chandra MD PhD MBA
University of Mississippi Medical Center
Primary Email:bpetty@umc.edu
Background: Nurse staffing shortages remain a national challenge, with Mississippi facing particularly high vacancy and turnover rates, leading to increased burnout and potential for adverse patient outcomes. During the COVID-19 pandemic, 62% of nurses reported heightened levels of burnout due to staffing strain (American Nurses Association, 2020). In response, the University of Mississippi Medical Center (UMMC) initiated a Virtual Nursing Program to alleviate the bedside nurse workload and improve retention. The objectives for setting the program were multifold: 1. Reduce bedside nurse workload by assigning non-physical care tasks to virtual nurse. 2. Enhance patient-centered care through efficient admissions, discharges, and educational support. 3. Improve staff satisfaction and retention by alleviating workplace stress and fostering a supportive care environment.
Methods: UMMC initiated a Virtual Nursing Pilot in a 14-bed adult Med/Surg unit in March 2023. A dedicated virtual nursing hub was established in the hospital and equipped with two monitoring stations that allowed the virtual nurse to communicate with patients via two-way audio-video. In-room setup included PTZ cameras, iPads for patients, and audio system for direct communication. The virtual nursing hub was staffed with Virtual nurses from 9am to 9pm, seven days a week. Virtual RNs used secure chat and in-basket messages to communicate with the bedside care team and Epic EMR to manage tasks remotely, focusing on admissions, discharges, pain reassessment, safety checks, and patient education. Clinical workflows specific for virtual nurses were developed and training was provided to newly hired virtual nurses prior to activation of the program. Clinical workflows specific for virtual nurses were developed and training was provided to newly hired virtual nurses prior to activation of the program. A satisfaction questionnaire was given to the nursing staff before and six- and one-year post-implementation. Additionally, patient surveys were obtained prior to discharge by sending a link to the i-pads.
Results: Since implementation, every admission and discharge process handled by the virtual nurse saved 38 minutes and 31 minutes of the bedside nurse’s time for a cumulative total of 540 hours saved. Among the staff at the unit, the satisfaction rate with the admission process increased from 53.84% (n=7) before implementation to 92.86% (n=13) after 1 year of implementation. The satisfaction rate with the discharge process increased from 38.46% (n=5) to 78.57% (n=11) after 1 year of implementation. The satisfaction rate with the hourly nurse rounding process slightly increased from 69.23% (n=9) to 64.28% (n=9). Most importantly, the satisfaction rate with workload increased from 53.85% (n=7) to 78.57% (n=11). Reponses from the patients (n=42) demonstrated that 76.19% understood the role of virtual nurses, 77.50% preferred to receive coordinated care from the virtual nurse and bedside nurse for future visits, and 80.95% reported that communication with the virtual nurse was easy. Most importantly, since implementation, none of the bedside nurses in the unit have left their job.
Discussion: The Virtual Nursing Program at UMMC has shown promise in reducing nurse workload, and enhancing patient satisfaction. The planned integration of AI and predictive analytics will further advance patient safety and operational efficiency. This program could serve as a model for health care systems nationwide, addressing critical nursing staffing challenges with innovative technology and supportive care structures.
Telehealth Education Improves First Medical Contact Care and Acute Care
Lori Berry MNSc RN CNOR1, Amanda Johantgen RN Paramedic1, Renee Joiner BSN RN1, Austin Porter DrPH MPH2, Bala Simon MD Dr PH MPH FAAFP2, David Vrudny MPH CPHQ2, Sanjeeva Onteddu MD FAHA1, Krishna Nalleballe MD FAHA1, Thomas Pait MD1, Aliza Brown PhD FAHA TTS1
1University of Arkansas for Medical Sciences 2Arkansas Department of Health
Primary Email:BerryLori@uams.edu
Background: Telestroke programs have the capacity of providing advanced neurological care to disadvantaged areas for health care. However, care begins at first medical contact (FMC) performed by paramedics during field triage. The University of Arkansas for Medical Sciences (UAMS) Institute for Digital Health and Innovation (IDHI) –teleStroke Program has provided stroke recognition and protocol guidelines since 2015 to paramedics across the state. To determine the efficacy of care from FMC, we examined the transport mode of all telestroke consults from 2019 to 2023 on time metric analysis of door to CT (D2CT) time.
Methods: Retrospective analysis by calendar years 2019 to 2023 were reviewed for yearly numbers of consults treated with thrombolytics by the UAMS IDHI –teleStroke Program. Transport mode upon arrival by privately operated vehicles (POV) or Emergency Medical Services (EMS) were recorded. Emergency Medical Services protocols included pre-notification of the hospital during cases of suspected stroke and were noted during the review. Chi Square and ANOVA were used for analysis.
Results: Between 2019 to 2023, a total of 3,021 consults received thrombolytic treatment, 38.6% arrived via POV and 61.4% by EMS transport, p< 0.0001. Those arriving by EMS, 81.6% had pre-notification prior to arrival. Mean D2CT time in POV transports was 22.2±0.8 minutes, EMS without and with pre-notification D2CT were 22.0±1.4 and 9.3±0.3 minutes, respectively. Transport with EMS pre-notification significantly decreased D2CT time vs. without pre-notification and POV, p< 0.0001. There was no difference in D2CT time with POV vs. EMS without pre-notification, (22.2 vs. 22.0) p=0.90. With the exception of 2020, all years 2019 to 2023 were consistent in percentages of transport mode, for POV and EMS without pre-notification; POV 41.5%, 24.6%, 40.9%, 40.3% and 39.7%, respectively. Arrivals by EMS without pre-notification during 2019 to 2023 were percentages of 7.9%, 23.4%, 8.5%, 10.6% and 9%, respectively. Percentages of arrivals by EMS with pre-notification during 2019 to 2023 were consistent at 50.6%, 52%, 50.6%, 49.1% and 51.4%, respectively. There were no differences among calendar years for D2CT time in POV, EMS without and with pre-notification.
Discussion: Telehealth education of EMS is essential for stroke recognition and care provided at FMC with suspected cases of stroke by paramedics initiating pre-notification measures and saving critical minutes from D2CT time.
Implementing the Project ECHO Model: Lessons Learned from 8 ECHO Implementation Teams
Katy Allison PhD MPH, Cari Bogulski PhD, Hannah McCoy MPH, Rosario Silva MPH, Hari Eswaran PhD
University of Arkansas for Medical Sciences
Primary Email:kallison@uams.edu
Background: Project ECHO (Extension for Community Healthcare Outcomes) has emerged as a leading virtual learning community model for continuing medical education (CME). Project ECHO uses video-conferencing technology to train, advise, and support clinicians to improve access to specialty treatment in rural and underserved areas. The efficacy and utility of the ECHO model in health care training is well documented, though there is less literature focused on the determinants of ECHO implementation. This qualitative study aimed to assess facilitators and barriers to implementing the ECHO model and identify recommendations for future ECHO implementation.
Methods: We conducted virtual focus groups with eight Project ECHO implementation teams (n = 29 individuals) across the United States. As members of ECHO implementation teams, participants had a range of experience implementing ECHO, with roles such as: project directors; program managers, coordinators, and specialists; faculty experts and facilitators; clinical advisors; and project evaluators and quality improvement leads. Guided by the Consolidated Framework for Implementation Research (CFIR), these focus groups explored experiences implementing the ECHO model, assessed facilitators and barriers to program uptake and sustainability, and elicited recommendations for future ECHO programs. A semi-structured qualitative interview guide examined implementation influences across the five CFIR domains: inner setting, outer setting, characteristics of the individuals involved, innovation characteristics, and the implementation process.
Results: Analysis revealed implementation determinants across CFIR domains. Innovation characteristics included participants recognizing the advantage of ECHO’s virtual, case-based learning approach compared to other CME modalities. Determinants related to characteristics of individuals included recruitment of presenters with subject matter expertise, skills as educators, and understanding of the ECHO model. Implementation process determinants included participants highlighting the importance of balancing didactics with case presentations and Discussion because of Project ECHO’s emphasis on case-based learning. Support from the ECHO Institute was also described as a facilitator in planning for ECHO implementation. Outer setting determinants included scheduling and finding time to participate as challenges for clinician engagement, though most ECHO implementation teams suggested that program length, session frequency, and number of participants can be tailored to ECHO programs to accommodate needs. Additionally, funding was reported as a barrier to sustainability. Inner setting determinants included providing CME credit and setting expectations for attendance and case presentation, both of which were said to improve clinician engagement.
Discussion: This study builds on the growing body of literature documenting implementation determinants of Project ECHO as a telementoring model in health care training. By addressing barriers prior to implementing the ECHO model, future ECHO programs can be tailored to leverage resources, maximize attendance, expand reach, and ultimately improve learning outcomes.
State Licensure Policy Is Associated with Outpatient Telehealth Use in Medicare Beneficiaries
Nicholas Mohr MD MS, J. Priyanka Vakkalanka PhD MPH, Tracy Young MS
University of Iowa Carver College of Medicine
Primary Email:nicholas-mohr@uiowa.edu
Background: State licensure has been cited as a significant barrier to widespread telehealth adoption because of the administrative burden of obtaining medical licensure in host states. In response, states have developed strategies to reduce licensure barriers, such as the Interstate Medical Licensure Compact (IMLC). The IMLC was conceptualized to help streamline the traditional medical license application process for physicians in cooperating states with reduced administrative burden. States further relaxed licensure restrictions during the COVID-19 public health emergency (PHE). There remains a critical need to understand the role of licensure policy on facilitating telehealth availability and use. The objective of this study was to measure the association between state-level policies surrounding telehealth regulation and telehealth utilization between 2018 and 2022 among Medicare beneficiaries.
Methods: We conducted a quasi-experimental study using a 5% sample of age-qualifying Medicare fee-for-service beneficiaries between January 2018 through December 2022. Our exposure was state-level telehealth policy, captured as participation in IMLC and policy relaxation during the COVID-19 PHE. The primary outcome was any telehealth (any-TH), in-state telehealth (IS-TH), and out-of-state telehealth (OOS-TH) utilization, defined by telehealth vs. in-person visits and provider/beneficiary location codes. We divided the sample into the pre-COVID-19 era (January 1, 2018-February 29, 2020) and the COVID-19 era (March 1, 2020-December 31, 2022). For both the pre-COVID-19 and COVID-19 eras, we evaluated the association between state-level policies and any-TH, OOS-TH, and IS-TH through logistic regression, adjusting for patient-level characteristics (i.e., age, sex, race/ethnicity, rural-urban designation) and month/year of the encounter. In the adjusted models for the COVID-19 era, we additionally included the average TH utilization percentage from January 1 – June 30, 2021 within each state at the time of the encounter.
Results: We included 1,682,501 beneficiaries with 141,199,029 outpatient encounters. Of the total outpatient encounters, 137,969,293 (98%) were in-person and 3,229,736 (2%) were telehealth encounters (primary outcome), with a range from 1.0% of visits in South Dakota to 6.4% of visits in Hawaii. Of the total telehealth encounters, 3,037,275 (94%) were in-state and 192,461 (6%) were out-of-state encounters. Demographic characteristics for telehealth visits at the time of the first encounter were consistent over time: women (57%), ages 65-74 (57%), urban (78%), and white (85%). In the pre-COVID-19 era, IMLC participation was associated with an increase in any-TH utilization (aOR: 1.10; 95%CI: 1.07-1.13) and OOS-TH (aOR: 2.24; 95%CI: 2.09-2.40) but was not associated with IS-TH (aOR: 0.98; 95%CI: 0.96-1.01). In the COVID-19 era, we observed an increase in any-TH by IMLC participation (aOR: 1.07; 95%CI: 1.06-1.08) and COVID-19 policy relaxations (aOR: 1.08; 95%CI: 1.07-1.08). While these findings were consistent with IS-TH utilization, we observed a decrease in OOS-TH by IMLC participation (aOR: 0.74; 95%CI: 0.72-0.75) and COVID-19 policy relaxations (aOR: 0.83; 95%CI: 0.81-0.85), potentially attributed to the rise in IS-TH visits.
Discussion: We found that licensure policies are associated with telehealth adoption, highlighting the potential for strategic policy changes to improve health care access and delivery. Variability in IS- and OOS-TH utilization may indicate that while local policies can improve telehealth access, interstate barriers still exist. Our findings underscore the necessity for ongoing evaluation of licensure policies and their effects on telehealth utilization. As telehealth continues to evolve, understanding the implications of policy changes will be crucial for ensuring effective access to care.
Optimizing Virtual and In-Person Care Coordination Between Primary Care and Mental Health Teams
1VA Palo Alto Health Care System Menlo Park Division, Center for Innovation to Implementation 2VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy 3VA Greater Los Angeles Healthcare System, Center for the Study of Healthcare Innovation, Implementation 4Syracuse VA Medical Center, Center for Integrated Healthcare; Syracuse University, Department of Psychology 5University of California Los Angeles David Geffen School of Medicine, Division of General Internal Medicine and Health Services Research
Primary Email:Caroline.Gray@va.gov
Background: Though the COVID-19 pandemic caused severe disruption in health care services delivery, there was surprisingly little interruption of coordinated primary care and mental health services in the Veterans Health Administration (VA). Patient care access was maintained thanks to a rapid transition from in-person to virtual care. In the VA, primary care teams include embedded specialists to provide mental and behavioral health services. These Primary Care-Mental Health Integration (PCMHI) models facilitate timely access to effective mental health treatments, including same-day warm handoffs from primary care providers to integrated mental health specialists when a need is identified. This study sought to understand the impact of the pandemic-driven shift to virtual care on depression assessment and treatment and to explore provider-identified ways to optimize hybrid (virtual/in-person) integrated mental health care for primary care patients with depression.
Methods: We purposefully sampled and interviewed 46 primary care providers and integrated mental health specialists across three geographically diverse VA health care systems that included a total of 29 clinics. Interview participants represented a range of clinical roles, including medical physicians, psychiatrists, psychologists, social workers, nurses, and others. Interviews were conducted between January 2024 and July 2024 and lasted approximately 30 minutes. With permission from interview participants, interviews were audio-taped and later transcribed by a professional transcription service. Interview questions focused on characterizing changes to depression care pathways following the pandemic and best practices for hybrid (virtual/in-person) care delivery in the VA, based on Fortney et al’s Reconceptualized (Digital) Access Framework. Interview transcripts were coded and analyzed for themes using ATLAS.ti, a qualitative software program designed to facilitate data analysis.
Results: Participants indicated that post-pandemic use of virtual care helped increase Veteran access to depression treatment. Particularly, they cited an open-grid model, where integrated mental health providers cover clinics across a health care system by offering telephone or video visits to patients at other sites. Primary care and mental health coordination for warm handoffs appeared to work well, with providers switching from in-person (pre-pandemic) to virtual communication (e.g., instant messaging). Nevertheless, some primary care providers wished for more opportunities for in-person warm handoffs. When asked about the optimal mix of in-person and virtual depression care, there was some indication that primary care providers thought the initial assessment should be done in person, especially for patients presenting more complicated cases, including risk for suicidality and other co-occurring conditions. Ongoing care, namely cognitive behavioral therapy and medication management, was thought to be ideal for virtual delivery. Above all, participants emphasized the need for offering Veteran-centric care, or care that “meets the Veterans where they are” and encourages them to continue engagement in mental health care.
Discussion: Virtual expansion of primary care-based mental health care was felt by providers to have mitigated access barriers or even increased overall access for veterans with depression. However, an important role for in-person care remains and was often advocated by primary care providers. Care coordination between primary care and mental health was perceived as positive, despite a rapid transition to hybrid virtual and in-person care. Findings support that efforts to identify the optimal mix of in-person and virtual care should consider care availability alongside both providers’ and individual patients’ needs and preferences. Further research is needed that examines the quality of virtual and in-person primary care-based mental health care, as well as patient satisfaction and experiences with these care modalities.
Same Day/Next Day Cancer Care: Improving Patient Access Through Virtual First Appointment Approach
Amy Wright MSN RN
Jefferson Health
Primary Email:amy.wright@jefferson.edu
Background: There is a critical shortage of access for patients. Even in the absence of acute medical conditions, there are some cohorts of patients where waiting for care leads to increased stress and anxiety. Patients with newly diagnosed cancer are one group of patients where expedited care can help reduce anxiety. In many communities, patients with newly diagnosed cancer wait weeks for their first appointment with an oncologist. During this time, they do not have anyone to place their mind at ease or guide the patient through their journey. We created a Same Day/Next Day Cancer Care program aimed to expedite patient appointments, ease anxiety related to a new cancer diagnosis, have treatment started sooner and improve patient outcomes.
Methods: The Same Day/Next Day Cancer Care program was developed by following a set of guiding principles targeting patients with a new diagnosis of cancer. Principles included an enterprise approach, expansion of same day/next day and after-hours access, a dedicated virtual approach with advanced practice clinicians (APC) support, defined clinical pathways as well as collaboration with enterprise central scheduling. Subject matter experts from the enterprise engaged to develop workflows related to patient scheduling, recruitment, licensure and credentialing, APC operations, workflow, clinical pathways and physician collaboration, referrals and provider communication Methods:, compliance and billing. Program foundation was the work done by the APCs and disease specific leads regarding clinical pathways. They developed comprehensive pathways for patient care, additional testing needed and handoff communication to the specialty physician. The primary outcome of the program was to reduce the average lag time (in days) to specialty cancer physician for patients with a new cancer diagnosis. Secondary outcomes included time to oncology specialty, infusion commencement or surgery.
Results: Starting June 3, 2024, 342 patients had telemedicine visits by the Same Day/Next Day Cancer Care APCs. Patients ranged in age from 24 to 96, 62 being the average age. The program saw 58% (198) female patients and 42% (144) male. Patients that were seen through this program had new cancer diagnosis, incidental findings as well as newly diagnosed anemia. Of the 342 patients 77% (265) completed a follow up appointment with a specialty oncology physician (66% medical oncology, 31% surgical oncology, remaining 3% with radiation oncology, palliative care or hematology). Of the remaining patients, 7% (24) are scheduled for specialty follow up, 6% (21) cancelled follow up and 10% (33) did not require any additional follow up after APC guided testing. For those patients who completed follow up, the average scheduled lag time (in days) to APC appointment was 1.39 days. The average time from APC appointment to specialty oncology physician was 12.03 average days for medical oncology and 7.88 average days for surgical oncology. Downstream impacts related to APC appointment to first chemotherapy infusion and/or surgical intervention will be presented.
Discussion: Based on the data collected from June through October 2024, patients with new cancer diagnosis seen through the Same Day/Next Day Cancer Care program have had expedited appointments with experienced oncology providers (APC). APC providers have assessed the patient’s current needs (physical, psycho-social, financial etc.), ordered additional testing, ensured physician readiness and follow up appointments with the correct next step specialty physicians. This program has also led to expedited next steps with the right specialty cancer physician.
Virtual Checkout: Streamlining Patient Discharge Through Telehealth Innovation
Tony Fabiano MD
Jefferson Health
Primary Email:tonyfabianomd@gmail.com
Background: In April 2024, Jefferson Health launched the Virtual Checkout™ program within its 19-story outpatient facility, revolutionizing patient discharge by streamlining processes and improving patient experience. Traditional discharge processes are often cumbersome, leading to long wait times, reduced patient satisfaction, and fragmented care coordination. Virtual Checkout™ addresses these inefficiencies by leveraging telehealth to connect patients with remote checkout agents via touch-screen digital whiteboards, eliminating in-person checkout. This solution provides real-time discharge instruction, follow-up scheduling, and diagnostic appointments from the privacy of the exam room. The program also promotes equity by offering integrated workflows and translation services for non-English speakers and patients with disabilities, improving satisfaction and operational efficiency.
Methods: The Virtual Checkout™ program was developed using a novel integration of telehealth technology, enabling remote, real-time discharge workflows to replace traditional in-person procedures. The system was designed in collaboration with internal IT teams, medical record engineers, and our telehealth vendor, all enabled with proprietary code. Each exam room was equipped with a touch-screen digital whiteboard, allowing patients to initiate Virtual Checkout™ with a button tap to connect with a remote agent via video. The agent manages the patient’s follow-up care, including scheduling appointments and diagnostics. This system uniquely addresses discharge inefficiencies while maintaining care coordination and patient privacy. Piloting ensured smooth integration with clinical workflows, supported by continuous IT and clinical collaboration for seamless medical record integration and patient scheduling coordination. Challenges such as language barriers and room turnover were addressed through workflow optimization and iterative staff training. Since implementation, data on wait times and satisfaction have been tracked to guide ongoing improvements.
Results: The implementation of Virtual Checkout™ has led to significant improvements in patient satisfaction and operational efficiency. Since its April 2024 launch, 55,000 virtual check outs have been performed (now over 600 per day) with a median wait time to connect with a remote agent of 20 seconds, and median call duration of 4 minutes and 26 seconds. Over 9,000 appointments are scheduled per month. These metrics highlight the program's success in reducing delays and streamlining the checkout process. Patients report enhanced convenience, citing the benefit of avoiding front desk checkouts and ease of scheduling follow-ups before leaving. The program has improved patient privacy and satisfaction by allowing direct scheduling during virtual interactions. Staff have reported reduced bottlenecks and improved clinic workflows, along with faster room turnover. Virtual Checkout™ has also enabled matching patients with language-specific agents, critical for a facility serving over 70 languages. The centralized model has optimized resource allocation, reduced scheduling delays, and improved care coordination, especially for in-network services. Ongoing key performance data supports continuous improvement and scaling across Jefferson Health.
Discussion: The Virtual Checkout™ program offers a scalable, telehealth-enabled solution that improves patient experience and operational efficiency. Early success at Jefferson Health supports expansion across more locations, with ongoing refinements based on real-time data and patient feedback. Workflow optimization, language service expansion, and technological enhancements will ensure the program's long-term success and address emerging challenges. Virtual Checkout™ serves as a model for scaling telehealth solutions across diverse health care systems to tackle common operational challenges. The program demonstrates telehealth’s role beyond remote consultations—optimizing clinical workflows, reducing administrative burdens, and delivering connected care across an enterprise. This scalable solution is applicable to a range of health care settings, providing a transformative approach to patient care coordination and discharge processes.
Training Residents on High-Quality Referral Communications and EConsults: A Curriculum Guide
Meaghan Quinn MHSA1, Cassandra Pineda MPH2
1Association of American Medical Colleges and 2Greater New York Hospital Association
Primary Email:mquinn@aamc.org
Background: Health care providers often work in teams across specialties to care for individual patients from routine primary care services to those with complex medical needs. Teams must communicate effectively and efficiently for the benefit of their patients, especially as communication increasingly takes place through electronic modalities.
New tools like enhanced referrals and eConsults have created efficiencies, particularly at the primary-specialty care interface. These tools also have a role in value-based care as they help to promote the right care at the right time with the right provider. However, curricula related to effective referral communication and eConsults is not being widely integrated into residency training in the clinical learning environment (CLE). To address these gaps, the Greater New York Hospital Association (GNYHA) and AAMC Project CORE collaborated to develop a curriculum guide for training residents on effective referrals and eConsults in the ambulatory setting.
Methods: GNYHA and AAMC Project CORE developed the guide along with an advisory group of physician educators and those with expertise in optimizing referral and consultation communication between provider types across different settings.GNYHA and AAMC first developed project goals, leveraging insights from Project CORE and other national referral efforts. Next, a literature review was conducted to identify existing curricula and to understand learners’ experiences with training in this area.GNYHA and AAMC developed an outline for the guide, gathered applicable references and learning tools, and drafted the guide. With feedback from the advisory group, GNYHA and AAMC decided to 1) focus the guide on residents in the ambulatory setting, which resulted in both a more specific and more comprehensive guide, and 2) align the guide’s objectives to ACGME Core Competencies, which allows the guide to bolster an existing learning environment rather that to burden faculty with additional learning objectives. In fall 2024, the final draft was reviewed by the advisory group, GNYHA and AAMC leadership, and AAMC Group on Resident Affairs. The final version was published in the last quarter of 2024.
Results: The guide focuses on three areas:
Principles of General Provider-to-Provider Communication
Principles of High-Quality Referral and eConsult Communication
Principles of Effective Co-Management of Shared Patients Each area includes
a Background: section;
learning objectives (listed below) aligned to ACGME Core Competencies;
sample learning progressions to assess competency and
teaching tips.
Learning objectives:
Describe the characteristics of effective provider-to-provider communication
Define the different communication modalities available for provider-to-provideR communication and understand the types of scenarios in which they are appropriate
Describe the roles of treating and consulting providers in engaging and communicating with patients about referrals and eConsults
Describe the optimal referral process in the ambulatory setting
Discuss the EHR-based tools available to support effective referrals
Demonstrate understanding of an effective eConsult process, including the principles of a high-quality eConsult question and response
Identify the role of each provider in effective co-management of shared patients
Discussion: The curriculum guide was developed to seamlessly integrate optimal referral communications into existing CLEs so aligning learning objectives with ACGME requirements was a priority. Notably, it addresses challenging areas like systems-based practice, which can be difficult to teach residents who can often prioritize the provider-patient relationship. The learning progressions also provide clear examples of interprofessional communication. This guide can be adapted for medical education across the continuum as well as beyond the outpatient setting. Training future providers in innovative communication Methods: is essential to establishing a health workforce skilled in team-based care across disciplines, an increasing trend in the care delivery system. GNYHA and AAMC will leverage our platforms as medical education and academic health system stakeholders to disseminate this guide to faculty seeking to implement or optimize collaboration within and across the health care continuum.
Elements of Successful Video Telemedicine Implementation: Primary Care Provider Perspectives
VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy
Primary Email:cynthia.hou@va.gov
Background: The COVID-19 pandemic has transformed U.S. health care delivery into a hybrid model integrating virtual care. Telemedicine has shown the potential to improve access to care for patients in rural and underserved areas, increase patient satisfaction, and facilitate chronic disease management. However, many health care systems still lack clear, evidence-based guidelines on when to use telemedicine, leading to challenges in widespread adoption. At the Veterans Health Administration (VHA), the integration of video telemedicine in primary care teams faces similar obstacles. This study aims to identify factors that influence the adoption, utilization, and effectiveness of video telemedicine in primary care teams by comparing key elements of successful implementation across high and low video-using sites nationwide.
Methods: We calculated each site’s percentage of video telemedicine visits among total primary care visits from January 2023 to December 2023, ranking VHA medical centers accordingly. Four high and four low video telemedicine-using sites nationwide were selected based on their percentage of video use and site rurality. Using a purposive sampling strategy, we identified primary care providers (PCPs; physicians, nurse practitioners, and physician assistants) from these 8 sites to participate in 30-minute audio-recorded interviews via Microsoft Teams. A total of 18 interviews (11 from high video-using sites, 7 from low video-using sites) were conducted between July 2024 and November 2024. A rapid descriptive analysis initially identified key themes by site video usage for subsequent in-depth analysis. Thematic analysis using both inductive and deductive coding strategies was then used to capture themes grounded in the data while also incorporating a priori concepts derived from the PRISM (Practical, Robust Implementation and Sustainability Model) framework for successful program design and implementation. Atlas.ti (v.24) software was used for qualitative data analysis.
Results: Under PRISM’s intervention design element, participants across sites highlighted the flexibility of video telemedicine for primary care and chronic disease management. PCPs at high video-using sites valued telemedicine as a backup for limited in-person visits and reported better punctuality with virtual appointments. Conversely, PCPs at low video-using sites faced challenges from understaffing and heavy workloads, limiting time for telehealth training. Differences also emerged under PRISM’s implementation and sustainability infrastructure elements. High video-using sites benefitted from telehealth “champions” and supportive provider teams that fostered confidence and proficiency using video technology. In contrast, some low video-using sites relied primarily on telehealth clinical technicians for video telehealth appointments, limiting technical skill development among PCPs. Lastly, under PRISM’s recipient element, teleworking emerged as a key incentive. PCPs at high video-using sites valued having a remote work option at least one day a week, which they felt encouraged telemedicine use, while teleworking was not an option at low video-using sites despite some PCPs expressing a desire for it.
Discussion: These findings underscore the importance of organizational infrastructure and leadership support for sustainable video telehealth integration within the VHA. Successful implementation and sustainability of video telemedicine in primary care settings depend in part on intervention design, implementation and sustainability infrastructure elements, and recipient factors from the PRISM framework. The elements identified in high video-using sites for sustainable telemedicine adoption suggest that targeted organizational strategies and resource allocation can enhance video telemedicine integration across diverse clinical settings.
Applying the PICOTS-ComTeC Framework to Connected Health Clinical Trials in Pediatric Psychology
Eve-Lynn Nelson PhD, Emily Law PhD, E (Alice) Zhang PhD
University of Kansas Medical Center
Primary Email:enelson2@kumc.edu
Background: Pediatric psychology has long championed technology delivery in order to decrease barriers to evidence-based behavioral interventions. There are an increasing number of pediatric psychology clinical trials around a vast array of connected health options to reach children and families at home and in the community (e.g., schools, primary care clinics, etc.) These have been driven by technological advances, movement toward family-centered care, and the COVID-19 pandemic. One challenge to decision making around which clinical trial findings are prioritized to put into practice has been the variability in reporting quality and ambiguous connected health terminology across studies. In the proposed 45 minute presentation, the authors will translate five federally funded clinical trials into the new PICOTS-ComTeC framework (Zrubka et al., 2024) in order to illustrate potential value in pediatric psychology research and highlight challenges unique to pediatric populations.
Methods: Five completed randomized trials will be shared within the PICOTS-ComTeC (population, intervention, comparator, outcome, timing, setting, communication, technology, and context) frameork, a newly developed, flexible, and versatile tool to help the formulation of sufficiently specific and detailed definitions for connected health interventions and related research questions. These pediatric psychology trials span different topics (migraine pain management, insomnia, obesity, teen pregnancy, chronic poor attendance), settings (urban and rural; home and school), and connected technologies (internet-delivered asynchronous, mobile-delivered asynchronous, and telehealth-delivered synchronous). The authors will demonstrate the pros/cons of the PICOTS-ComTeC framework across these connected health RCTs utilizing mixed Methods: approaches and reflecting differences along the community-engaged research continnum.
Results: The authors will present facilitators and barriers in applying the PICOTS-ComTeC framwork with the the five pediatric psychology trials. Framework challenges specific to pediatric research will be highlighted, including: pediatric ethical and safety considerations; measurement of 2generation/whole family outcomes; consideration of developmental factors; and assessment of fidelity to connected health interventions within rural/distant settings. PICOTS-ComTeC descriptions related to trials incorporating new roles (e.g., community health workers) as part of the connected health intervention will be discussed, as well as family digital equity. The authors will describe component profile analysis related to the pediatric pain trial, a unique method for identifying core treatment components of evidence-based treatments and how findings informed the adaptation of a sequenced internet intervention program. PICOT-ComTeC framework will also be discussed in relation to sustainability.
Discussion: WIth connected health research examples drawn from five diverse pediatric psychology clinical trials, the authors will compare and contrast the utility of the PICOTS-ComTeC framework with related frameworks and models, summarizing specific needs associated with pediatric clinical trials. They will conclude with a Discussion of how using the PICOTS-ComTeC framework can help researchers convey the complexities and relevance of their findings across decision-makers as connected health technologies evolve. They will describe this process in tandem with dissemination science and communications best practices. They conclude with a summary of how connected health research in pediatric psychology can be advanced with such frameworks, with the hope of more effectively sharing actionable Results: for clinicians and communities and driving better outcomes for all children and families.
Distinguishing Implementation Strategies Among Primary Care Sites with High and Low Video Use
Briana Lott MPH, Cynthia Hou MS, Sona Hovsepian LCSW, Danielle Rose PhD, Lucinda Leung MD PhD, Claudia Der-Martirosian PhD
VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy
Primary Email:briana.lott@va.gov
Background: With the onset of the COVID-19 pandemic, Veterans Health Administration (VA) primary care (PC) experienced a substantial increase in telehealth appointments, including video-based encounters. Despite nationwide expansion of video-based services in primary care, uptake of video-based visits varied by each medical facility at the VA. Guided by the Non-Adoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) implementation framework, the objective of this study was to identify implementation strategies that distinguished between VA medical facilities with high vs low video use, two years after the onset of the COVID-19 pandemic. The study findings provide insights on how to facilitate the implementation and continued use of video-based telehealth services in primary care at all medical facilities at the VA and other health care systems.
Methods: We conducted interviews with providers and staff at select sites to gauge experiences with video-based PC visits, using an interview guide informed by the NASSS framework. To identify sites, we applied a positive and negative deviance approach to select the highest and lowest 10% of video telehealth utilizing PC sites from 130 VA medical centers nationally in 2022, resulting in 26 sites (13 high, 13 low) for possible recruitment. To identify interviewees, we used a purposive sampling strategy, conducting 30-minute interviews (8/16/2022-10/4/2022) with PC team members (physicians, nurses, clinical pharmacists, social workers, mental health specialists, scheduling clerks, local PC leadership) from 5 high and 5 low sites. We then employed five a priori NASSS domains (1.patient condition/illness, 2.technology, 3.adopter system, 4.health care organizations, 5.adaptation over time) to direct content rapid analysis of the interview transcripts. Two coders mapped identified examples of specific scenarios and strategies of video use in PC into the 5 NASSS domains and 15 corresponding sub-domains. The identified examples from the interview transcriptions were then mapped into Expert Recommendation for Implementing Change (ERIC) strategies.
Results: Study sample included 7 urban (5 high,2 low), 3 rural (all low) sites. We interviewed 41 PC team members. The percent of video-based PC use at high sites varied between 13%-17%; the corresponding percent for low sites was ≤1%. Qualitative analyses identified implementation strategies shared by high and low sites, most were VA-wide, national policies (e.g., change physical structure and equipment) initiated at onset of the COVID-19 pandemic. Among high performing video-based PC sites, there was also strong engagement ERIC strategies. From the health care organization domain, we found that high performing sites promoted adaptability by implementing virtual days, where teleworking was encouraged on a regular basis. For the adopter system domain, we found that high performing sites revised professional roles by engaging nursing staff in scheduling, initiating, and conducting video visits. For the technology domain, sites provided local technical assistance by engaging PC team members in creating tailored technical assistance protocols with local oversight. Making trainings dynamic (health care organization domain) refers to PC team members creating interactive trainings that catered to different learning styles and local work contexts.
Discussion: The study findings guided by NASSS domains, then mapped into ERIC strategies, identify implementation strategies that distinguish between medical facilities with high versus low telehealth use in primary care. The ERIC implementation strategies found to be in common among high and low video-based PC sites were predominantly system-wide, national policies and procedures mandated at most VA sites. Local/site-level engagement that incorporated site-directed ERIC strategies distinguished between high and low video use sites. High sites appeared to have robust local VA leadership support and personnel buy-in to concurrently deploy a set of site-directed strategies, such as promoting adaptability, revising professional roles, providing local technical assistance, and creating dynamic trainings. Findings highlight the importance of incorporating a collective approach at the system as well as local/site level to facilitate successful adoption and use of telehealth services in primary care.
Leveraging a Learning Ecosystem to Standardize Virtual Care Delivery for Chronic Cardiac Diseases
Sruthi Cherkur MPH CPHQ, Carly Beastrom MHA, Gary Myers MS
American Heart Association
Primary Email:Sruthi.Cherkur@heart.org
Background: Accelerated from response to COVID-19, the utilization of telehealth has increased significantly to reach patients. A report from the American Medical Association found physicians using virtual visits grew from 14% in 2016 to 80% in 2022. However, complexities including varied health system resource settings, differing state-based reimbursement policies, and lack of clinical guidance on integration of telehealth for chronic disease management, causes significant variation in care delivery. Rapid adoption of telehealth care models necessitates evidence-based quality recommendations for the consistent delivery of high-quality telehealth care. As a leader in evidence-based guidelines and quality improvement, the American Heart Association (AHA) is bridging this gap through a three-year pilot initiative, convening a multi-stakeholder community embracing implementation science to achieve the goal of standardized delivery of high-quality virtual care for all chronic cardiac disease patients.
Methods: The multi-stakeholder learning ecosystem, launched on July 1, 2023, includes four components: 1) A diverse cohort of 31 outpatient clinics across the country sharing challenges and solutions for delivering virtual care to chronic cardiac disease patients, and testing pilot quality metrics. Clinics were invited to apply to participate in the initiative and were selected based on telehealth services, patient population served, clinic type and resource setting, and geographical diversity. 2) A multi-disciplinary writing committee of seven clinical experts were identified through experience in the telehealth field, chronic care, and academic writing. This Committee generates evidence-based quality recommendations through a literature review and landscape analysis of virtual care for chronic disease management. 3) An alliance consortium comprised of organizations across the industry and public sectors, invested in telehealth and quality of care to support the ecosystem through solutions. 4) AHA staff drive quality improvement and facilitate insights across the ecosystem to bridge knowledge gaps. These learnings will be amplified and disseminated, with potential for ongoing impact beyond the initiative end in June 2026.
Results: This initiative aims to establish a set of metrics to measure quality of virtual care delivery for the management of chronic cardiac diseases. Rooted in the Four Domain Model of Virtual Care and Value, these metrics encompass the domains of Equity, Economic, Experiential, and Functional. Pilot quality metrics are tested through data collection across the 31 learning collaborative clinics with quarterly aggregate data reported by each clinic for the preceding quarter. Benchmark groupings by clinic types provide appropriate data comparisons. AHA staff support data collection and analyze data trends, clinical value, and feasibility. These metrics are refined iteratively through feedback from the learning collaborative and Writing Committee to establish final metrics and assess performance over time. In addition to this quantitative data, qualitative data such as process mapping and evaluation surveys are conducted and assessed to provide valuable insights on implementing these metrics, common barriers experienced across the cohort, and solutions to improve quality of care delivery.
Discussion: This unique initiative design, incorporating both evidence-based research and implementation science approaches, allows for the development of quality recommendations rooted in science and feasible to implement in a complex and rapidly evolving care setting. Grounding pilot data metrics in established frameworks, while simultaneously testing metrics within a wide range of telehealth care delivery models across various clinic types, offers both credibility and validation. Additionally, the real-time insights of implementing these metrics and continuous improvements made from data analysis create valuable model sharing opportunities and use cases spanning a variety of clinic types and telehealth care models. This benefits health care organizations across the country in measuring quality of their own virtual care models for managing chronic cardiac diseases. These contributions can support increased access to patients receiving high-quality standardized care for their disease management.
Impact of Telehealth Use for Primary Care Among Mississippi Medicare Beneficiaries with Hypertension
1University of Mississippi Medical Center 2The University of Texas Health Science Center at Houston 3The University of Texas School of Public Health
Primary Email:yzhang4@umc.edu
Background: Hypertension is one of the most prevalent chronic conditions among Medicare beneficiaries and a major, modifiable risk factor for cardiovascular and renal diseases. Effective hypertension management is essential to prevent adverse outcomes, often relying on consistent primary care interventions. The COVID-19 pandemic accelerated the adoption of telehealth, making health care services more accessible, particularly for hypertension management. However, as the pandemic subsides, debates about the cost-effectiveness of telehealth in the post-COVID-19 era persist. In Mississippi, where one-third of residents live in primary care shortage areas, telehealth presents an opportunity to bridge gaps in health care access. This study evaluates the impact of telehealth utilization within primary care settings on sociodemographic disparities, health care resource utilization (HCRU), spending, and antihypertensive medication adherence among Medicare beneficiaries with hypertension in Mississippi.
Methods: We conducted a retrospective cohort study using Medicare claims data from 2019 to 2021, focusing on beneficiaries diagnosed with hypertension. The outcomes assessed included HCRU, measured by outpatient visits, emergency department (ED) visits, inpatient admissions, and 30-day readmissions; medical and pharmacy spending covered by Medicare, as well as beneficiary out-of-pocket (OOP) spending and total gross spending; and first-line antihypertensive medication adherence, analyzed at the patient-year level. Beneficiaries’ use of telehealth for primary care service was identified for each year. To address potential confounding, we applied a Marginal Structural Modelling approach that accounted for both time-invariant baseline demographic factors and time-varying socioeconomic and primary care utilization factors. Specifically, we applied inverse probability of treatment weighting to balance covariates across the study population. We then utilized generalized linear mixed-effects models for HCRU and spending outcomes, and mixed-effects models for antihypertensive medication adherence, and incorporated individual-level random effects and exchangeable correlation structure to account for repeated measures.
Results: We identified 152,143 study participants, of whom 59,739 (39.27%) used telehealth services across. Telehealth was more commonly used by participants who were younger, female, White beneficiaries, those entitled due to disability insurance benefits, dually enrolled in Medicaid, residing in non-rural areas, and with a higher comorbidity index. Telehealth users had higher continuity of care scores and more primary care visits in 2019. Additionally, they accessed a broader range of primary care providers, though with a lower proportion of services from surgeons and other specialists. Telehealth utilization was associated with a 0.9% increase in outpatient visits and a 5.9% increase in ED visits, indicating increased triage touchpoints. A 14.1% decrease in inpatient admissions and a 23.7% decrease in 30-day readmissions per-person-per-year (PPPY) were also noted. Telehealth utilization also significantly reduced all spending PPPY: 12.4% in Medicare medical spending, 26.2% in beneficiary OOP medical spending, 13.5% in gross medical spending, 12.6% in Medicare Part D spending, 0.7% beneficiary OOP pharmacy spending, and 5.2% gross pharmacy spending. It was further associated with a 3.6% increase in antihypertensive medication adherence.
Discussion: Telehealth use among Medicare beneficiaries with hypertension was associated with improved antihypertensive medication adherence and increased outpatient and ED visits, but reduced inpatient admissions and 30-day readmissions, suggesting its potential to enhance hypertension management by augmenting primary care services. The associated decrease in Medicare, beneficiary OOP, and overall medical and pharmacy spending indicates effective cost management under current Medicare telehealth reimbursement policies. However, significant sociodemographic disparities in telehealth access, particularly among older, minority, and rural populations, highlight concerns regarding the digital divide. Addressing these disparities and addressing health equity is crucial post-pandemic.
Evaluating a New Virtual Nursing Model: Strategies for Systemwide Expansion and Sustainability
Caitlin Koob PhD MS, Jillian Harvey PhD MPH, Ryan Kruis PhD, James McElligott MD MSCR, Peter Gardella MBA BSN RN, Dee Ford MD MSCR, Emily Warr MSN RN
Medical University of South Carolina
Primary Email:cak240@musc.edu
Background: The U.S. health care system aims for safe, effective, person-centered, efficient, and equitable care. However, workforce issues impact patient outcomes and costs. COVID-19 intensified these challenges, particularly for nurses who faced unprecedented circumstances with limited resources. As a result, there will be an estimated deficit of 3.2 million health care workers by 2026 nationwide, and in one state, 39% of surveyed nurses reported intentions of leaving their job within one-year. These concerns are relevant in South Carolina, where 41 of 46 counties are experiencing a health care workforce shortage. To address these concerns, a Virtual Nursing program was developed as an innovative care delivery model, leveraging teams of remote, virtual nurses (VRN) to support bedside nurses in providing care via technology. VRN offset time-intensive tasks, allowing bedside nurses more time for patient care. This presentation describes the implementation and expansion of a novel VRN model.
Methods: The Exploration, Preparation, Implementation, and Sustainment (EPIS) framework is applied to iteratively and rigorously evaluate the implementation of evidence-based interventions, such as VRN, across health care settings. Each EPIS phase is well-structured to provide dynamic, real-time feedback, guide data-driven decisions, and evaluate program resources, activities, and outcomes. Multiple data sources are triangulated for ongoing evaluation, including information from patients’ electronic health records (EHR), provider efficiency data within EHR, and program tracking within REDCap. Primary outcomes of interest include VRN utilization data, service unit types provided by VRN, and patient satisfaction. Service unit types describe the support provided by VRN, including tasks related to admission, discharge, care plan, education, quality surveillance, and documentation compliance. Additionally, Hospital Consumer Assessment of Health care Providers & Systems (HCAHPS) is a standardized survey of patients’ perspectives of hospital care, capturing patients’ experience with admission, discharge, and communication with nurses. Descriptive statistics are used to analyze quantitative data.
Results: Exploration/Preparation: VRN was designed to alleviate strained nursing-to-patient staffing ratios, support bedside nurses, and offer remote opportunities for nurses, supporting retention. Financial investments and nursing leadership engagement were critical for preparation. Implementation: From October 2023 to 2024, 6,521 patients were served by VRN. VRN provided 20,924 service units, averaging 3.2 units per patient. VRN services included admission tasks (41%), care plan management (42%), education (45%), quality surveillance (51%), documentation (25%), and discharge tasks (6%). A majority of VRN care was completed within EHR, as 22% of VRN service units required video. Additionally, nearly two-thirds (63.6%) of VRN services were requested by the floor unit, rather than being initiated by VRN (36.4%). Sustainability: To date, utilization and patient satisfaction data suggests this VRN model is well-received. Patients’ report improved experiences in admission, discharge, and communication with nurses in all units where VRN is deployed. In fiscal year 2025, VRN will expand from five to 32 units systemwide.
Discussion: National efforts to address gaps related to health care access, quality, and workforce have elicited little success, often encouraging health care providers to relocate to rural and otherwise remote locations to meet the widespread unmet needs among patients and providers alike. Additionally, health care costs are rising disproportionately to measurable improvements in health care quality and outcomes nationwide. Technology provides opportunity to improve health care access and quality, while also reducing the burden placed on health care providers that often leads to burnout. Based on preliminary findings, VRN may provide a strategic first step to improving health care access, quality, patient outcomes and satisfaction, and alleviating the stressors within the health care workforce. Ongoing evaluation will examine the impact of VRN on patient outcomes, bedside and virtual nurses’ perspectives of burnout and job satisfaction, and system-level cost savings.
Virtual Prenatal Care Utilization, Social Determinants of Health, and Stressful Life Events
Don E. Willis PhD, Pearl McElfish PhD MBA, Clare Brown PhD MPH, Jennifer Andersen PhD, George Pro PhD MPH, James Selig PhD, Cari Bogulski PhD
University of Arkansas for Medical Sciences
Primary Email:DEWillis@uams.edu
Background: Timely prenatal care is associated with a reduction in maternal mortality, pregnancy complications, and postpartum depressive/anxiety disorders. Prenatal care utilization is also related to several social determinants of health including education, rural status, race/ethnicity, socioeconomic status, insurance status, and exposure to stressful life events. Virtual prenatal care as the potential to address barriers to timely prenatal care utilization; however use of telehealth is also associated with many of the same social determinants of health. Little is currently known about the associations between receipt of virtual prenatal care and exposure to stressful life events. To fill this gap in the literature, we examined associations between virtual prenatal care utilization, social determinants of health, and stressful life experiences.
Methods: We analyzed cross-sectional pooled survey data from phase 8 of the Pregnancy Risk Assessment Monitoring System (PRAMS) Automated Research File (ARF) for mothers who gave birth in 2020 or 2021. Our analytical sample (Nf11,966) covers a total of 15 sites across the US, including 14 US states (DE, GA, IA, IL, LA, MA, MI, MO, NE, NY, OR, PA, UT, WY) and New York City. Virtual prenatal care utilization was assessed on the Maternal COVID-19 Experiences questionnaire supplement administered in 2020 and 2021. We defined virtual prenatal care utilization as anyone who received either virtual prenatal care only, or a combination of virtual and in-person prenatal care.
Results: Approximately a third (35%) of women utilized virtual rather than in-person only prenatal care. In adjusted analyses, odds of receiving any virtual prenatal care were greater for mothers who identified as Asian (aOR=1.23; 95% CI[1.01, 1.51]) or Hispanic (aOR=1.61; 95% CI[1.37, 1.88]), relative to White mothers, and mothers who experienced homelessness (aOR=1.90; 95% CI[1.27, 2.84]) or job loss (aOR=1.25; 95% CI[1.04, 1.51]). Adjusted odds were lower for mothers who did not have a bachelor’s degree, had previously given birth, had no insurance prior to becoming pregnant (aOR=0.69; 95% CI[0.56, 0.85]), were rural residents (aOR=0.51; 95% CI[0.41, 0.63]), had been exposed to incarceration (aOR=0.49; 95% CI[0.30, 0.79]), and had given birth in 2021 rather than 2020 (aOR=0.77; 95% CI[0.69, 0.86]).
Discussion: Social determinants of health and exposure to stressful life events are not uniformly associated with either greater or lesser odds of utilizing virtual prenatal care. Virtual prenatal care utilization may arise from positions of advantage or protection from stress in some circumstances, and disadvantage or stressful life experiences in other circumstances.
Building Foundational Telemedicine Skills: A Core Training Curriculum for Graduate Medical Learners
Kristie Busch DO1, Ariel Sulcov MPH1, Peter Greenwald MD MS FACEP1, Neel Naik MD1, Rahul Sharma MD MBA FACEP1, Lauren Wasson MD MPH2, Christine Lauren MD MHA3
1Weill Cornell Medicine, New York-Presbyterian Hospital 2New York Presbyterian Hospital, Columbia University Irving Medical Center 3Columbia University Medical Center, NewYork-Presbyterian Hospital
Primary Email:krb9003@med.cornell.edu
Background: Telemedicine plays an important role in health care delivery. Although short term telemedicine visits appear to have peaked in 2020, there is good reason to believe that telemedicine will remain an important and growing part of the health care landscape. It has the potential to expand access, streamline coordination, and improve efficiency. A unique skill set is required for effective telemedicine, yet Graduate Medical Education (GME) programs often lack formalized training in telemedicine competencies. We believe these skills should be incorporated into GME. There are known best practices in our bedside manner, and we believe proper web side manner is equally as important. We developed and implemented a novel training program designed to teach first year residents foundational telemedicine skills aligned with the American Association of Medical Colleges (AAMC) and Accreditation Council for Graduate Medical Education (ACGME) telemedicine competencies.
Methods: The course aligned AAMC and ACGME competencies and was a first iterative step in the development of a curriculum to be deployed across a 2,600 bed, 7 hospital system. Learners spanned surgical and medical specialties and more than 90% were in year 1 or 2 of training. Faculty teachers were adult and pediatric Emergency Medicine faculty with years of experience in telemedicine. The course was structured in two parts. The first part consisted of 5 asynchronous online modules: “Setting Your Stage,” “Refining Virtual Communication Skills,” “Preparing for Technical Challenges,” “Creating a Script for a Virtual Physical Exam,” and “Adapting the Decision-Making Process for the Virtual Space”. The second part was 2 simulated patient (SP) encounters and 2 faculty lead group structured debriefing sessions using the PEARLS debriefing method held at the Weill Cornell Medicine Center for Virtual Care. Content was specialty agnostic. Learners used QR digital posters that linked content from the modules to in-person scenarios and helped students navigate the physical space. Pre and post survey questionaries were completed with assurances that no grading or administrative response would be linked to answers.
Results: A total of 277 GME trainees participated in the initial course iteration. Pre and post surveys assessed learners’ confidence using a scale from “not at all confident” to “very confident”. Students also reported on their telemedicine preparedness and their impressions of course design quality. Of the 161 learners completing both pre and post surveys, 92.5% reported the pre-modules helped them prepare to conduct encounters and 98.8% found the debrief sessions valuable. 96.9% of participants reported that the in-person sessions helped them with history-taking and physical examination. Confidence questions included A Adhering to the medicolegal rules and regulations of a telemedicine visit B Appearing professional and having appropriate “webside manner” in telemedicine C Conducting a virtual physical exam in telemedicine (including vital signs) D Handle emergencies in telemedicine E Obtaining history in telemedicine F Properly triage and refer a patient in telemedicine G Understanding access and equity in the context of telemedicine. Measures of confidence increased in all but B and E, where overall confidence remained unchanged but extreme confidence decreased. All measures of course quality had a greater than 80% positive response.
Discussion: This work has several limitations. Our course was designed for first-year residents, but including residents from other years may have influenced our findings. We report here pooled survey responses, in future work we hope to link pre and post survey responses for individual learners. Although we designed our modules to be specialty agnostic, our initial iteration did not have enough of each specialty to determine if all specialties benefited equally. Overall, learners valued the initial institution-wide training program, appreciating the blend of self-learning, interactive posters, and in-person sessions. We are intrigued by the difference in levels of confidence between competencies. We are evaluating how this should affect future course refinements and wonder if at least in some cases, learners' confidence levels may diminish as their knowledge about the intricacies of telemedicine increases. In the future, we will enhance our approach to better meet individual learners' needs.
The Impact of Telehealth on Environmental Health: Cases in New Jersey, Washington, Florida & Arizona
Jason Goldwater MA MPA, Yael Harris PhD MHA
Laurel Health Advisors, LLC
Primary Email:jgoldwater@lh-advisors.net
Background: Laurel Health Advisors has explored the impact of telehealth on environmental health across New Jersey, Washington, Florida, and Arizona, analyzing its potential to reduce health care-related ecological stressors. By enabling remote consultations, telehealth has reduced patient travel, thus lowering carbon emissions and traffic congestion, particularly in densely populated and rural areas where long travel distances are standard. In states like Arizona and Florida, telehealth has played a role in mitigating health risks related to extreme weather by maintaining patient access to care during climate-related disruptions. Additionally, telehealth has supported environmental health monitoring in New Jersey and Washington by facilitating remote consultations for patients with respiratory and allergy-related conditions exacerbated by pollution or seasonal changes. The findings suggest telehealth is a practical or environmental impact while enhancing patient care continuity.
Methods: In assessing telehealth’s impact on environmental health, Laurel Health Advisors used a mixed-Methods: approach, combining quantitative data analysis with qualitative insights. The team first gathered data on telehealth usage patterns and estimated reductions in patient travel, calculating the resulting decreases in carbon emissions. Geographic information system (GIS) mapping was applied to visualize regions where telehealth reduced health care access-related transportation. Additionally, the team interviewed health care providers and patients to understand telehealth’s role during climate-related events, such as hurricanes in Florida and extreme heat in Arizona, where telehealth facilitated uninterrupted care. Environmental and health metrics—such as air quality impacts on respiratory conditions—were analyzed in New Jersey and Washington to assess how telehealth supported patients with ecological health challenges. This method provided a comprehensive view of telehealth’s environmental benefits and its role in supporting health resilience amidst climate variability.
Results: The study revealed that telehealth significantly benefited environmental health in New Jersey, Washington, Florida, and Arizona. Findings indicated notable reductions in patient travel, leading to lower carbon emissions, especially in rural and high-traffic regions. In Florida and Arizona, telehealth was crucial during extreme weather, ensuring care continuity for patients affected by climate-related disruptions, such as hurricanes and intense heatwaves, thereby reducing strain on emergency services. In New Jersey and Washington, telehealth helped manage respiratory conditions aggravated by poor air quality, with patients reporting better access to care for asthma and allergies without needing to travel. Patient and provider feedback highlighted improved health outcomes and increased satisfaction due to reduced environmental exposure risks.
Discussion: The analysis of telehealth’s impact on environmental health in New Jersey, Washington, Florida, and Arizona highlights its dual role in improving health access and reducing environmental impacts. By reducing patient travel, telehealth supports emission reduction and minimizes patients' exposure to pollution and weather-related risks, especially in states experiencing seasonal pollution and climate-driven events. The findings suggest that telehealth’s capacity to maintain care continuity during hurricanes, heatwaves, and poor air quality events is crucial for health resilience, especially for vulnerable populations. However, the study also emphasizes the importance of enhancing digital infrastructure and addressing digital literacy to maximize telehealth’s environmental health benefits. Laurel Health Advisors recommended that states continue investing in telehealth as part of sustainable health care strategies, as it aligns with broader public health goals.
Managing the Portal Message Surge: To Bill or Not to Bill
Courtney Furrow-White RN MPM1, Danielle Carder MSc Public Health2
1Vizient 2Association of American Medical Colleges
Primary Email:courtney.furrowwhite@vizientinc.com
Background: Patient-initiated messages through electronic patient portals have increased dramatically since COVID-19, overwhelming health care providers and systems. Patients have embraced the ability to message their providers, but the current system lacks a sustainable workflow to manage the influx of messages. To address this, payers are classifying in-depth messages as eVisits, billable medical encounters that require medical decision-making and provider time. This project focused on understanding how health systems are responding to patient-initiated portal communication, the usage of eVisits and its impact on access, equity, patient experience, care team experience, and cost.
Methods: CPSC billing data from 2020–2023 was analyzed to understand 78 practice plans’ usage patterns of eVisit codes. Medicare Part B pays for eVisits or patient-initiated online evaluation and management conducted via a patient portal. In addition to analyzing CPSC claims data, AAMC and Vizient launched a survey, in which forty health systems across 24 states responded to the survey. This survey was designed to gather qualitative and quantitative information about care delivery models and approaches to address patient-initiated electronic communication, for both organizations billing for patient-initiated portal messages and organizations who are not billing. Based on the CPSC claims data and member survey data we then selected 10 organizations for in-depth interviews with clinicians and administrators at these organizations to understand their approach, infrastructure, facilitators, barriers, and lessons learned around patient-initiated portal communication. Organizations selected for interviews included both billing and non-billing organizations across the United States.
Results: Billing data analysis, survey results and interviews showed quite a bit of variation in billing for eVisits among organizations. Across the four-year period, some organizations have sustained and/or increased usage of eVisits, others have stopped billing for eVisits in this period after the height of COVID, while others are only beginning to bill for eVisit encounters. We examined the top specialties that eVisits codes were billed: primary care (family medicine, GIM), dermatology, emergency medicine, pediatric primary care, and endocrinology. The top primary diagnosis for eVisits include dermatitis and rashes, screenings and follow-up encounters, covid-19 infection, urinary tract infection, and bronchitis and other upper respiratory diseases. From the survey findings there is varying levels of patient engagement with the patient portal. In this sample, an average of 51-75% of a health system’s patient population is signed up to access the patient portal. Nearly all respondents reported their portal offered medical advice messages, scheduling services and medication refill services, however only 57% offered structured eVisits. Only 25% of respondents capture patient, provider and staff satisfaction with the portal.
Discussion: Patient portal communication must be continuously improved based on evolving patient needs, feedback from care teams, and technological advancements. Organizations need to establish efficient workflows, allocate appropriate resources, and implement effective triage systems to address the increasing number of portal messages. Additionally, providers and staff may need additional training to effectively navigate and prioritize messages, ensuring that patient needs are met in a timely and satisfactory manner. By proactively addressing these challenges and leveraging patient portal messaging as a valuable communication tool, organizations can enhance patient engagement, improve care coordination, and deliver more patient-centered care. We will share portal enhancement strategies for improved engagement, optimized workflows that balance patient needs and provider burden, thus determining if billing for eVisits is an effective approach for improving access and satisfaction for organizations.
The Case for Payment Parity for Telehealth: A Statewide Study of Telehealth in New Jersey
Jason Goldwater MA MPA, Yael Harris PhD MHA
Laurel Health Advisors, LLC
Primary Email:jgoldwater@lh-advisors.net
Background: Laurel Health Advisors conducted a comprehensive study on telehealth utilization and its impact on the State of New Jersey, identifying telehealth's role in improving health care access in metro and underserved areas. Through data analysis and stakeholder engagement, they examined how telehealth services addressed care gaps, patient satisfaction, and care outcomes. The study provided insights into barriers, such as technology access and patient-provider communication, while recommending strategies for sustainable telehealth expansion in the state. Laurel Health Advisors highlighted telehealth's potential for cost savings, quality care improvement, and equity enhancement, offering New Jersey evidence-based policy recommendations to guide telehealth integration across health systems. This study was the first statewide study of telehealth, issued through an Executive Order by Governor Phil Murphy. It will be used to determine payment parity within the State.
Methods: Laurel Health Advisors employed a mixed-methods: approach, integrating quantitative data analysis and qualitative stakeholder interviews to better understand telehealth's impact and barriers. They analyzed telehealth usage patterns, patient outcomes, and service cost data to measure effectiveness across various demographics. In addition, structured interviews and focus groups with health care providers, patients, and policy stakeholders provided context on telehealth’s accessibility, usability, and integration within existing care models. They used thematic coding for qualitative data to identify common challenges, such as digital literacy and technology access, while leveraging statistical models to assess trends in telehealth’s role in reducing disparities. This multi-layered approach enabled the team to craft targeted recommendations for enhancing telehealth infrastructure and policy in New Jersey.
Results: The study revealed significant findings about telehealth's potential and limitations within the state. The data demonstrated a marked improvement in health care access for underserved communities, with telehealth helping bridge geographical and mobility barriers. Patient satisfaction scores were notably high, especially in convenience and reduced wait times. However, the study highlighted ongoing challenges, particularly around digital literacy and provider licensure, affecting telehealth's reach and effectiveness. Additionally, the analysis showed that telehealth positively impacted managing chronic conditions through more frequent touchpoints. However, there remained gaps in provider reimbursement and policy support for sustained telehealth adoption. Laurel Health Advisors recommended targeted investments in digital infrastructure and policies that incentivize telehealth integration to further capitalize on these benefits and support a more equitable health care delivery model statewide.
Discussion: Laurel Health Advisors examined both the transformative potential and existing limitations of telehealth in New Jersey’s health care landscape. While telehealth significantly improved access and convenience for underserved populations, challenges such as digital literacy and infrastructure disparities underscored the need for targeted policy and investment strategies. The findings emphasize that while telehealth has proven effective in managing chronic care and reducing appointment no-show rates, further digital equity and provider reimbursement improvements are crucial for long-term adoption and effectiveness. It's suggested that telehealth’s sustainability depends on supportive regulations, infrastructure development, and continuous feedback from patients and providers to adapt services to evolving needs. The study highlighted telehealth as a powerful tool for health equity, recommending that New Jersey integrate these insights to shape a robust, inclusive telehealth policy framework.
Increasing Access to Telehealth for HIV Care Through Tailored Digital Navigation
Chandler Douglas MA, Gretchen Weiss MPH, Erin Starzyk PhD MPH
JSI Research & Training Institute
Primary Email:chandler_douglas@jsi.com
Background: The Telehealth Strategies to Maximize HIV Care initiative, a Special Projects of National Significance initiative funded by the Health Resources and Services Administration’s HIV/AIDS Bureau, aims is to identify and maximize the use of telehealth strategies that are most effective in improving linkage to care, retention in care, and health outcomes for people with HIV who receive services through the Ryan White HIV/AIDS Program (RWHAP). The multi-site evaluation project uses implementation science to assess the impact of telehealth coordination strategies on clinic, provider, and patient outcomes. Key areas of interest include the role of telehealth coordination strategies in supporting equitable implementation of telehealth by addressing challenges to access that result from the digital divide, ensuring all patients understand the telehealth options available to them, and tailoring digital health navigation strategies to meet the needs of priority populations.
Methods: The abrupt pivot to telehealth during the COVID-10 pandemic did not allow for strategic and intentional identification, implementation, and evaluation of telehealth strategies. While studies show positive uptake of telehealth for HIV care, other data raise concerns of widened health disparities associated with social determinants of health. This project, which began in August 2022, provides an important opportunity to evaluate the impact of telehealth coordination strategies on addressing the digital divide in telehealth delivery for people with HIV. Telehealth coordination includes administrative coordination (e.g., workflows, policies, and staff training) and patient coordination (e.g., assessing preferences and readiness for telehealth, providing digital navigation in preparation for telehealth visits, and being available to troubleshoot technological challenges during telehealth visits). Enrolled patients complete pre- and post- visit surveys to assess needs, preferences, and satisfaction with telehealth. Clinic staff respond to pre-visit needs, such as by providing hands-on support to onboard patients to the patient portal and conducting a mock telehealth visit to demonstrate the platforms’ functionality.
Results: Between February 2024 and October 2024, a total of 335 patients were enrolled. The average age is 50 and 77% of enrollees are under 100% of the Federal Poverty Level. The most frequently reported navigation services patients report receiving prior to their telehealth visit are mock visits, written instructions, help logging into the patient portal, and help setting up the patient portal. Patients report a high level of satisfaction with telehealth after their visit and perceived barriers to telehealth decreased. Among patients who indicated in the pre-visit survey that they had not had a telehealth appointment in the past 12 months, 91% reported they would like to have a telehealth appointment in the future. Among those who reported they had a telehealth appointment in the past 12 months, 96% indicated they would like to have a future telehealth appointment.
Discussion: Findings to date indicate that telehealth coordination strategies increase access to telehealth for people with HIV, decrease perceived barriers to telehealth, have a positive impact on patient satisfaction with telehealth, and increase the likelihood of future telehealth utilization. Increased understanding of patients’ perceived barriers to accessing telehealth and effective strategies for addressing these barriers supports improved telehealth delivery. In particular, digital navigation strategies tailored to meet the needs of priority populations within the RWHAP, including low-income individuals, older populations, rural communities, and racial and ethnic minorities, promotes equitable implementation by addressing the digital divide. In addition to improving patient outcomes, this information is critical for determining the resources and supports (e.g., staffing, workflows, policy, training) necessary for sustainable telehealth program planning.
Implementing a Virtual Weight Management Program in Rural Primary Care: Pilot Results: and Insights
Caitlin Koob PhD MS, Jillian Harvey PhD MPH, Ryan Kruis PhD, James McElligott MD MSCR, Sarah Hales PhD
Medical University of South Carolina
Primary Email:cak240@musc.edu
Background: Rates of overweight and obesity in South Carolina (SC) remain high, and for those residing in rural areas, access to nutrition counseling and lifestyle change programs for weight management are limited. Collaborative care management (CoCM) is a multi-disciplinary approach that has improved access to health care in prior studies, often implemented among patients with mental health conditions. The purpose of this study was to develop Primary Care Integrated Weight Management (PCIWM), an adapted CoCM model, designed to increase access to nutrition and weight management counseling via telehealth. Additionally, this study evaluates the pilot implementation of PCIWM among adults who received care at five primary care clinics within a large health system in SC. To our knowledge, this is the first program to adapt CoCM for weight management. Therefore, this presentation aims to 1) describe and evaluate the pilot PCIWM and 2) identify strategies to improve adoption and inform sustainability.
Methods: A multidisciplinary care team—including Registered Dieticians (RDs), primary care providers (PCPs), practice managers, and a weight management consultant—was established to develop a PCIWM workflow and patient registry within an academic medical center and four affiliated rural primary care clinics. The PCIWM workflow incorporated RD documentation, routing encounter notes to PCPs, and monthly consultations between RDs and the weight management consultant. From December 2022 to May 2024, patients who were >=18 years and BMI >25kg/m2 were referred to PCIWM (Nf61). Participants underwent a nutrition assessment, set goals, and received medical nutrition therapy from RDs, as part of their primary care plans. Patients were offered monthly follow-up sessions with RD, and their weight (in kilograms) was recorded at initial assessment and 3-month follow-up. Additionally, RDs and weight management consultants collaboratively developed and distributed a survey via email to check in with patients between sessions (Nf11). Data was sourced from electronic health records, PCIWM encounters, and survey respondents. Descriptive statistics were used to examine patient characteristics at baseline, initial service utilization, and survey responses.
Results: Overall, enrolled patients were an average of 46.8 years old (SD=12.5), and a majority were female (85.3%) and identified as White (65.5%). Additionally, enrolled patients identified as Black (26.2%) or Other/Unknown (8.2%). Many patients were married (63.0%) and/or worked full-time (42.6%). The average base weight among enrolled patients was 115.0 kilograms (SD=32.0). Of PCIWM patients, 29% were actively engaged and had an average of 3.4 RD visits, with a mean duration of 100.7 minutes. Of the 11 patients who responded to the between session survey, the majority (63.6%) reported adhering to their nutrition goals “well” or “very well” the prior week. Others reported challenges adhering to their personalized nutrition goals, largely due to time and/or motivation. Of the 61 patients who enrolled in PCIWM, 45.9% cancelled or did not attend their first appointment and did not reschedule and 8.2% overall did not have updated weights from referral. Still, of those who attended their scheduled follow-up appointments and had updated weights, 51.9% maintained (within 1 kg) or lost weight.
Discussion: Among engaged patients, PCIWM demonstrated promising preliminary Results: to support weight management as a pilot program. However, ongoing research is needed to consider patient-level barriers, such as patient readiness for behavior change through the Theory of Planned Behavior, to encourage improved uptake and sustained participation in dietary counseling for weight management. Additional screening may inform the referral process for greater adherence to PCIWM, partially addressing loss to follow-up and subsequent data challenges in this pilot phase. With a larger sample, research is needed to examine associations between long-term patient outcomes, patient demographics, and PCIWM engagement, compared to a control group. Lastly, policy barriers, including limited telehealth reimbursement coverage for RDNs, remain relevant in the sustainability and expansion of this model and should be further investigated.
The Impact of Telehealth Lactation Support on Sustaining Breastfeeding Among Medicaid Patients
Crystal Jones RDCS MHS, Cheng Peng PhD MPA MS, Rebecca Jones MPH, Karina Leal RN, Mayra Leal AS, Sophie Mayers BA, Cari Bogulski PhD, Ashton Porter MD, Hari Eswaran PhD
University of Arkansas for Medical Sciences
Primary Email:cdjones@uams.edu
Background: The American Academy of Pediatrics recommends that all infants are exclusively breastfed for a minimum of six months, however in Arkansas, only 24.4% of mothers are exclusively breastfeeding at six months. Breastfeeding initiation rates are high in Arkansas at 74.9%, indicating that some barrier must prevent sustained breastfeeding. Easy access to professional lactation consultants through telehealth can possibly reduce barriers that prevent prolonged breastfeeding through continuity of education, troubleshooting for breastfeeding problems, and positive emotional support. The objective of this study is to evaluate the feasibility and acceptability of postnatal virtual lactation visits with a lactation consultant and the impact telelactation has on initiating and sustaining breastfeeding at 2 months postnatal.
Methods: A cohort of one hundred pregnant women were recruited with 37 lost to follow up. Participants received standard-of-care remote lactation support via telehealth with appointments at approximately 2 days post-discharge, 7 days post-discharge, 1-month post-discharge, and 2 months post-discharge with additional support as needed. Participants completed a pre-survey at enrollment consisting of demographics, social support, infant feeding intention, breastfeeding attrition prediction, breastfeeding knowledge, and general health questions. After two months, participants completed a post-survey consisting of length of breastfeeding, breastfeeding knowledge, social support, length of maternity leave, and experience of discrimination as well as a semi-structured interview.
Results: Infant Feeding Intention scores were high with an average score of 13.25 (SD=2.74) out of 16. The Vermont Breastfeeding Attrition Prediction Scale (BAPT) scores were high with an average score of 22.60 (SD=4.93) out of 38 with scores over 20 indicating a high likelihood to sustain breastfeeding. The Vermont BAPT consists of three subscales including Breastfeeding Knowledge, Social Support, and Perceived Behavioral Control. The average scores on the Breastfeeding Knowledge and Perceived Behavioral Control subscales where high with an average score of 11.11 (SD=1.88) and 7.90 (SD=2.61) respectively out of a maximum total of 18 and 12 respectively. The Social Support subscale was low with an average score of 3.59 (SD=2.36) out of 8. Breastfeeding knowledge was significantly increased (p<0.0001) after the telelactation intervention with an average pre-survey score of 70.00 (SD=5.25) and post-survey average score of 74.25 (SD=20.53). Participants reported an overall positive experience with the telelactation visits, highlighting the convenience, the opportunity to build rapport with a lactation consultant, and the support and education provided.
Discussion: The use of telemedicine to provide professional breastfeeding support and education via video is a promising modality to increase both initiation and duration of breastfeeding through increased access to post-natal health care. Telehealth has the potential to provide easier access to breastfeeding support services while simultaneously addressing barriers for women living in rural and urban areas by reducing travel time and introducing flexibility and convenience to the health care model. Participants feedback towards both the telehealth model and the ability to sustain a relationship with a lactation consultant were overwhelmingly positive. Notably, the telelactation intervention improved breastfeeding knowledge, with a significant increase seen post-intervention. These findings underscore the effectiveness of telelactation in enhancing breastfeeding education and support, emphasizing its potential as a critical resource for sustaining breastfeeding practices.
Innovating Telehealth: A Federated Learning Approach to Optimize ECHO Data Utilization and Access
1University of Missouri School of Medicine 2University of Missouri
Primary Email:mkhmmd@health.missouri.edu
Background: Telehealth has been widely implemented to address various health care access barriers. Extension for Community Healthcare Outcomes (ECHO) Project utilizes telehealth technologies to connect primary care clinicians to specialists with the goal of improving capacity to care for patients in rural areas. The global expansion of tele-ECHO resulted in hours of de-identified case data and didactic presentations, currently inaccessible to participants. Availability of this data would allow participants to access knowledge and EBM recommendations quickly, and researchers and administrators to utilize this learning model to advance practices. Access to ECHO data is limited due to potential security risks associated with data-sharing and available resources. The objective of this project is to design and implement a novel decentralized federated learning (FL) framework to break down the silos of tele-ECHO data-sharing and allow a more robust decentralized approach for research and evaluation.
Methods: The proposed workflow will allow for more seamless and secure data sharing between tele-ECHO hubs. There are over 750 ECHO hubs in the world in 59 countries. In the US, 332 ECHO hubs are operating in 48 states. FL enables a machine learning model to be trained by a server without knowing the actual data of the clients. Local models from clients are aggregated by the server over multiple rounds. In decentralized FL, there is no server, but the clients interact to learn a global model. The participating tele-ECHO hubs would act as clients and be able to share case data with their individual institution where it is then generated into a local training model. This training model is then sent to other hubs requiring secure signatures and authentication from both parties before being added to the global model. The global model is generated by utilizing the case-based learning, which is shared by several ECHO hubs from a widespread region to the training task publisher and compiling the data into an evidence-based practice guideline for management of many common conditions. Optimizing the communication cost will be one of the key challenges to address.
Results: Our FL ECHO framework aims to support the case-based sharing process in the global ECHO network with each localized central server orchestrating only regional data sources. For example, Missouri-based Show-Me ECHO only has access to their individual raw data for training a localized neural network. Data is then catalogued in a local database. No raw data is shared with other hubs, instead model updates are exchanged with participants which allows collaborative learning without compromising data security or privacy. A variety of models can be trained and evaluated depending on the modality of the data (e.g., images, text, audio).
Discussion: Machine learning models, such as FL, have only recently been introduced to telemedicine platforms. So far, these models have been used for secure data-sharing of patient data for clinical decision support in traditional or direct-to-consumer telemedicine models. To our knowledge, this is the first proposed framework for Project ECHO, which may have significant impact on building communities of practice and further supporting project scalability. FL ECHO Framework will facilitate knowledge and experience-sharing, improve access to care, and may improve provider satisfaction.
Expanding the Pediatric ECHO Model: QI, Private Practice in the “Hub”, and School Nurse Involvement
Brailyn Weber BS BA1, Sarah Asch MS MD2, DeAngela Ivory BS MPH3, Vanessa Trammell BS MS CIPM CSM3
1University of North Dakota School of Medicine 2Hometown Pediatric Dermatology, PLLC
3University of Mississippi Medical Center
Primary Email:brailyn.weber@und.edu
Background: Approximately 98% of pediatric dermatologists who currently practice in the U.S. work in a metropolitan area of the country. This creates a significant geographic barrier to care for children who live in less populous areas, particularly in the Upper Midwest. To educate and assist health care professionals who practice in these access-limited areas, we created Pediatric Dermatology for the Upper Midwest ECHO, a HRSA-funded virtual learning platform that meets on a monthly basis. This project is a unique collaboration between a major academic institution, a private practice pediatric dermatologist, and a rural-based medical student. As retention of knowledge is unknown, we have incorporated a quality improvement (QI) component to our ECHO. Participants complete a quiz immediately following the ECHO session (post session quiz), and they repeat the same quiz approximately 3 months later (recall quiz) as a QI.
Methods: Descriptive statistics were used to analyze ECHO session attendance data from March 2024 to September 2024, for a total of 7 sessions. Specific endpoints of interest were attendee location, attendee profession, and attendee distance to a pediatric dermatologist. Participant recall quizzes are actively being completed and received on a monthly basis. This data will be compared with post session quiz data to assess the extent of which attendees retain the information they learn during each session.
Results: Our target audience consists of health care providers in the Upper Midwest, and accordingly, 45.5% of our participants are from rural and/or urban cities in Minnesota, North Dakota and Nebraska. Participants from the East and West coasts as well as several other countries (India, Ecuador, Tanzania) have also attended. School nurses make up nearly 50% of our participant population, while pediatricians and other physicians account for about 35%. The remainder is made up of advanced practice providers, clinic nurses, and research personnel. School nurses were nearly twice as likely to be 100+ miles or 2+ hours from a pediatric dermatologist, or to be unsure of their closest pediatric dermatologist compared to all other attendees, showcasing that many are from rural communities. Pending the acquisition of further recall quiz data, our final presentation will also include an analysis of attendee retention of knowledge through comparison of post session and recall quiz answers with QI intent to improve this retention.
Discussion: Our Results: showcase a preponderance of school nurse attendees, emphasizing their unique role as a first point of medical contact for children in rural communities. Future directives aimed at improving health care access in these areas should consider school nurse involvement. Further, our comparison of post-session and recall quiz data provides a quality improvement initiative that may be used by other project ECHOs to assess participant retention of information. This will be particularly helpful for ECHOs that reach across multiple states or health systems, where data capture Methods: within single state metrics or health systems is not possible. According to the American Academy of Pediatrics, health care outcomes improve when clinicians are confident, competent, and knowledgeable. Through our project ECHO, we hope to help our attendees build upon these core fundamentals within pediatric dermatology, ultimately helping them improve health care outcomes for their patients.
Telehealth and Willingness to Pay for Internet Services
Maysam Rabbani PhD1, Cari A. Bogulski PhD 2, M. Kathryn Allison PhD2, Hari Eswaran PhD2, Corey J. Hayes PharmD PhD MPH2
1Montclair State University 2University of Arkansas for Medical Sciences
Primary Email:rabbanim@montclair.edu
Background: Telehealth is becoming integral to health care delivery, which may create a higher need for better internet. This is the first study to examine whether users are willing to spend more on their internet if they are (1) more experienced in using telehealth, (2) more optimistic about telehealth benefits, and (3) less concerned about the difficulty of using telehealth.
Methods: We surveyed 5,200 Americans about their willingness to pay (WTP) for internet speed and quality on the one hand, and their (1) prior use of telehealth, (2) opinion about the benefits of telehealth, and (3) opinion about the difficulties of using telehealth. We stratified the sample using the three aspects above and conducted a conjoint analysis to estimate the WTP for internet speed and quality within each stratum.
Results: Compared with respondents who had never used telehealth, respondents who had used five to six different types of telehealth services were willing to spend 50.4% more on their internet plans. Users who most firmly believed in the benefits of telehealth were willing to spend 59.2% more than the most pessimistic users. Users who had the lowest concerns about the difficulty of using telehealth were willing to spend 114% more than users with the most perceived difficulty.
Discussion: We found strong ties between the WTP for internet and prior telehealth use and perceptions of telehealth benefits and barriers. Thus, internet expenditures may be influenced by users' anticipation of using telehealth. Future studies may investigate the causality of the relationship.
Eye Tracking and Usability Metrics During Admissions and Discharge Encounters Among Virtual Nurses
Jennifer Morelli MPS RN, Melissa Coffel MS, Saif Khairat PhD MPH FAMIA
University of North Carolina at Chapel Hill
Primary Email:jennifer_morelli@unc.edu
Background: Virtual nursing (VN) is an innovative care delivery model enabling experienced nurses to deliver patient care from a distance using telehealth tools. The VN model is being adopted by many U.S. health care systems, as it relieves nurse burden, thus improving nurse satisfaction and enhancing patient support. Little is known about how the shift from the bedside to VN affects the nursing workflow. Due to the inherent demands of continuous computer-based tasks, VNs are at a heightened risk of burnout related to electronic health record (EHR) use. Eye tracking metrics such as fixation count and frequency can serve as physiological markers for attention and cognitive processing. This study aims to utilize eye-tracking and usability metrics to gain insights into cognitive processing and EHR interface workflow among virtual nurses during admissions and discharge encounters. This study was supported by the Health Resources and Services Administration (HRSA) under grant number 6 U3GRH40003‐01‐01.
Methods: A cross-sectional study of virtual nurses (VNs) was conducted over five days during regular 12-hour shifts at a Southeastern tertiary hospital’s Virtual Care Center. Tobii Pro Lab® (v1.207) was installed on VN computers to gather usability data, and a screen-mounted eye-tracking device (Tobii Pro Spark®) captured fixation data. VNs used two monitors: one for the patient video feed and the other for EHR documentation. The eye tracker was mounted on the documentation screen only, focusing on metrics specific to VN workflow. Nurses were observed during patient admission assessments and discharge education. Prior to recording, nurses were oriented with the device and instructed to complete tasks as usual, followed by a brief calibration. Task engagement metrics included patient encounter duration, clicks, keystrokes, and eye fixations during EHR documentation and patient interactions. Data was analyzed with Tobii Pro Lab® (v1.241) and SAS JMP® (v18.0), providing insights into VN workflow during patient care activities.
Results: Four virtual nurses, with a collective bedside nursing experience ranging from 23 to 38 years and each with 10 years of experience using their institution’s EHR were recorded for a total duration of 14 hours 41 minutes over a period of 5 days. In total, 12 admission assessment encounters and 16 discharge education encounters were recorded. Admission assessment encounter durations averaged 19 min 53 sec (SD: 7 min 42 sec) while discharge education encounters averaged 19 min 8 sec (SD: 8 min 12 sec). Admission assessment tasks averaged 271.08 clicks (SD: 56.70) compared to discharge education tasks which averaged48.75 clicks (SD: 17.46). Keystrokes averaged 372.42 (SD: 318.23) for admission encounters and 424.63 (SD: 824.97) for discharge encounters. Total number of whole fixations averaged 1087.83 for admissions (SD: 802.51) and 1455.56 for discharges (SD: 849.59), with average fixation durations of 301.42ms during admission assessments (SD: 51.46) and 254.06ms during discharge education (SD: 51.84). In total, fixation times averaged 348.66sec in total per admission encounter (SD: 263.08) and 391.02sec total per discharge encounter (SD: 257.91).
Discussion: Our Results: suggest that admissions demand longer task durations and significantly more clicks, underscoring a higher complexity in navigation and data entry. In contrast, discharges—though involving fewer clicks—require markedly more keystrokes and a greater fixation count, reflecting intensive focus and typing demands. These distinct cognitive and manual requirements underscore a critical need for task-specific interface designs that can streamline workflows and alleviate cognitive load for virtual nurses. This study supports the urgency of optimizing design to reduce repetitive strain, potentially freeing up valuable time for more complex clinical tasks. Future research is needed to evaluate these metrics across diverse clinical roles, settings, and experience levels to determine whether these patterns hold universally, guiding broader, impactful improvements in clinical technology and workflow.
Enhancing Perinatal Care for Adolescent Mississippians Through Telemedicine
Gracie Little BS, Cameron Cloud BS BA, Molly Clark PhD ABPP
University of Mississippi Medical Center
Primary Email:llittle4@umc.edu
Background: While the value of in-person health care is undeniable, telemedicine has emerged as an innovation to address gaps in health care accessibility, particularly benefiting rural and underserved communities. Mississippi faces high rates of infant mortality and teen pregnancy, exacerbated by socioeconomic challenges and limited access to care. Adolescent mothers are at increased risk for maternal and fetal medical issues, including pregnancy-related hypertensive disorders and preterm births, as well as increased rates of depression and anxiety. Mississippi’s predominantly rural landscape (79.3%) is associated with higher rates of teen pregnancy, barriers to perinatal education, and difficulties accessing routine care. While existing studies often emphasize pregnancy prevention in this population, this study aims to explore the utilization of telemedicine as a resource for adolescent mothers during the perinatal period, with the potential to mitigate poor maternal and fetal outcomes.
Methods: Data for this study were obtained from deidentified patient records using the University of Mississippi Medical Center (UMMC) Patient Cohort Explorer (PCE), linked to UMMC's Research Data Warehouse. This virtual warehouse was developed by UMMC’s Center for Informatics and Analytics and contains medical records from the electronic health record system, EPIC, for 1,441,186 patients across 58,730,430 encounters. The analysis focused on records from pregnant individuals aged 13 to 19 who received care at UMMC from January 1, 2013, to September 30, 2024. A descriptive analysis was conducted using PCE filter presets, applying principles of inclusion and exclusion to identify telehealth utilization patterns. Demographic and health care utilization data for 6,741 pregnant teenagers across 46,156 encounters were extracted for analysis.
Results: Among the 6,741 pregnant teenagers seen at UMMC, this sample consisted of 71.7% African American teenagers, followed by Caucasian (21.1%), Other (6.5%), and Unknown (0.7%). There were 4.8% of the patients who identified as having Hispanic or Latino ethnicity. Approximately 10.5% of the patients currently or formerly smoked tobacco. Regarding payor status, 79.1% had Medicaid coverage, 12.2% had private insurance, 8.1% were self-pay, and 0.6% were “other”. There were 241 pregnant teenagers (3.56% of the sample) who were seen exclusively via telehealth across 297 encounters (0.64% of total encounters). A significant portion (61.4%) of these telehealth patients were seen after January 1, 2020. The racial and ethnic distribution of patients seen exclusively via telehealth did not differ significantly from the overall sample of pregnant teenagers. Regarding tobacco usage, however, telehealth-exclusive users demonstrated a higher prevalence of tobacco use, with 17.1% being current or former smokers. For payor status of telehealth users, 29.3% had Medicaid coverage, 3.0% had private insurance, 67.3% were self-pay, and 0.3% were “other”.
Discussion: Since 2013, many pregnant teenagers received health care services at UMMC, with 3.58% utilizing telemedicine. Telehealth users exhibited a higher prevalence of tobacco use, emphasizing the need for integrated cessation programs to mitigate maternal and fetal health risks. Medicaid and self-pay patients comprised 96.6% of telehealth users, suggesting a relationship exists between payor status and medium of communication, warranting further investigation. Existing research supports telemedicine outcomes and accessibility are often comparable, and in some cases superior, to traditional in-person perinatal care. This study suggests telemedicine can improve access to care for pregnant adolescents in Mississippi. Study limitations included the inability to investigate chief complaint or pregnancy outcome due to PCE preset constraints. Future research should explore patient motivations, satisfaction, and health outcomes to enhance telemedicine’s impact on perinatal care in Mississippi.
Improved Quality of Life in Heart Failure with Mobile Health Applications
Background: The Heart Failure Society of America (HFSA) reports that more than six million people over the age of 20 and residing in the United States are living with heart failure(HF), and more than 960,000 new cases of HF are diagnosed annually (Heart Failure Society of America [HFSA], 2023). More than three million individuals in the United States have HF with reduced ejection fraction (HFrEF), which increases their risk for morbidity and mortality (Rao et al., 2022). Approximately one in four HF patients is readmitted to the hospital within 30 days from discharge, and approximately 50% are readmitted within six months. (Khan et al., 2021). The use of mHealth apps has demonstrated the potential to improve the quality of care and life of patients with HF through adherence to guideline-directed medical therapy (GDMT), decreased risk for hospital readmission, and reduced mortality (Rao et al., 2022).
Methods: Using the Donabedian model, structure (organizational requirements, i.e., the setting where health care is provided), process (actions to be taken, i.e., the use and recommendation to use a mHealth app), and outcome (the Results:, i.e., to determine if the use of a mHealth app in HF patients could be incorporated into standardized care with the ultimate goal of improved quality of life) were used to create a survey to determine if patients would use and cardiology providers would recommend using a mobile health application to improve HF quality of life (Tossaint-Schoenmakers, et al., 2021). According to Tossaint-Schoenmakers (2021), the quality of life of HF patients using mHealth apps is a product of the various features and relationships of these categories as their interaction can be bidirectional, not simply a separation between cause and effect. The data collected from the purposive sampling surveys was analyzed using descriptive statistics and chi-square testing to evaluate relationships within the collected data from the patient surveys such as participant characteristics (i.e., age, number of years with HF, and number of hospitalizations).
Results: Patient participants qualified for the study based on their class of HF (NYHA stage II or III), determined by the stakeholder practice’s staff who screened patient charts before the distribution of the survey. The patients received study information and directions instructing them as to how to indicate participation consent (a signature waiver was obtained from the IRB to maintain patient anonymity). The patient survey was distributed to n=22 patients, completed by n=19 (86.4%) HF participants, and n=18 (81.8%) met the criteria for the study, n=1 (4.5%) patient did not qualify (not a resident of New York State), and n=2 (9.1%) patients declined participation. The patient survey was completed by 18 qualifying participants, and the provider survey was completed by four qualifying participants. Chi-Square testing of HF patient responses demonstrated no statistical significance associated with the patients’ age (Pearson’s Chi-Square .518), number of years having HF (Pearson’s Chi-Square .518), and number of hospitalizations for HF exacerbations (Pearson’s Chi-Square .308) in relation to their willingness to use a mHealth app.
Discussion: Though the sampling was small, the findings are encouraging and in alignment with the review of the evidenced-based literature. A total of 61% of HF patients surveyed indicated that they would be willing to use a mHealth app to improve their HF quality of life. Of the almost 39% of those HF patients not willing to utilize a mHealth app, the most common reason was due to not being good with technology (16.7%). From a provider perspective, 75% surveyed were physicians with one advanced practice provider participant, half (50%) of those surveyed providers would recommend the use of a mHealth app to 50% of their patients with 75% of providers concerned about the advanced age of their patients and 50% doubtful of patient access to mobile telephones and electronic devices.
Weight of Complexity: The Prevalence, Causes, & Solutions to Malnutrition in Complex Chronic Illness
Jennifer Tisdale MBA BSN RN-C1, Kaitlyn Barber BS1, Joy Johnson BS PM Cert1, Regina QaDan DNP FNP-BC1, Yunxi Zhang PhD1, John Swint PhD2, Lindsey Kuiper PhD1, Lincy Lal PhD2, Jenna Dear MD1
1University of Mississippi Medical Center 2The University of Texas School of Public Health
Primary Email:jotisdale@umc.edu
Background: Children with complex medical needs often struggle to achieve adequate growth, leading to Failure to Thrive (FTT), which affects 5-10% of pediatric patients and can result in developmental delays and immune compromise. At Children’s of Mississippi, the state's only children's hospital, the Complex Care team manages over 1,400 children, with nearly half at risk for FTT. Our study used Remote Patient Monitoring (RPM) to enable early intervention, lower hospitalization rates, and enhance care access for families facing socioeconomic challenges. The study’s objectives were to identify factors contributing to FTT in children with medical complexity, enhance understanding of malnutrition prevalence in complex pediatric cases, and implement RPM to monitor and address malnutrition. Building on Cincinnati Children’s Hospital’s 2021 pilot, which demonstrated improved patient outcomes, this project aimed to replicate and expand upon those successes.
Methods: This cohort study aimed to examine 30 pediatric patients at risk for FTT over six months, using RPM to monitor growth and feeding behaviors. Eligible participants were children aged 1-10 with FTT and feeding tube support; exclusions applied to those over 10, without feeding tubes, or lacking internet access. Interventions followed a structured approach, beginning with baseline assessments gathering demographics, health metrics, and caregiver contact details. Weekly RPM monitoring enabled Bluetooth-enabled data submissions to track weight and feeding, complemented by educational sessions to support caregiver understanding and engagement. Technology training and sample equipment demonstrations in face-to-face consent sessions further strengthened caregiver participation. Follow-up data collection spanned six months, with weekly health metrics recorded to ensure comprehensive monitoring and support.
Results: Indicate that 6 out of 15 (42%) of participants showed an upward weight trend, suggesting that RPM positively impacted growth in this high-risk population. Additionally, 50% of patients maintained stable weights, reflecting effective weight management likely due to regular monitoring and caregiver support. However, 8% of patients exhibited a downward weight trend, which may be influenced by individual factors such as age and health conditions. Notably, a lack of compliance with weekly weigh-ins and educational surveys may have contributed to these declines, as these components are crucial for reinforcing nutritional practices and tracking progress.
Discussion: This study shows that RPM can effectively support weight stability and growth in pediatric patients at risk for FTT. However, the small sample size limits generalizability, and further research with a larger cohort is recommended. Future studies should consider enrolling inpatient FTT patients ready for discharge, allowing face-to-face education and consent to improve caregiver buy-in and compliance with RPM. Educating caregivers on scale and app use prior to discharge may further enhance engagement and adherence. The observed stability and gradual weight gain in most patients underscore RPM's potential, alongside structured tracking and caregiver education, as a viable approach for FTT management. These findings highlight the need for tailored interventions to support compliance and address diverse patient needs. Overall, RPM offers promise for FTT management, though optimized engagement strategies and larger studies are needed.
A Decentralized Public Health Model for Substance Use Disorder Treatment via Connected Care
Julio Cespedes MBA BS, Sophie Durham PharmD, Christina Graham, Jonathan Hubanks PharmD, Renia Dotson MD FACS MPH MBA
Mississippi State Department of Health
Primary Email:julio.cespedes@msdh.ms.gov
Background: Substance Use Disorders (SUD) are alarmingly under-identified and under-treated. The existing US care system identifies severe and chronic cases, leaving a larger cohort of mild, moderate cases unidentified and without intervention despite the well-established efficacy of brief screening, motivational, and treatment Methods: (i.e., Screening, Brief Intervention, and Referral to Treatment, SBIRT) conducive to implementation in medical clinics. The Mississippi State Department of Health (MSDH) provides essential care statewide in 86 clinics. MSDH reported 19% of males in Mississippi over age 18 binge drank in the past month. An estimated 564,490 people over age 18 needed SUD treatment, but 70/82 counties are geographic mental health shortage areas, seventh in nation in mental health care deserts. MSDH implemented a statewide universal SUD digital screening program linked to comprehensive evidence-based SUD medication assisted treatment (MAT) delivered through remote telehealth providers.
Methods: SBIRT is an evidence-based tool used to rapidly 1) detect alcohol and substance use causing harms or placing individuals at risk for future harms; 2) provide a brief awareness raising and motivation enhancing intervention; and 3) refer individuals with severe substance use concerns to treatment.
MSDH designed an identification-to-treatment care pathway using EHR digital health tools and integrated telehealth capabilities. Patients receiving care for any reason at all 86 MSDH clinics are screened for SUD. Backend logic indicates to clinic clerks a screener is needed and generates a QR code clerks scan with an electronic tablet to generate a personalized screener for patients with branching logic and automated scoring integrated directly into patient’s electronic medical record. Scores are automatically risk stratified and generate EHR messages directing clinical teams to appropriate score-based interventions. Highest risk patients are referred to treatment via EHR to LCSW/RN navigators linking patients to treatment with addiction medicine specialists via video telehealth. An electronic evaluation tool collects demographic, social connection, descriptive clinical data, outcomes data from patients at intake, 6 months, and discharge.
Results: Universally screening unique patients presenting at MSDH’s state-wide 86 clinic network led to nearly 1% of the state’s population screened for SUD. Referrals for addiction medicine were received from 45 clinics representing 44 unique counties in Mississippi. Active patients are treated via telehealth in 48 different clinics representing 47/82 unique counties in the state. Patient No Shows were 37.5% lower than clinic network average. Abstinence from alcohol or illegal drugs improved by 58.3% for MSDH patients at 6 month follow up compared to national average improvement of 38.7%. Compared to intake, there was a 30% improvement in MSDH patients who were currently employed or attending school and 6.3% improvement in patients who had stability in housing. Mental health outcomes included a 30.8% reduction in depression; a 6.7% reduction in anxiety; a 45.5% reduction in trouble understanding, concentrating, or remembering; and a 50% reduction in trouble controlling violent behavior. 0% of patients were using opioids or other stimulants compared to 25% and 12.5% respectively at intake. Other drug use outcomes included a 40% reduction in alcohol use and a 50% reduction in cannabis use. Use of tobacco and nicotine decreased by 17.6%.
Discussion: A significant population of Mississippians have alcohol and drug use patterns with risk of negative health and psychosocial outcomes. SBIRT can be operationally difficult to implement, but the MSDH technology-enabled SBIRT screening model is notable as all care is fully integrated into existing clinic care delivery pathways. Technology ensures quality and fidelity for the entire SBIRT procedure and provides ability to monitor each care step across a state-wide network of clinics. Connected care enabled decentralized addiction medicine treatment to the entirety of Mississippi via a limited clinical workforce. Preliminary treatment outcomes and comparative measures indicate the model is as or more effective to similar in-person care, supporting access for patients in treatment deserts. The approach should be explored further for its ability (a) to remove barriers to access, (b) to form a therapeutic alliance with the patient, (c) to provide evidence-based pharmacotherapy via telehealth.
Brain Works: Designing and Implementing an ECHO Series About the Developing Brain to Rural Educators
Stephanie Punt PhD1, Cordaris Butler MA2, Mariana Rincon Caicedo MA2, Kristy Gagnon BA3, Robert Stiles MA MPH3, Eve-Lynn Nelson PhD3
1University of Califorina Los Angeles 2University of Kansas 3University of Kansas Medical Center
Primary Email:spunt@mednet.ucla.edu
Background: Interventions to support professional development and learning among school professionals are needed in rural and under-resourced communities. Geographic isolation and rising costs of continuing education programs further hinder professional learning. Understanding childhood and adolescent developmental stages is an important first step in helping students learn about their brains, how they think, and how they can cope with big emotions. With recent brain health equity initiatives by federal bodies, there has been an increasing interest in tailoring education toward educators and students that emphasizes how learning about the brain can be used to capitalize on learning and classroom behaviors. School professionals are in a unique and pivotal position through which they can apply knowledge about how the brain works to the learning environment. Telementoring initiatives are a way to address health equity issues in their ability to reach more people in a dynamic and responsive way.
Methods: Our team, Telehealth ROCKS has extensive experience with delivering Project ECHO-based teletrainings and telementoring experiences to geographically isolated regions. Project ECHO (Extension for Community Healthcare Outcomes) was designed to support health professionals working in rural and under-resourced communities to improve patient outcomes. ECHO connects multidisciplinary professionals located at “expert hubs” with members of a community-based workforce or “spokes” utilizing video-conferencing technology. Based on local community and stakeholder feedback from recent resilience and well-being Project ECHOs delivered to school professionals across under-resourced areas across the Midwest, we developed a three-part training series focused on brain development in children and adolescents. During this series, brain health, developmental milestones, biology behind emotions, and neuroanatomy are discussed by psychologists and neuropsychologists. Former ECHO participants and local school professionals were invited to participate and filled out a pre-series survey. Demographic information was collected as well as information about their profession, skills they hope to learn, and previous experience with our ECHOs.
Results: In total, 148 people filled out the pre-survey data, with 199 attending the first session and 288 pre-registering for the second session. 49% of participants had attended a previous ECHO training by our team and 86% of participants had previously participated in a training (any kind) on brain development. Most participants (66%) currently work extensively with students in elementary school. Among participants who responded to a feedback survey (n=43), many expressed interest in additional information, with most interest around the topics of regulation skills (53%) brain development (30%), and intervention and motivation skills for students (16%). 94% of attendees indicated that they incorporate information about the brain and developmental milestones into their teaching, 92% indicated the knowledge gained is helpful in their work with children, and 37% reported limited access to this information outside of this resource. When participants were asked what they would like to put into practice or “work on” until the second session, 33% (15/45) reported implementing calm/calming techniques, and 31% (14/45) limiting multi-tasking. 96% Of participants affirmed being motivated to share their learning.
Discussion: Bolstering and supporting school personnel through increasing exposure to brain health concepts as well as developmental milestones helped increase participant knowledge related to the role of coping with big emotions as well as improving learning and memory approaches in the classroom. Programs that directly tap into areas that the community stakeholders requested assistance with can have downstream positive effects on student well-being, stress, and cognition. Future interventions will have to evaluate how learning about brain health and the synergistic effect of emotions and cognition can quantitatively impact student learning.
Chronic Conditions Associated with Video-Based Primary Care at the Veterans Health Administration
VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy
Primary Email:caroline.yoo2@va.gov
Background: Video-based care continues to offer advantages to patients, especially for those with access barriers (e.g., lack of transportation) or a need for flexibility (e.g., childcare). Many chronic conditions are managed in primary care settings, and their treatment often requires frequent follow-ups. Video-based care can provide opportunities for follow-up visits while minimizing disruptions to patients’ lives. Prior studies have explored video use in primary care in terms of the likelihood of choosing video, utilization rate, and characteristics at patient, provider, and organization levels. However, there is a knowledge gap in terms of which chronic conditions are managed via video. Studies of visit diagnosis may suggest the suitability or preference for video visits for certain conditions. The objective of this study was to identify the top five chronic conditions that are more likely to be managed by video-based care among primary care patients at the Veterans Health Administration (VHA).
Methods: We conducted a nationwide retrospective study of primary care visits at the VHA, examining the association between chronic conditions and video-based care in primary care settings over 11 months (1/1/2023-12/1/2023). Using electronic health records, we identified the diagnosis of each visit and grouped the diagnoses into 27 chronic conditions categories. Video visits were identified using clinic and CPT codes. We first calculated the unadjusted percentage of primary care and video-based visits by chronic conditions and identified the top five conditions utilizing video-based visits. We used multivariable logistic regression model to examine the association between chronic conditions and the likelihood of a video-based visit, adjusting for patient socio-demographics characteristics known to be associated with video use, such as age, gender, race/ethnicity, marital status, rurality of residence, and VA’s definition of military service-related disability in determining benefits, and clustering of visits within patients. We calculated predicted probabilities of video use for each chronic condition.
Results: We identified 4,428,172 patients and 18,861,266 primary care visits during the study period. The mean age for patients was 62.9 (SD=16.5), 89.8% were male, 33.7% were non-White, 34.9% resided in rural areas. Overall, video-based visits represented 4% of total primary care visits (760,977 visits). In unadjusted analyses, we compared the prevalence of video visits versus total primary care visits by diagnoses. Hypertension was the most frequently addressed diagnosis in video-based care (14.0% of video visits) compared to its representation in all primary care visits (9.7%). Diabetes was the second most common diagnosis in video visits (10.1%), compared to 11.2% in all primary care visits. Musculoskeletal pain accounted for 7.2% of video visits (versus 4.0% in all primary care visits), hyperlipidemia for 4.1% (versus 2.3%), and other cardiovascular diseases (CVD) for 3.3% (versus 2.9%). After adjusting for clustering effect of visits within patients and patient characteristics, the predicted probabilities of video-based visits were 7.7% (95%CI:7.6-7.8) for hyperlipidemia, 7.1% (95%CI:7.0-7.2) for hypertension, 7.1% (95%CI:7.0-7.1) for musculoskeletal pain, 7.0% (95%CI:6.9-7.1) for other CVD, and 4.9% (95%CI:4.8-4.9) for diabetes.
Discussion: This study provides insights regarding which chronic conditions are more managed by video-based primary care. The study findings indicate chronic conditions, such as hyperlipidemia, hypertension, musculoskeletal pain, other cardiovascular diseases, and diabetes were associated with higher likelihood of video use in primary care settings. For these conditions, video-based care may be a preferred modality of care for patients to manage their chronic conditions in between in-person/in-clinic visits. Further studies are needed to understand how these preferences impact primary care utilization and quality of care. Having a better understanding of which health conditions are well suited for video-based primary care can help guide clinical policies and practices of telemedicine for chronic care management. This study can serve as a foundation for future research, which can ultimately guide the creation of evidence-based hybrid (virtual and in-person) care models in primary care.
Telehealth and Patient Portal Use Disparities Before and During the COVID-19 Public Health Emergency
Jennifer Andersen PhD, Clare Brown PhD MPH, Rosario Silva MPH, Don E. Willis PhD, Mir Ali PhD, Mahip Acharya PhD, Cari Bogulski PhD
University of Arkansas for Medical Sciences
Primary Email:JAAndersen@uams.edu
Background: Digital tools such as patient portals and telehealth visits have the potential to increase health care access for underserved patient populations. The COVID-19 public health emergency (PHE) ushered in unprecedented levels of telehealth utilization; however, this rapid adoption has been met with concerns about how equitably these tools are being utilized among vulnerable patient populations. Evidence suggests that racial/ethnic and rural disparities in both telehealth and patient portal utilization pre-dated the COVID-19-PHE, and research is mixed on whether these disparities have been exacerbated by the COVID-19-PHE. The current study examined whether associations between race/ethnicity and the likelihood and number of patient-initiated messages changed from pre- to post-COVID-19 PHE.
Methods: We conducted a retrospective pre/post analysis of electronic health record data from a large academic medical center from April 2019 to February 2021. Patients were included if they were age 18+ and had at least one health care encounter documented in the year prior to and the year following the declaration of the PHE (n = 80,153). Outcome variables included: 1) a binary indicator of any patient portal messaging; 2) a binary indicator of any telehealth utilization; 3) a count variable of the number of patient portal messages sent; 4) a count variable of the number of telehealth encounters. The key independent variable of interest was a binary pre/post indicator of the PHE. Covariates included age, sex, race/ethnicity, rural status, health literacy, and Medicaid/self-pay insurance status. In addition to the main effects for the primary independent variable and covariates, we included and interaction between the post-PHE variable and race/ethnicity. Data were fit to four models: logistic regression models for binary indicators of patient portal messaging and telehealth encounters and linear regression models for the number of patient messages and number of telehealth encounters among individuals with ≥1 message/encounter.
Results: We found higher rates of patient messaging (43% vs 37%; p< 0.001) and telehealth (34% vs 1%; p< 0.001) from pre- to post-PHE as well as an increase in the number of messages (8.5 vs 10.1; p< 0.001) and telehealth encounters (0.03 vs 2.15; p< 0.001) among those with ≥1 health care encounter. There were lower odds of messaging for rural, male, Black, Hispanic, older, and Medicaid/self-pay covered patients. There were higher odds of messaging with increases in health literacy. There were lower odds of telehealth utilization for rural, male, and Black patients, as well as with increasing health literacy. There were higher odds of telehealth utilization for older, other race/ethnicity, and Medicaid/self-pay covered patients. Black patients had increased odds of telehealth utilization (aOR=1.76, p< 0.001) from pre- to post-PHE relative to White patients. Among patients who sent ≥1 message during the study period, Black patients had an increase in the number of messages (β=0.76, p< 0.001) relative to White individuals from pre- to post-PHE. Among patients with ≥1 telehealth visit during the study period, Black patients had a decline in the number of visits from pre- to post-PHE relative to White patients (β=-0.14, p< 0.001).
Discussion: We found large increases in patient messaging and telegraphy utilization in the post-COVID period. Consistent with prior literature, we found lower likelihood and number of patient messages sent among Black patients, but also found that relative to White patients, Black patients had a relative increase in the number of patient portal messages in the post-COVID-19-PHE period. We also found that rural patients sent fewer patient messages and had fewer telehealth encounters relative to urban patients. Although digital tools such as patient portals and telehealth visits have increased since the COVID-19 PHE, additional examination and interventions are needed to ensure that all patients who would benefit from the use of these tools are able to access them.
The Social-Return-on-Investment of Telehealth Across Four Rural Counties in Washington State
Jason Goldwater MA MPA, Yael Harris PhD MHA
Laurel Health Advisors, LLC
Primary Email:jgoldwater@lh-advisors.net
Background: Laurel Health Advisors developed a social Return on Investment (ROI) model to evaluate telehealth’s impact in four rural counties in Washington State—Okanagan, Grant, Chelan, and Douglas. This initiative focused on quantifying telehealth's social and economic benefits by analyzing factors such as health care access, patient travel cost savings, and outcomes related to chronic disease management. Laurel Health Advisors assessed telehealth's ability to enhance health equity in these regions, where geographical barriers had long limited access to timely care. Engaging local health providers and community organizations gathered data on utilization rates, patient and provider satisfaction, and economic effects, including potential reductions in emergency room visits and hospital admissions. The resulting model offered a comprehensive understanding of telehealth's value.
Methods: Laurel Health Advisors employed a comprehensive methodology to develop the social ROI model. First, they collected quantitative data from Washington's All Payer Claims Database on telehealth utilization, patient demographics, and health care cost savings, analyzing metrics such as reduced travel expenses, decreased emergency room visits, and improved access to preventive care. This was complemented by qualitative Methods:, including interviews and surveys with health care providers, patients, and community leaders to capture perspectives on telehealth's impact on accessibility and quality of care. To quantify social outcomes, they used a valuation framework that assigned economic values to health outcomes and access improvements such as fewer missed workdays and enhanced chronic care management. By integrating these data points, the team created a dynamic model to estimate telehealth’s social and economic return on investment, offering actionable insights for stakeholders to support sustainable telehealth adoption in rural regions.
Results: The Results of Laurel Health Advisors’ social ROI mode highlighted telehealth’s substantial social and economic value. The analysis showed marked cost savings from reduced travel for patients, especially those with chronic conditions requiring regular appointments. Emergency room visits and hospitalizations also declined as telehealth improved preventive care access, helping manage health issues before escalation. Community feedback underscored high patient and provider satisfaction, with telehealth increasing service accessibility and continuity of care. The model quantified these benefits, revealing significant positive ROI by factoring in reduced health care costs, economic gains from fewer work absences, and improvements in population health. The findings offered compelling evidence for further investment in digital infrastructure and policy support to scale telehealth sustainably, enhancing care access and quality across Washington's rural communities.
Discussion: The social ROI model for telehealth in Washington’s rural counties underscores telehealth’s transformative role in improving access to health care and economic efficiency. While Results: show promising ROI regarding reduced travel costs, emergency visits, and enhanced chronic care, they also highlight the necessity for digital infrastructure improvements, particularly broadband expansion, to reach underserved populations. Community feedback emphasized the value of telehealth in addressing health care disparities, though barriers like digital literacy persist. Laurel Health Advisors suggested that long-term policy and funding support for telehealth is significantly essential to sustain equitable access in geographically isolated areas. The insights from this study offer a replicable framework, suggesting that a well-supported telehealth system can be instrumental in achieving health equity and economic resilience in rural regions.
Expanding Telehealth Interventions as an Equitable Step for Hispanic/Latinx Youth
Mariana Rincon Caicedo MA1, Stephanie Punt PhD2, Eve-Lynn Nelson PhD3
1University of Kansas 2University of Califorina Los Angeles 3University of Kansas Medical Center
Primary Email:mrinconc@ku.edu
Background: Children and adolescents of Hispanic/Latine (H/L) origin face significant health disparities, specifically related to access to efficacious interventions for mental health disorders. Internalizing disorders are common among H/L youth, but research evaluating interventions among this population is scarce. The aim of this narrative review was to utilize an objective framework to examine the existing implementation and outcome literature related to internalizing disorder interventions among H/L youth as well as describe to what extent telehealth interventions are utilized and may provide a future avenue through which treatment equity can be addressed.
Methods: A comprehensive search of scholarly databases yielded 18 articles (discussing 13 individual studies) included in this review. The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) Framework was utilized to assess study information regarding populations included in this research area thus far, identify potentially valuable adaptations and strategies used to increase engagement and impact of interventions among H/L participants, and the general efficacy of interventions for this population.
Results: Participant ages ranged from 4 to 17 years. Articles were published between March 1994 and February 2023. The total study sample size (M=132.6, SD=97.7) and Hispanic participant sample sizes (M=96.1, SD=85.3) ranged from 16 – 341 participants. Heterogeneity in outcome measurement variables impeded the direct comparison between articles and interventions. Findings yielded valuable information regarding strengths and barriers in providing services to this population, key adaptations implemented to make the interventions culturally appropriate, which included conducting the intervention in Spanish, having materials accessible in Spanish, and having bicultural providers involved. Recruitment sources varied across studies including community-based events, primary care clinics, and school-based organizations. Of these 18 studies, only one utilized telehealth in its nascent form, telephone-only contact to facilitate intervention delivery. One study reported improved acceptability with telephone-delivered, therapist-assisted bibliotherapy. Besides this study’s self-paced intervention that included one telephone-based therapist support condition, none of the other identified studies used telehealth with both visual and audio components.
Discussion: H/L children and adolescents face significant health disparities and continue to have reduced access to interventions for internalizing disorders. Anxiety, depression, and other internalizing disorders appear to be common among H/L youth and are present at even greater rates in youth grappling with substance use, developmental, and externalizing disorders and chronic health conditions. While recent efforts have been made to develop culturally appropriate interventions for anxiety and depression, few have been implemented in youth. Our review of the literature highlights this scarcity in the accessibility of culturally-adapted interventions for H/L youth, especially as telehealth remains an underutilized modality in this population. Future studies will need to directly address this paucity in the literature and strive to develop ways through which health equity may be addressed.
Demographic and Health Care Utilization Patterns of Direct to Consumer Telehealth for URI
Seyedehyasmin Moghaddamziabari, James Marcin MD MPH, Tonya Khounani, Daniel Black, Daniel Stein, Derek petersen, Aniket Alurwar, Guibo Xing
University of California Davis
Primary Email:ymoghaddam@ucdavis.edu
Background: Express Care is a direct-to-consumer, on-demand video platform providing same-day, non-urgent medical consultations. It aims to improve health care access and reduce unnecessary visits to urgent care and emergency departments for non-urgent conditions, such as upper respiratory infections (URIs). This study aims to compare the demographic characteristics and health care utilization patterns of Express Care users and non-users for URIs to assess whether Express Care effectively addresses health care access barriers and serves as a substitute for in-person care.
Methods: A retrospective analysis was conducted on patients with URIs at UC Davis Health from 2018 to 2025. Demographic, health care utilization, and comorbidity data were compared between Express Care users and non-users. ICD-10 codes were used to identify encounters for URIs; California Healthy Places Index (CAHPI) scores were used to assess social determinants of health; the Elixhauser index was used to determine comorbidity burden; and linked census data was used to determine zip code median household income. Outcomes included differences in health care access, utilization patterns, and substitution for in-person care. Statistical comparisons of key demographic variables between cases and controls were made using chi-square tests and t-tests in SAS.
Results: 26,991 unique patients from a total of 38,205 URI encounters were analyzed, including 2,863 (10.61%) Express Care users and 24,128 (89.39%) non-users. 65.17% of Express Care users were female, compared to 62.57% of non-users. The racial/ethnic distributions showed that 56.65% of Express Care users and 53.87% of non-users were Non-Hispanic-White, while 14.29% of Express Care users and 15.94% of non-users were Hispanic/Latino. Although the mean age was similar between groups (mean age 40.10 years for Express Care users vs. 40.16 years for non-users), Express Care users were most common (50.96%) in the 31-50 age category, with relatively fewer users in the 0-17 (4.66%) and older than 65 years (10.75%) categories. Express Care users, similar to non-users, were predominantly covered by commercial insurance (84.84%), with relatively fewer on Medicare (11.25%), and Medicaid (3.91%). The CAHPI score was 13.33% lower for Express Care users, with a mean of 0.26 (SD: 0.40) versus 0.30 (SD: 0.39) for non-users. Express Care users had a lower comorbidity burden, averaging 1.44 (SD: 1.66) compared to 1.69 (SD: 2.01) for non-users. Median household income was lower for Express Care users ($97,380) compared to non-users ($100,112).
Discussion: This analysis of mostly commercially insured patients demonstrates that Express Care attracts a healthier population with fewer comorbidities. However, Express Care users were from lower-resourced communities with zip-codes associated with a lower median household income. Further research will focus on exploring Express Care's usage patterns, including the frequency of visits, types of conditions treated, and its potential to substitute traditional in-person services.
Balancing Patient Care and Climate Action: The Role of EConsults in Reducing Travel and Emission
Devin Miller MPH, David Saxon MD, Stephanie Grim MS MPH, Mayra Loera De Luna, John Thomas PhD
University of Colorado - Peer Mentored Care Collaborative
Primary Email:devin.2.miller@cuanschutz.edu
Background: Health care delivery often requires travel to urban academic medical centers (AMCs) for specialty care. This travel can create significant burdens for patients, especially those in rural areas, and contribute to environmental pollution. eConsults offer an asynchronous communication model between primary care providers (PCPs) and specialists, enabling patient care without requiring in-person visits. While telemedicine’s environmental benefits have been explored, the impact of eConsults on reducing travel, fuel consumption, and greenhouse gas emissions remains under-examined. This study analyzes the environmental and travel-related outcomes of the University of Colorado’s eConsult program, demonstrating how telehealth innovations can enhance care access and contribute to environmental sustainability
Methods: This retrospective observational study analyzed data from the University of Colorado’s eConsult program from July 2018 to September 2024. Program data were extracted from the electronic health record (Epic) and included eConsult volume, patient demographics, and travel savings metrics. eConsults that replaced in-person specialist visits were identified, and round-trip travel distances were calculated using patient home zip codes and the academic medical center’s location. Travel time savings were estimated using Google Maps route optimization, and travel cost savings were calculated using IRS standard mileage rates. Fuel consumption and emissions reductions were estimated using average passenger vehicle fuel economy (22.9 miles per gallon) and emission factors from the Environmental Protection Agency (EPA). eConsults converted to in-person visits or denied for logistical reasons were excluded from the analysis. Program growth was forecasted and future emissions savings through 2029 to provide a long-term view of the environmental impact.
Results: Between July 2018 and September 2024, the eConsult program processed 26,970 requests, with 20,468 (76%) completed, replacing in-person visits to specialists. The program saved a total of 888,098 miles of travel, 13,037 hours of travel time, 38,781 gallons of fuel, and $174,314 in travel costs. Emission reductions included 365 metric tons of CO2, 0.062 tons of nitrogen oxide, 0.015 tons of methane, and 0.003 tons of nitrous oxide, totaling 365.08 metric tons of greenhouse gasses. The program experienced significant growth, with eConsult volume increasing from 436 in its first year to 4,992 in the first 3 quarters of 2023, reflecting an annual growth rate of 52.8%. Forecasting models project the program could eliminate over 1.1 million miles of travel and reduce 478 metric tons of CO2 emissions by the end of 2029. These findings highlight the dual benefits of eConsults in improving health care access and contributing to environmental sustainability.
Discussion: This study demonstrates that the eConsult program reduces patient travel, fuel consumption, and greenhouse gas emissions. By replacing in-person specialist visits, the program saved substantial time, costs, and emissions, underscoring the potential of telehealth to improve access, especially for rural patients, while minimizing environmental impact. The reduction of CO2 aligns with national decarbonization goals and highlights health care’s role in reducing emissions. The program’s rapid growth suggests increasing adoption of telehealth could further amplify environmental benefits. Future research should explore additional factors, such as socioeconomic impacts, patient outcomes, and the potential for expanded use of telehealth services. Overall, eConsults demonstrate a promising model for integrating sustainable practices into health care delivery while enhancing patient care and access.
KangaZoom: Neonatal Intensive Care Virtual Visits Program
Adithi Mahankali1, John Feltner MS1, Meg Larkin BSN RN RNC-NIC2, Reece Alstat BS2, Rachel Umoren MBBCh MS1,2
1University of Washington 2Seattle Children's Hospital
Primary Email:adithipm@gmail.com
Background: Long-term neonatal intensive care unit (NICU) hospitalizations are associated with emotional and financial stress for the families. Family visits support bonding with the baby and active involvement in their care leading to healthier outcomes. Live-streaming video platforms have been utilized in many NICUs for virtual visits to supplement in-person presence and allow for interaction with extended family and friends. The objective of this study is to describe the implementation of a regional referral Level IV NICU virtual visit program and evaluate its impact on caregiver and patient bonding during the infant’s hospitalization.
Methods: Mixed methods program evaluation utilizing program logs, surveys and interviews of parents and caregivers who used the virtual visits at least once during the NICU stay. The Seattle Children’s NICU receives referrals from a 4-state region in the Pacific Northwest. In 2021, the KangaZoom program was introduced as an option for families to supplement in-person visits. The caregiver received a dedicated Zoom meeting ID which they used for the duration of the infant’s NICU stay. Nursing staff supported the virtual visit using a bedside ipad. The frequency, duration, and number of participants for each visit were available through the Zoom platform. Caregivers were identified through their relationship with the patients for which virtual visits occurred. Data collection on caregiver perspectives using surveys and interviews is in progress.
Results: 61 virtual visits were logged from July 2021-June 2022 (year 1), 130 virtual visits were logged from July 2022-June 2023 (year 2), and 230 virtual visits were logged from July 2023-June 2024 (year 3). The median call duration was 20 (IQR 51) minutes for year 1, 20.5 (IQR 53) min for year 2, and 34 (IQR 90.25) min for year 3. The median number of participants was 3 (IQR 1) participants for year 1, 2 (IQR 1) participants for year 2, and 2 (IQR 1) participants for year 3. Most caregivers used the program one to two times during the hospitalization (Range 1-69), and many of the calls occurred between 7am - 7pm. A total of 5 surveys have been completed with overall positive views on the program.
Discussion: The KangaZoom virtual visits program was implemented successfully in a Level IV NICU to supplement in person visits with ongoing data collection on caregiver impact.
Telemedicine Curriculum Integration in an Undergraduate Nursing Program at Hardin-Simmons University
Aaron Duebner PH-Dc MSN RN CNE, Sandra Welling PhD RN PAHM CCM CNE, Mary Gaukler Giannavola MSN MBA RN-BC CHSE
Hardin Simmons University
Primary Email:aaron.duebner@hsutx.edu
Background: As telehealth becomes essential in health care, nursing education must evolve to prepare future professionals for virtual care challenges. The COVID-19 pandemic highlighted significant gaps in nursing students' knowledge and familiarity with telehealth technologies. Many students lack the technical and interpersonal skills necessary for effective telenursing, underscoring the urgent need for curriculum reform. This curriculum aims to shape the nursing students' understanding, preparedness, competency and perceptions of telehealth.
Methods: This initiative is guided by the Four P’s of the Telehealth Framework. This framework emphasizes the importance of patient-centered care and provider preparedness, offering a structured approach to developing telehealth competencies needed in the evolving health care system. Targeting 75 undergraduate nursing students at Hardin-Simmons University (HSU), the project incorporates innovative curricular elements designed to enhance telehealth education. Key components of the curriculum include Interactive Learning Experiences-These are woven throughout the program to foster engagement and knowledge retention. Didactic Sessions-Classroom instruction that covers theoretical foundations and principles of telehealth. Clinical Training-Hands-on experiences that allow students to apply their knowledge in real-world settings including rural health settings. Telehealth Simulation-Simulated telehealth scenarios that provide students with opportunities to practice and refine their skills in a controlled environment. Structured Debriefing Sessions-These sessions encourage self-discovery, reflection and critical thinking, allowing students to analyze their experiences and integrate feedback into their practice.
Results: It is expected that the preliminary findings will indicate that while students hold positive attitudes toward telehealth, their specific knowledge of telenursing practices is inconsistent. It is expected after completion of the program that students will show a higher level of knowledge, confidence and competency in telehealth. Data will be collected through surveys, simulation debriefs, and clinical assessments, utilizing validated instruments to assess knowledge, skills and attitudes.
Discussion: This project underscores the importance of integrating telehealth competencies into nursing curricula, preparing students for an evolving health care environment. By enhancing technological proficiency and critical thinking, HSU aims to develop skilled nurses capable of improving patient outcomes, ultimately contributing to better health care access and quality in diverse settings.
Nonverbal Behavior in Telehealth Visits: A Narrative Review
Conor Duffy MS, Eric Benotsch PhD
Virginia Commonwealth University
Primary Email:duffyc2@vcu.edu
Background: Patients and providers have reported that communication and building rapport are challenges in telehealth. One potential factor that contributes to these challenges is that telehealth impedes patients’ and providers’ ability to use and interpret nonverbal behaviors (NVBs). Telehealth alters some NVBs (e.g., eye contact, hand gestures) and eliminates others (e.g., touch). Prior research has demonstrated that NVBs such as forward lean, direct body orientation, and eye contact are associated with perceptions of greater physician empathy and rapport during in-person health visits. However, as the nature of NVB differs between telehealth and in-person care, it is critical to examine whether, and in which contexts, these findings extend to telehealth visits. This review aimed to synthesize evidence on the role of NVBs in telehealth visits. Specifically, we investigated which NVBs have been examined in the context of telehealth and the methodologies that have been used in this research.
Methods: To identify relevant studies, a systematic and reproducible search was conducted using PubMed, PsycINFO, CINAHL, and EMBASE. Search terms included words related to telehealth, NVB in general, and specific NVBs identified through relevant literature. After removing duplicates, 315 studies were included in the initial search. The principal investigator screened abstracts for relevance and then obtained and reviewed the full texts of relevant articles. Studies that reported findings related to NVB in the context of synchronous telehealth visits were selected for data extraction. For studies that met inclusion criteria, the following information was extracted: whether NVB was the primary topic of the study, sample characteristics, study design, types of NVB examined, patient and provider perspectives, associations between NVBs and patient-centered outcomes, methodologies used to examine NVB, and a summary of findings. We determined whether NVB was the primary topic of the study based on whether NVB was referenced in the authors’ research objectives and/or measures.
Results: Data were extracted from 50 studies. Thirteen studies examined NVB in telehealth as a primary aim of the study. The categories of NVB examined most frequently were gaze (25 studies) and facial expressions (18 studies). Additionally, eight studies reported findings related to gesture, five head movements, four proxemics, and four posture. Twenty-six studies used qualitative approaches, 10 quantitative, and 14 mixed methods. Most studies examined provider (28 studies) and/or patient perspectives (19 studies), while only 3 studies examined associations between NVBs and patient-centered outcomes. Patients and providers reported that it was more difficult to make eye contact and to interpret facial expressions and gestures in telehealth visits. Providers reported some strategies to facilitate more positive communication in telehealth, including leaning forward, exaggerating facial expressions and gestures, monitoring their own facial expressions, and positioning themself directly in front of the camera. Quantitative studies examining associations between NVBs and patient-centered outcomes found that gazing at the camera (vs. screen), mimicry of smiles and frowns, and head nods are associated with more positive outcomes.
Discussion: This review found that six NVBs– gaze, facial expression, gesture, kinesics, head movement, proxemics, and posture– have been studied in the context of telehealth. Patient and provider perspectives revealed some potential strategies that could be used to enhance the quality of communication in telehealth visits. However, it is important to note that there is little empirical evidence for the effectiveness of these strategies. These recommendations were primarily identified from qualitative research exploring patients’ and providers’ perspectives on NVB in telehealth rather than examining associations between specific NVBs and patient-centered outcomes. While this field has generated valuable initial evidence, there is a need for future research to use quantitative measures of NVBs and examine the role of NVB in naturalistic telehealth visits. This research will inform the development of evidence-based interventions that improve patient-provider communication in telehealth visits.
Asynchronous Care Addressing Access Issues in the Pediatric Dermatology Population
Melanie Hazlewood, LSW
Cincinnati Children's Hospital
Primary Email:melanie.hazlewood@cchmc.org
Background: Access to pediatric dermatologists is notably restricted, with wait times for appointments reaching up to 4-6 months. This delay can adversely affect the timely diagnosis and treatment of skin conditions in children, thereby increasing the urgency for effective solutions. Telemedicine has been proposed to streamline dermatological services for pediatric patients. eVisits, an asynchronous form of telemedicine is an emerging viable solution to address the significant access issues, while allowing health care providers to deliver care remotely, thereby eliminating some traditional barriers associated with in-person visits, such as logistical challenges and lengthy waiting periods.
Methods: Since 2022, the dermatology division has initiated and launched a total of five eVisits addressing various conditions aimed to enhance accessibility, provide efficient care, and improve overall patient satisfaction. The evaluation of the eVisit programs was conducted using data obtained from the electronic medical record system. We evaluated the eligible dermatology visits that could be provided care via an eVisit, rather than an in person visit. We monitored completed eVisits monthly, versus canceled visits, new patients versus repeat patients, reason for visit, as well as revenue and clinician time to complete the eVisit on a quarterly basis.
Results: eVisits enhance health care access by overcoming traditional barriers such as scheduling conflicts, limited clinic hours, and transportation issues, offering numerous benefits. Firstly, they provide convenience, enabling patients to participate from home at their convenience while saving time and travel costs. Secondly, they promote efficiency by allowing clinicians to systematically review patient data. Additionally, eVisits can generate financial gains by reallocating suitable care from in-person visits to virtual ones, optimizing the overall visit schedule. Lastly, the data collected through eVisits contributes to the medical record, helping clinicians identify trends and improve patient care. In Fiscal Year 2024, four dermatology clinicians successfully conducted 406 eVisits across a range of diagnoses, effectively optimizing their in-person appointment availability for patients who require face-to-face consultations. This shift illustrates the clinicians’ ability to leverage telehealth to address a broader spectrum of dermatological concerns while ensuring that those in need of more intensive care receive timely, in-person attention.
Discussion: eVisits effectively address access issues in pediatric dermatology by offering patients uninterrupted treatment and the flexibility to attend appointments at their convenience. For clinicians, these asynchronous visits enhance treatment adherence and streamline organizational processes while generating revenue. This model improves access to care by allowing clinicians to prioritize in-person appointments for patients who require them, all while efficiently addressing medical concerns, answering questions, and delivering necessary care through a convenient platform.
Videoconferencing-based Child Behavioral Health Assessment and Interventions: A Systematic Review
E (Alice) Zhang PHD1, Annaleis Giovanetti PhD2, Stephanie Punt PhD3, Don Hilty MD4, Eve-Lynn Nelson PhD1
1University of Kansas Medical Center 2San Diego VA 3University of Califorina Los Angeles 4UC Davis School of Medicine
Primary Email:zhange1224@gmail.com
Background: Behavioral health challenges are prevalent among youth, with 1/5 of children and adolescents experiencing a diagnosable behavioral, emotional, or developmental condition. The rising rates of mental health struggles and suicide attempts, particularly during the COVID-19 pandemic, led to a national child mental health emergency declaration, underscoring an urgent need for accessible care options. Telehealth, specifically videoconferencing-based telebehavioral health ((VC-TBH), has emerged as a key solution for bridging care gaps. While evidence for TBH effectiveness has grown, especially in structured environments, a need remains to better understand the unique strengths and limitations of VC-based assessments and interventions in more diverse, often unsupervised settings like homes. This review examines the efficacy of pediatric VC-TBH, aiming to characterize treatment types, settings, and research gaps.
Methods: This systematic review adhered to PRISMA guidelines, using a MeSH-based keyword search across PubMed and PsycINFO for studies published between January 2000 and September 2023. Focusing on randomized control trials of synchronous VC-TBH assessments and interventions for pediatric populations, four concept areas structured the search: population, video conferencing, behavioral health, and service. A multi-stage, iterative selection process involved at least two independent reviewers for screening and inclusion, with any discrepancies resolved by consensus with a third reviewer. Studies met inclusion if they targeted youth under 18 with behavioral and developmental conditions, utilized replicable manualized psychotherapeutic techniques, and were peer-reviewed in English. Exclusions included studies without a primary behavioral health focus, those focusing on non-video technology, and non-peer-reviewed publications. Reviewers independently assessed the risk of bias using the Cochrane RoB 2 tool, examining domains like allocation concealment and reporting bias. A customized data extraction form supported the systematic synthesis of intervention characteristics, outcomes, and study quality.
Results: A total of 41 studies originated from 34 RCTs were identified. Participant ages ranged widely from 1 to 18 years, with a mean sample size of 62.24, emphasizing the broad applicability of telebehavioral health across developmental stages. Most studies included caregivers (typically mothers) alongside child participants, with male children comprising the majority in 26 trials. Conditions focused on included anxiety, depression, autism, disruptive behaviors, traumatic brain injury, and various chronic health conditions, with interventions like cognitive behavior therapy, parent child interaction therapy. Most studies are U.S.-based, although international representation from Canada, Sweden, and Iran demonstrated global relevance. Most interventions (59%) occurred at home, with fewer in clinical or school settings, underscoring the flexibility of videoconferencing. Effectiveness comparisons generally favored or matched in-person care, with VC shown effective for anxiety, depression, and developmental disorders and comparable outcomes for medical conditions like obesity, epilepsy, and TBI.
Discussion: This review highlights the role of VC-TBH in managing a variety of conditions, including depression, anxiety, ADHD, autism, and pediatric chronic illnesses. VC-TBH demonstrates outcomes comparable to in-person care across diverse settings and populations. VC-TBH increases accessibility and shows strong efficacy for psychotherapy and family interventions. Expanding research that focuses on individualized technological and clinical settings, as well as addressing provider satisfaction, can enhance VC-TBH adoption and optimize its role in pediatric behavioral health.
The Journey to Establish a Multisite Central Telemetry Monitoring Center
Laura Lopez RN MSN PCCN, Cindy Welsh RN MBA FACHE
Advocate Health
Primary Email:laura.lopez@aah.org
Background: In 2018, Advocate Health Care was on a journey to become a High Reliability Organization. Part of that journey included conducting an inventory of safety events and identifying areas for improvement. One of those clinical areas with a high volume of events and utilization, was telemetry. The system committed to decreasing safety events and embarked on a multi-year journey to do so. As part of the plan to standardize care around telemetry monitoring, a decision was made to create a central telemetry monitoring center (CTC) in which all nine adult hospitals would have their telemetry patients monitored in a remote, central location. The advantages of this approach were many, a few among them were standardizing workflows around patient monitoring, economies of scale in staffing and freeing of highly sought and scarce space on the hospital campus.
Methods: The organization embarked on a journey to bring seven unique monitoring areas and two sites with a de-centralized model together in one location with one scope of service and a standardized workflow including: guidelines around lead management to ensure continuous monitoring, electronic order sets for telemetry indication and duration (using AHA guidelines), use of the EMR to enhance telemetry patient identification and CTC to bedside care team communication. Additionally, two big keys to success: an escalation algorithm that defines action to be taken around specific arrhythmias and an initiative that significantly impacted patient safety events – the concept of one tele box per patient per stay.
Results: The organization was successful in launching a remote telemetry monitoring center for 9 sites with the ability to monitor over 1,400 patients. Data collection has shown that a central monitoring center with standardization of care, utilizing an escalation algorithm for decision making, has had a positive impact, that improves patient safety. This had led to a significant decrease in safety events. The efforts in the process improvements have eliminated previously seen gaps and/or errors in monitoring. Utilizing the escalation algorithm has promoted the culture where the patient's leads are addressed within 5 min to be able to resume monitoring. The data also shows emergency response teams are activated accurately to get help to all the patients that meet a threshold or display a lethal rhythm quickly.
Discussion: These initiatives and their Results: will be discussed, including the many lessons learned along the journey.
Telehealth and Post-Stroke Gender-Based Care Patterns
1Tulane University 2University of Arkansas for Medical Sciences
Primary Email:bwalker6@tulane.edu
Background: Strokes are one of the top causes of death and disability in the United States. Patients who survive a primary stroke are at a significantly increased risk for a secondary stroke with about 10% suffering a recurrence within one year and a quarter suffering a recurrence within five years. Post-stroke follow-up care plays a pivotal role in establishing recurrence prevention strategies and in improving long-term outcomes. However, the uptake of post-stroke care remains low, with approximately 40% of stroke patients receiving no follow-up services. Telehealth may be a convenient care option for stroke follow-up care. Additionally, while women tend to fare worse following a stroke, multiple descriptive studies have shown that women are also more likely to use telehealth, further positioning it as a potentially equity-increasing care modality.
Methods: We utilized data from the Arkansas All Payer Claims Database (APCD) for care between the years 2016 to 2023 (i.e., four years before and four years during the 2020 COVID-19 pandemic). Patients with at least one ICD-9 or ICD-10 diagnosis code for an ischemic or hemorrhagic stroke were included. Annual unique patients with at least one telehealth visit were identified using CPT and place of service codes while annual unique patients with a secondary stroke were identified using ICD-9 or ICD-10 codes. We then used regression analysis to assess patterns of telehealth uptake and secondary stroke by gender (i.e., male versus female) and insurance (i.e., Medicaid versus commercial) in the pandemic era versus prior to the pandemic era.
Results: Telehealth use among stroke patients was at negligible levels until the 2020 COVID-19 pandemic when about 6% of patients used telehealth regardless of gender or insurance coverage. Utilization then decreased through 2023 to about 2% with no overall statistically significant differences by gender: between 2020 and 2023, women with Medicaid utilized telehealth 3.32 percentage points more often than between 2016 and 2019 (95% CI: 1.04 to 5.61, p=0.012), while men with Medicaid utilized telehealth 3.30 percentage points more often (95% CI: 0.86 to 5.73, p< 0.01). Women with commercial insurance similarly increased telehealth utilization by 3.68 percentage points (95% CI: 0.92 to 6.43, p=0.02), as did men by 4.03 percentage points (95% CI: 1.63 to 6.42, p< 0.01). The pandemic era was also associated with fewer secondary strokes: women with Medicaid saw 7.32 percentage points fewer secondary strokes (95% CI: 13.55 to 1.11, p=0.03), while men with Medicaid saw 5.90 percentage points fewer secondary strokes (95% CI: 11.20 to 0.60, p< 0.03). Women with commercial insurance similarly saw 12.99 percentage points fewer secondary strokes (95% CI: -24.55 to -1.42, p=0.03), as did men by 7.32 percentage points (95% CI: -16.35 to 1.70, p=0.09).
Discussion: This descriptive analysis finds that telehealth utilization rates were similar across genders and that its use coincides with a decrease in secondary stroke rates among stroke patients in Arkansas. While this potential link is promising, there are several limitations to this study including potential internal validity challenges given that this research is only associative in nature and potential external validity challenges given that it utilizes data from a single state. It is also unclear whether telehealth is used as a substitute for in-person care or as a complement. That said, these findings provide a foundation to further explore the role that telehealth may play in decreasing the risk for a secondary stroke among stroke patients. This was made possible by the HRSA of the US DHHS as part of the National Telehealth Centers of Excellence Award (U66RH31459). The contents are those of the authors and do not necessarily represent the official views of HRSA, HHS or the US Government.
Realizing the Value of Virtual Care Programs
Judd Hollander MD, Frank Sites RN BSN
Jefferson Health
Primary Email:judd.hollander@jefferson.edu
Background: Advancing virtual care health requires a realistic conversation that moves past innovation and “coolness” and begins to evaluate technology in the same manner as any other device being introduced into the health system. That focus is on value, which takes into account quality of care as well as cost. We have conceptual frameworks to measure quality of care but many researchers have had difficulty evaluating the costs of telemedicine. We developed several models to determine value of telemedicine programs which have been validated among executive leadership and financial leadership and rolled out in practice to determine if initial assumptions were met during implementation.
Methods: We established a multidisciplinary team of health system leaders to determine value and return on investment of 4 different telemedicine programs – remote patient monitoring, tele-triage in the emergency department, a comprehensive inpatient telemedicine program, and virtual check out in the ambulatory care setting. Programs were rolled across major hospitals or regions in our network and comparison of baseline assumptions and actual quality and costs were compared to those really achieved.
Results: Overall, the individual programs evaluated a range of <1000 patients per year to over 100,000 per year. With respect to quality of care, there was significant variability across programs as to whether they obtained the expected quality goals or not. When they did not obtain the expected goals it was always due to workflow and operations and not technology. With respect to financial performance, there was also variability based upon program. Technology costs were usually within target, but changes in full time equivalent and staffing were sometimes not realized.
Discussion: Telemedicine should not be thought of as a single entity. Programs have variable value propositions. Technology related costs were predictable, but staffing costs were not always achievable. Proper implementation of a telemedicine program requires attention to workflows and operations.
Repeat Hospitalizations Among Chronically Ill Medicare Beneficiaries Using Telehealth Post-Discharge
Yvonne Jonk PhD, Heidi O’Connor MS, Jean Talbot PhD, Deborah Thayer MBA
University of Southern Maine
Primary Email:yvonne.jonk@maine.edu
Background: A previous study found that the use of telehealth services for post-acute follow-up care is associated with higher rates of 30-day rehospitalization. Given that patients using telehealth tend to be more medically complex and have higher rates of comorbidity than patients not using telehealth, identifying a comparable control group when assessing differences in health outcomes is important for ensuring an unbiased assessment of the impact that using telehealth has on re-hospitalization rates. This study contributes to the literature by comparing 30-day re-hospitalization rates among patients using telehealth for post-acute follow-up care with rates among matched controls who did not use telehealth for follow-up.
Methods: The 2020-2022 5% Medicare Inpatient and Outpatient Limited Data Sets (LDS) were used to identify the study cohort consisting of hospitalized Medicare Fee-for-Service (FFS) beneficiaries aged 65 and over who used telehealth follow-up within 30 days post-discharge. We profiled the telehealth cohort’s set of chronic conditions and created a two-to-one matching algorithm using propensity scores to identify a comparable set of controls who had not used telehealth for post-discharge follow-up care. The matching algorithm incorporated age, gender, chronic conditions, Johns Hopkins’ adjusted clinical groups Resource Utilization Bands (RUBs), and beneficiaries’ rural-urban county location. Follow-up in-person, telehealth, and home health (HH) care were identified using the Restructured Betos evaluation and management codes; specific HCPC/CPT codes and modifiers; and HH visits obtained from Medicare HH LDS files, respectively. Logistic regression analysis was used to assess the influence of telehealth versus in-person follow-up on rehospitalization rates. Combinations of telehealth, in-person, and HH services within the 30-day follow-up period were included as potential factors reducing the risk of rehospitalization.
Results: Of those beneficiaries with follow-up visits, 57.6% used in-person visits only, 22.5% used a combination of telehealth and in-person visits, and 8.7% used telehealth only. Over a third (34.9%) of hospitalized beneficiaries used telehealth, either alone or in combination with in-person outpatient visits or HH services. In logistic regression, controlling for risk severity using the RUB categories, beneficiaries using telehealth only were less likely to be rehospitalized within 30 days post-discharge than beneficiaries who used in-person only care (OR = 0.80). Beneficiaries using a combination of in-person and HH services or a combination of in-person, HH and telehealth visits were more likely to be re-hospitalized than beneficiaries who used in-person only care (OR = 1.28 and 1.32, respectively). The risk of rehospitalization was highest for patients diagnosed with congestive heart failure (CHF) (OR = 1.25) and anemia (OR = 1.24). Among patients with CHF, those who received a combination of telehealth and HH follow-up had lower odds of rehospitalization than those who used in-person only care (OR = 0.59). Telehealth alone lowered the risk of re-hospitalization for patients diagnosed with anemia (OR = 0.72).
Discussion: Over half of patients hospitalized used in-person only follow-up care, and over a third used telehealth either alone or combined with in-person or HH services. The risk of rehospitalization was lowest among beneficiaries using telehealth only, and highest among patients using combinations of in-person, telehealth, and HH follow-up care, even after controlling for risk severity. The use of telehealth in combination with HH visits reduced the risk of rehospitalization for patients diagnosed with CHF, while the use of telehealth alone was associated with lower risk of re-hospitalization for patients with anemia. These findings underscore the importance of considering the appropriateness of telehealth follow-up care for specific disease conditions. Additional work addressing the underlying reasons for the observed patterns associated with follow-up care, including the role that patient complications post-discharge played in the use of the various types of follow-up care is needed.
Implementation of a Telemonitoring Program for Patients with Uncontrolled Hypertension
Carly Brown PharmD1, Yunxi Zhang PhD2, Lincy Lal PharmD PhD3, John Swint PhD3, Saurabh Chandra MD PhD MBA2, Donald Clark MD MPH2
1University of Mississippi School of Pharmacy 2University of Mississippi Medical Center 3The University of Texas School of Public Health
Primary Email:cbb5542@umc.edu
Background: Hypertension is a major contributor to cardiovascular morbidity and mortality. Remote patient monitoring (RPM) offers a promising solution by enabling real-time monitoring of blood pressure (BP) and timely intervention. A previous pilot study conducted at the University of Mississippi Medical Center (UMMC) among rural and underserved patients with uncontrolled hypertension demonstrated that remote telemonitoring with hypertension management is associated with greater reductions in BP than with usual clinic-based care. This current study seeks to evaluate the long-term implementation of a remote telemonitoring program in routine clinical practice for patients with uncontrolled hypertension.
Methods: A retrospective chart review was conducted at UMMC to evaluate the reduction in BP of patients with uncontrolled hypertension enrolled into RPM from 2018-2022. Patients received a kit containing a tablet and Bluetooth compatible BP monitor with cuff to obtain daily BP measurements and receive health education. After enrollment, each patient received an onboarding call by a registered nurse followed by a comprehensive medication review with a pharmacist. All patients received daily nurse monitoring and were contacted via telephone to discuss out of range measurements and monthly BP averages. A medication intensification protocol was implemented in September 2020. Patients enrolled on the program after this time received medication titrations directly from the clinical pharmacist. The control group was identified using a propensity score matching on age, sex, race, and baseline BP. After matching, a comparison between the last systolic and diastolic BPs was conducted using a Wilcoxon rank-sum test. A sensitivity analysis was used to evaluate the program's short-term effectiveness on BP. Additionally, a linear regression was utilized to estimate the effect of RPM on BP change, adjusting for baseline BP, age, sex, and race.
Results: A total of 210 patients successfully completed the RPM program between 2018 and 2022. RPM patients had a mean (SD) age of 62.6 (12.1) years, 63.2% were women, 78.3% were Black individuals, and 20.6% resided in a federally designated rural area. Patients receiving remote telemonitoring showed greater reductions in clinic systolic and diastolic BP when compared to the matched control group receiving routine clinical care only for BP management (mean (SD): 11.64 (23.58) mmHg vs 8.29 (20.18) mmHg and 5.19 (14.33) mmHg vs 2.16 (12.25) mmHg). When evaluating patients who returned to clinic within 30-days post discharge, patients completing the remote telemonitoring program on average experienced a greater reduction by 6.72 mmHg in systolic BP (p = 0.020) and 5.53 mmHg in diastolic BP (p = 0.002) from baseline compared to the control group.
Discussion: Patients receiving BP telemonitoring achieved greater reductions in systolic and diastolic BP when compared to patients receiving routine clinical care. These findings suggest that a remote telemonitoring program may help patients achieve better BP control. Further research is needed to understand the economic impact and long-term clinical outcomes associated with the use of a telemonitoring program for hypertension management.
A Mixed-Methods: Study on State Telehealth Policy and Mental Health Care Access
Lucinda Leung MD PhD MPH1,4, Alexander McCourt JD PhD MPH2, Pushpa Raja MD MSHPM3, Jose Escarce MD PhD4, Susan Ettner PhD4, Jasmeen Santos MPH4, Valerie Nguyen MPH4, Christine Thompson BA4, Haiyong Xu PhD4, Claudia Der-Martirosian PhD4
1VA Greater Los Angeles Healthcare System, Center for the Study of Healthcare Innovation, Implementation, & Policy 2Johns Hopkins Bloomberg School of Public Health 3Department of Psychiatry, David Geffen School of Medicine, University of California, Los Angeles, California 4Department of Medicine, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles
Primary Email:lleung@mednet.ucla.edu
Background: Gaps in mental health care access persist and disproportionately affect disadvantaged populations. Telehealth existed historically to expand care access across geographic space and time. It rapidly expanded to close care access gaps widened by the COVID-19 pandemic. The pandemic made it possible to naturalistically examine the effect of telehealth policy changes on mental health care access nationally. Yet, telehealth expansion also highlighted the Digital Divide, or the gap between those who have access to broadband internet, computers/smartphones, and the digital literacy required to use these devices and those who do not. This panel will describe an explanatory sequential mixed-Methods: study to 1) describe the landscape of telehealth policies and laws nationally; 2) examine the effect of policy expansion on patient-reported mental health care access; and 3) obtain the perspectives of state health leaders on the policy-to-practice pathway focusing on disadvantaged populations.
Methods: This study used legal mapping research Methods: to characterize the effective dates and specific provisions of telehealth policies (e.g., Medicaid reimbursement of audio-only visits) before and during the COVID-19 pandemic in all 50 U.S. states and Washington, D.C. We then examined state factors (e.g., rurality, broadband internet availability) explaining these telehealth policies using discrete-time hazard models. Next, we employed a difference-in-difference approach to predict state telehealth policy effects on access outcomes using a nationally representative survey of 181,854 individual respondents (10/28/2020-5/9/2022). Using the Household Pulse Survey, we examined policy effects on “Did you need counseling or therapy from a mental health professional, but did not get it for any reason?”, adjusting for time, state, individual (e.g., sociodemographics) and contextual level factors (e.g., COVID-19 deaths, unemployment). Finally, we used qualitative Methods: to obtain insight from 22 state health leaders (e.g., mental health commissioners, primary care association leaders, Medicaid officials) on how state telehealth policy expansion influenced mental health services delivery, with a focus on improving safety-net care.
Results: Among 50 states and D.C., an average of 2.5 telehealth policies (range: 0-6) were in effect for Medicaid patients during the five-year study period. There was greatest adoption of the audio-only reimbursement policy, which occurred in 33 states. No state factor (e.g., size, rurality, Medicaid Expansion) appeared to be associated with telehealth policy expansion. During the pandemic, 1 in 5 individuals surveyed reported not getting needed mental health care; however, those living in states that adopted 2+ telehealth policies were 2 percentage-points less likely to report not getting needed mental health care than those living in states that did not adopt any policies (p=0.02). Comparing legal mapping Results: against state leader understanding of specific policies, we found approximately 50% concordance and a near-equal distribution of discordance, uncertainty, or lack of comment. Key facilitators to get from policy to practice included pre-existing telehealth policies and multi-partner support from state leadership, Medicaid agencies, primary care and mental health organizations. However, implementation barriers remained (e.g., poor access/costly broadband internet; digital health illiteracy; care coordination issues).
Discussion: Policy plays an important role in the implementation and sustainment of evidence-based tools, such as telehealth. Our research team used legal mapping Methods: to document a variety of telehealth policies across all 50 states. Using our 50-state survey, we identified an effect from states having 2+ telehealth policies on improved patient-reported mental health care access. In obtaining state health leaders' perceptions of the policy-to-practice pathway, we found a high degree of uncertainty and inconsistency surrounding interpretation of telehealth policies. Consistent with prior literature based mostly on clinicians, we identified key barriers (e.g., internet, digital literacy) and facilitators (e.g., leadership support, multi-sector partnership) surrounding policy implementation. By characterizing variations in telehealth policies and their downstream effects, our findings aim to inform equitable dissemination, implementation, and sustainment of high-quality telehealth services.
Improved Patient-Provider Interactions in Telehealth Encounters Assisted by an AI-based Scribe
Yueh-Yun Lin PhD, Vanessa Trammell BS MS CIPM CSM, Lindsey Kuiper PhD, Tearsanee Davis DNP FNP-BC PMHNP Saurabh Chandra MD PhD MBA
University of Mississippi Medical Center
Primary Email:ylin@umc.edu
Background: Strong patient engagement has the potential to transform Telehealth into a vital component of comprehensive, patient-centered care. Several barriers can hinder patient engagement during telehealth visits. One of the key barriers is the absence of a personal connection with the provider that is established over a Telehealth platform as opposed to face-to-face visit. Documentation and other administrative tasks can significantly prevent meaningful patient-provider interactions. Artificial intelligence (AI) scribing is designed to assist clinical providers by transcribing patient interactions, medical histories, and clinical notes. This allows physicians to focus more on patient care rather than administrative tasks potentially leading to more meaningful conversations and improved patient-provider interactions. In this study we have explored the impact of AI scribe on provider reported experience with technology and patient engagement.
Methods: In this study, Ambience Healthcare AI scribe technology was employed to assist with real-time medical documentation during Telehealth visits. The AI-driven platform utilizes advanced speech recognition and natural language processing (NLP) to transcribe provider-patient interactions during Telehealth visits. After obtaining IRB approval, a pre-post intervention study was conducted by recruiting and training 19 health care providers across three specialty areas (urgent care, behavioral health, and geriatrics) to utilize the AI-scribing tool. All providers were given a pre-intervention survey before implementation, as well as two post-intervention surveys at 1 month and 3 months
Results: Among the 19 participants, 89.47% (n=17) were female, 84.21% (n=16) were aged between 35 and 54 years old, and 15.79% (n=3) were at least 55 years old. Before implementing the AI-scribing tool, 21.05% (n=4) reported regular scribing to be associated with burnout feelings, with 15.79% (n=3) reporting being unsatisfied with the time they spend on regular scribing and 21.05% (n=4) stating they don’t have control over their workload with regular scribing. With their understanding prior to utilizing the AI-scribing tool, 52.63% (n=10) believed it would improve their efficiency in documentation, 57.89% (n=11) anticipated being comfortable using an AI-scribing tool, and 52.63% (n=10) expected to be able to increase time with patients. After implementation, 50.00% (n=6) reported that using an AI-scribing tool decreased their burnout feelings at 1 month and increased to 61.54% (n=8) at 3 months. Compared to regular scribing, 76.92% (n=10) were more satisfied with the documentation and also reported increased time spent on patient engagement after 3 months of implementation (increased from 66.67% [n=8] at 1 month). The satisfaction with the quality of the AI-scribing tool also increased from 66.67% (n=8) to 84.62% (n=11).
Discussion: This study explored the use of AI-scribe technology to enhance patient engagement during Telehealth visits. Our findings indicate that AI scribes can significantly improve the efficacy of patient-provider interactions by automating documentation tasks, allowing health care professionals to focus more on patient communication and care. Future research will focus on addressing cost-effectiveness of the technology.
Yunxi Zhang PhD1, Yueh-yun Lin PhD1, Lincy Lal PharmD PhD2, Jennifer Reneker PhD1, Elizabeth Hinton MSIS1, Saurabh Chandra MD PhD MBA1, John Swint PhD3
1University of Mississippi Medical Center 2The University of Texas Health Science Center at Houston 3The University of Texas School of Public Health
Primary Email:yzhang4@umc.edu
Background: Telehealth leverages cutting-edge technologies to transform health care delivery. The diversity and rapid evolution of integrating various advanced technologies into health care services create challenges in standardizing telehealth services. This lack of standardization raises concerns about service quality, prompting regulatory bodies, professional groups, and other telehealth stakeholders to develop operational guidelines and evaluation frameworks. The relevant heterogeneity of the telehealth services and programs underscores the need for a comprehensive framework to guide the evaluation. We conducted a scoping review of existing telehealth evaluation frameworks to support this approach and illustrated its use on a remote patient monitoring program.
Methods: The scoping review was conducted following the Joanna Briggs Institute methodology for scoping reviews and in accordance with a published protocol, associated registration with the Open Science Framework (AYTUS). The databases searched include PubMed, Health Technology Assessments, and Web of Science Core Collection. A Population, Concept, and Context framework was adopted for document selection. Specifically, we included reviews, reports, and white papers related to telehealth evaluation frameworks and associated measurements. We focused on telehealth services and programs delivering health care services through a variety of modalities, such as store-and-forward telemedicine, remote monitoring, real-time counseling, audio and video conferencing, and videotelephony, as well as emerging innovations, such as virtual realities and artificial intelligence, integrated with telehealth platforms. We sought documents published in English across various health care settings, including primary care, specialty care, and rural health care for both adult and pediatric patients. Given the complexity of the data, we utilized two auxiliary frameworks from Telehealth Centers of Excellence, to enhance structure and lend clarity in our synthesis.
Results: We identified 5,782 records published between 2019 and 2023, with 12 telehealth evaluation frameworks included in the final review. Stakeholder roles were synthesized to include technology developers, providers, patients/caregivers, payers, health care institutions, and policymakers. Using the foundational domains from the primary auxiliary framework, the sustainable telehealth development framework, we categorized diverse (sub)domains into four key themes: program implementation, clinical impact, economic impact, and equity. Then, we employed a secondary auxiliary framework, the telehealth maturity framework, to further structure the key themes across telehealth developmental stages of program feasibility, pilot exploration, established program, and optimization. When evaluating telehealth programs, it is essential to consider the interplay between stakeholder perspectives and program developmental stages across evaluation themes, leading to the creation of a three-dimensional, multi-stakeholder, multi-stage, theme-oriented evaluation framework. We illustrated the framework through a use case on a remote patient monitoring program for blood pressure management, based on measures from the included frameworks.
Discussion: As the first scoping review to synthesize existing evidence of telehealth service and program evaluation in the U.S., our work illuminates the diversity and complexity inherent within telehealth evaluation across the U.S. health care system. It underscores the challenges of developing a universal standard in telehealth evaluation, but reveals the possibility of a flexible approach that considers diverse stakeholders, developmental stages, and specific environmental contexts of telehealth programs. Our three-dimensional telehealth evaluation framework offers an inclusive and adaptive approach to evaluate telehealth services and programs, designed to meet the varied needs of a broad spectrum of telehealth stakeholders. Through the three-dimensional telehealth evaluation framework, stakeholders could craft their tailored evaluation plan to align with specific developmental stages and thematic interests of their program.
UNITE Telemental Health Clinic Engagement and Impact: Improving Access for Mississippi Universities
Background: Universities Network of Integrated Telemental Expansion (UNITE) is a grant-funded initiative launched in April 2024 by the Department of Psychiatry at UMMC to help address increasing mental health needs of Mississippi college students. UNITE encourages health equity and promotes academic success through timely mental health care interventions. Telemental health is the provision of mental health services using telecommunication technology, specifically live, interactive video-teleconferencing or audio-only communication. This innovative approach to health care provision demonstrates comparable effectiveness as in-person care for clinical assessments and treatments; although, efficacy and effectiveness may vary by patient demographic and clinical characteristics. This analysis reports UNITE Clinic’s initial program outcomes across Mississippi’s eight public Institutions of Higher Learning (IHL). Students attending these universities can benefit from the accessible care offered by UNITE.
Methods: UNITE was funded in 2023 by congressional-directed legislative spending, with collaboration of SAMSHA and UMMC and grant funding through June 2024. All program implementation costs were covered by this grant for the eight Mississippi institutions. The UNITE Clinic telemental health counseling and medication management services are free for patients, and coverage exclusions include prescription medications and other diagnostic services. UNITE’s virtual design prioritizes ease of access for patients with mental health challenges. Students enrolled in classes at these public institutions can schedule next-day appointments using the UNITE website. An online registration form connected to a cloud-based EHR, EPIC, is used to schedule appointments that last 30-60 minutes. Students can attend up to 8 sessions per semester. A multidisciplinary team of LPCs, counseling trainees, and psychiatric NPs from UMMC facilitate these encounters. For the purposes of program evaluation, deidentified patient data is collected via EPIC for analysis. Variables of interest span service utilization rates, locations, and patient demographic characteristics, which were used to evaluate program engagement and impact.
Results: From April 15, 2024 to October 31, 2024, UNITE Clinic served 89 patients across 389 telemental health encounters. Of these visits, 104 sessions (26.74%) were scheduled for medication management and 285 sessions (73.26%) were for mental health counseling. There were 310 completed encounters with 81 no-show or cancelled sessions within 24 hours, which constituted a no-show rate of 20.72%. Session utilization rates increased as institutions adopted and advertised the program. Of patients who reported sex assigned at birth, 27.76% were male and 72.24% female. Of patients seen through UNITE, 47.04% were African American, 43.19% were Caucasian, 5.14% were Asian, 4.37% were Other, and 0.26% did not specify race. The Index of Medical Underservice (IMU) Score weighted by encounters across college counties is approximately 48.06. Of telehealth encounters, 57.84% were from Mississippi public institutions whose main campuses were in rural medically underserved counties and 42.16% were from institutions in non-rural medically underserved counties, as designated by the Health Resources and Services Administration (HRSA).
Discussion: Findings reveal the impact of the UNITE Clinic, enhancing access to mental health services for IHL college students across Mississippi, a predominantly rural and medically underserved state. Notably, there were 15.86% more rural than non-rural telemental health encounters, and 100% of these encounters were from underserved communities. The weighted IMU Score of 48.06 highlights the degree of medical underservice observed in patients across all encounters. Findings from this study align with the current literature indicating that telemental health care can significantly reduce wait times and expand service capacity, with lower no-show rates compared to in-person visits. Limitations of this study included restricted access to patient diagnoses and provider recommendations when assessing clinical outcomes. Future research should investigate culturally informed, tailored approaches to program implementation, alongside patient capacity limitations for on-campus mental health providers.
Mississippi’s Mental Health Outlook: Telehealth as a Solution to Mississippi Hospitals’ Dire Need
Tearsanee Davis DNP FNP-BC PMHNP-BC FAANP1, Ryan Kelly MS2
1University of Mississippi Medical Center Center for Telehealth 2Mississippi Telehealth Association
Primary Email:tcarlisle@umc.edu
Background: In Mississippi, there is a growing need for mental health services for all populations. Currently, the availability of qualified mental health providers poses a challenge for health systems with a need and desire to provide these services. This survey was intended to gather information regarding mental health and psychiatric services currently being provided in rural hospitals in the State of Mississippi and the role that telepsychiatry may play in supporting these needed services in our communities. In understanding the strategies currently in use, we can better understand how to use Telehealth resources to build models of care to efficiently address the mental health treatment needs in rural and underserved areas.
Methods: 102 hospitals in Mississippi were surveyed: Total hospital responses: 61 Response percentage: 60%, 2 print solicitations and 5 electronic solicitations were sent. There were 50 follow-up calls to the hospitals.
Results: 61 responses were received from hospitals throughout the State of Mississippi. 69% of respondents did offer mental health/psychiatric clinical services within the hospital. The top three leading responses included substance use disorders, medication management, and depression screening treatment. 31% of clinics and hospitals do not admit patients for psychiatric services. Out of 49 respondents, 61.22% provided medication management, 18.37% group therapy, 36.73% case management, 40.82% behavioral therapy, 12.24% family therapy, 69.39% substance use disorders, 48.98% depression screening and treatment, 8.16% dialectical behavior therapy, 10.20% residential treatment, 42.86% inpatient treatment, 46.94% outpatient treatment, 4.08% other services. 64% provided emergency psychiatry services with 37% contracting with outside teams. The average number of ER consults from 56 hospitals was 15. The top 3 payors were Medicare, Medicaid, and commercial insurance. 50% of 60 respondents had a formal agreement with a mental health facility, and 79% were greater than 20 miles away from mental health treatment facilities.
Discussion: There is a high need for psychiatric services in Mississippi hospitals, particularly in the emergency room and clinical setting. Of note, there is a discrepancy between facilities with high need and those of low need. This is likely due to the availability of services in the community. Some hospitals currently utilize outsourced telepsychiatry services. Others likely have a need without a contractual agreement for telepsychiatry services in place. High volumes likely correspond to more robust programs. It is suspected that low-volume programs have a high need without available services. Most patients have to travel long distances for psychiatric services. Locally provided services could result in better patient care and increased local revenue. Telehealth could be a viable solution for addressing these gaps in care in a sustainable way when local resources are not available.
Implementation of a Tele-critical Care Program in Two Rural Mississippi Hospitals
Andrew Wilhelm MD, Kyle Brewer MBA FACHE, Angela Haller, Saurabh Chandra MD PhD MBA
University of Mississippi Medical Center
Primary Email:awilhelm@umc.edu
Background: Rural hospitals play a vital role in providing health care to underserved communities in Mississippi, but they often face challenges such as limited access to specialized expertise, lower patient volumes, and financial constraints. These factors can result in delays in care for critically ill patients, leading to worsened outcomes and increased strain on local health care systems. Tele-critical care (Tele-ICU) addresses this by using remote monitoring and communication technologies to connect rural hospitals with critical care specialists. This allows intensivists to support non-critical care physicians and advanced practice providers, improving patient care. Although Tele-ICUs have been in use for over two decades, their adoption is uneven. A 2021 study by Dunc et al. found that Tele-ICUs are more common in urban hospitals, particularly academic centers, while rural hospitals, especially in the South, have lower utilization rates.
Methods: We developed a Tele-critical Care Program (TCCP) and implemented it in two rural hospitals in Mississippi. The hospitals were selected based on need assessment and “buy-in” from all key stakeholders in the covered hospitals (administration, nursing and bedside providers). Out of state critical care physicians were licensed in the state of Mississippi and provided EMR access, and external vendor portal to connect to the mobile carts. Existing workflows were adapted for remote rounding on patients in the Emergency Department and the Med/Surg unit.
Results: From November 23-Octotber 24, 227 consults were provided at one rural hospital and from March 23-October 24, 248 consults were provided at the second rural hospital. The implementation of TCCP has been very well received at both hospitals. Financial analysis at both hospitals showed that from November 2023 to May 2024, the TCCP provided a direct financial impact of $278,821 for one rural hospital. The largest financial value for this critical access hospital was the ability to keep patients local and transfer them to their swing-bed unit. This allowed them to increase their swing bed unit LOS by 3 days for the analyzed period. From April 2024 to August 2024, the TCCP provided a direct financial impact of $366,548 for the other rural hospital. This rural referral center received an increase in reimbursement capture due to 68% of those patients remaining in the local facility.
Discussion: Implementing a TCCP in rural Hospitals has the potential to significantly enhance the ability of local health care providers to deliver high-quality care to their patients. By enabling real-time expert support, the program can reduce unnecessary transfers, optimize care delivery, and improve clinical outcomes for patients in rural and underserved areas. As demonstrated the TCCP also has the potential to serve as a cost-effective model for extending the reach of specialized care to rural populations, ensuring that rural health care systems are equipped to meet the growing needs of their communities. The program can be scaled to other rural and underserved areas, further addressing the rural health care disparity on a broader level.
Designing AI for Teleradiology
Elizabeth Krupinski PhD
Emory University
Primary Email:ekrupin@emory.edu
Background: Eye-tracking technologies have been used for decades to assess the impact of technologies on clinical decision making in medical imaging. eHealth and telemedicine present new opportunities to integrate images and other visual data into routine clinical care. Artificial intelligence (AI) tools can work synergistically with these data to improve the efficacy and efficiency of data analysis and interpretation by the human decision maker. However, we know little about the optimal ways to present AI output to providers. This study used radiology image interpretation with AI-based decision support to explore the impact of different types of AI output on reader performance.
Methods: Eight radiologists and radiology residents participated as observers in this IRB approved study. Each participated in 5 sessions separated by at least 3 weeks to promote forgetting. In each session two series of 40 chest x-ray images with no COVID or mild, moderate, or severe COVID were viewed in random order. Each series provided a different form of AI feedback from an in-house developed AI tool: no AI provided, a heat map, a probability graph, heat map plus probability graph, or a single word (normal, mild, moderate, severe). In every trial the original image was displayed on a computer screen and the reader was required to render a decision (normal, mild moderate, severe) plus their confidence in that decision (possible, probable, definite). After providing a decision the AI output was displayed and they could either keep their original decision and confidence or change either/both decisions. Throughout the trial, a Tobii eye-tracking system was used to record their visual search patterns.
Results: Overall, the residents had more decision (p < 0.0001) and confidence (p < 0.0001) changes with the provision of the AI output than the experienced radiologists, although the format did not appear to have a significant impact. The form of the AI output did however affect the visual search patterns. The single word did not add significantly to viewing time and overall readers simply glanced over to the word and then back to the image. The heat maps, probability graphs, heatmap plus graphs resulted in significantly more time spent looking at the output as well as back and forth between the chest image and the AI output.
Discussion: The potential for eye gaze to be incorporated into AI and other technologies is immense. The key to the success of AI tools in medical imaging will be to incorporate the human into the overall process to optimize and synergize the human-computer dyad, as at least for the foreseeable future, the human is and will be the ultimate decision maker. Our Results: demonstrate that the form of the AI output is important as it can impact clinical decision making and efficiency. Perhaps of equal importance is that it may impact different users in different ways, especially trainees versus those with more experience.
Using RE-AIM to Evaluate a Virtual-Only Specialty Care Program
Jillian Harvey PhD MPH, Cortney Belton RN MBA, Peter Gardella MBA BSN RN, Caitlin Koob PhD MS, Ryan Kruis PhD, James McElligott MD MSCR, Emily Warr MSN RN
Medical University of South Carolina
Primary Email:harveyji@musc.edu
Background: Patients often face difficulties accessing in-person care, resulting in delays and poor health outcomes. In South Carolina, all 46 counties are designated to have some health professional shortage areas. As a result, patients face challenges accessing specialty care, averaging a 3-6 month wait for in-person specialty care. To overcome the access issues, a virtual-only specialty service line was developed to increase access to specialty providers and offer an alternative to in-person care. The model provides 100% virtual care in high-demand specialties and primary care. The Virtual Specialty program also coordinates local referrals for in-person lab work, imaging, and pharmaceuticals based on the patient’s proximity. The program goals include reducing wait times and increasing access to specialty care. The program includes Direct-to-Consumer Endocrinology, Rheumatology, Neurology, Pulmonology, Benign Hematology, Sleep Medicine, and Primary Care for new and returning patients.
Methods: The RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework guides a data-driven evaluation of the Virtual-only Specialty program, incorporating multiple data sources and evaluation tools to track process and outcome measures and inform program quality improvement and data-driven decision-making. Data sources include program tracking data, REDCap, the electronic medical record and the telehealth platforms, and qualitative data from users. Business Intelligence Tools are used to create program-level dashboard scorecards, and maps illustrating patient home locations. Dashboards have been designed to increase leadership’s access to real-time data trends and facilitate quality improvement. Primary outcome domains of interest include utilization, patient satisfaction, patient costs associated with travel (e.g., transportation, lodging, time off work, childcare); and cancellations, wait times, reschedules, and no-show appointment rates. In addition, tracking the use of MUSC and Affiliate resources for testing and in-person care needs is important to validate the return on investment. Quantitative data are analyzed using descriptive statistics, and qualitative content analysis is utilized to identify themes.
Results: Reach: From October 1, 2023, to October 23, 2024, 13,216 Virtual Specialty visits occurred, for 10,215 patients. Effectiveness: New visit appointment wait times have been reduced to less than 8 days for all programs, except Sleep Medicine which is still building capacity. The time to next appointment has decreased by several months for in-person waits in high-demand specialties of rheumatology and endocrinology. Patient experience ratings are consistently higher for the 100% virtual practice compared to hybrid in-person/virtual care. Patients report immediate impacts for the increased access, and ability to initiate medications and treatments faster than they would have with the first-available in-person visit. Adoption: Endocrinology was consistently the highest volume service each month, followed by Rheumatology. Implementation: The program went through a 4 phase implementation process. Maintenance: Returning patients made up 58% of the visits. The Virtual Specialty patients reside across the entire state, saving considerable time and travel costs for the patients. Average monthly patient no-show rates are 9-11% (national Endocrinology benchmark is 14%). Specialty Pharmacy is an area of growth.
Discussion: Initial lessons learned include the challenge of establishing a highly accessible digital front door while also leveraging Electronic Health Record tools. In addition, current South Carolina regulation limitations on prescribing schedule 2 and 3 medications create barriers to care. Virtual Specialty service will continue to expand through innovative partnerships with divisions of MUSC, collaboration with additional specialty departments and providers, coordination with trusted affiliated organizations, successful continuity of care with in-person needs, and ensuring a patient-centric approach. Early Results: show increased access to timely care, improved patient experience, and lower patient no-show rates compared to national benchmarks. Navigating in-person needs across the state will require referral relationships in many communities and with the local MUSC providers.
Enhancing Public Understanding of Health Indicators Through Digital Tools: Design Thinking Insights
John Geracitano, Saif Khairat PhD MPH FAMIA
University of North Carolina at Chapel Hill
Primary Email:johngera@unc.edu
Background: The growth of digital health care tools produces opportunities and challenges: while access to health data has expanded, public understanding lags behind. The pandemic revealed critical gaps in digital health literacy and internet access for underserved communities, emphasizing the need for accessible tools to support informed health decisions. In partnership with design-thinking graduate students and the NIH-funded Center for Virtual Care Value and Equity (ViVE), this project explored ways digital platforms can bridge these gaps by improving public understanding of health indicators.
Methods: This project prioritized end-user needs, ensuring their requirements shaped every phase. Three student-led teams, collaborating with ViVE researchers, applied human-centered design principles to improve public understanding of health indicators. Design sessions addressed user needs and tested assumptions to enhance health data accessibility for diverse communities, fostering student learning and impactful community solutions. Key Methods: included listening sessions, card sorting, and guided tours, centering on assumptions that users desire to understand health data but face barriers like digital literacy gaps, internet access issues, and platform complexity. The teams examined diverse user preferences, especially for underserved communities, to guide the development of tools meeting varied health literacy levels.
Results:
Two design thinking sessions included 21 participants (session 1: n=12, avg. age = 27.78, SD = 2.17; session 2: n=9, avg. age = 27.75, SD = 1.95), with graduate students and community members testing assumptions, needs, and strategies to enhance health data accessibility. Participants indicated that data privacy and security are essential for establishing trust in health platforms. High mobile device usage promotes a requirement for fast, responsive, mobile-first designs. Barriers to access underscored the importance of simplified interfaces, intuitive navigation, and offline functionality to support users with limited digital resources. Visual aids were preferred for complex health information as engaging alternatives to text-heavy content. Users desired customizable features to filter health indicators by personal needs, such as local health data. Participants valued quantitative data and qualitative evidence, including patient reviews, for a well-rounded understanding of health care access. Human-centered design elements like storytelling made health data more relatable, while generational and language differences affirmed a need for multilingual support and accessible design for diverse digital literacy levels.
Discussion: These sessions identified potential approaches to strengthen the usability and inclusivity of digital health tools for underserved populations. The Results: mark essential elements for cultivating user trust and engagement by accounting for security, mobile compatibility, and visual communication. Integrating both qualitative and quantitative data, paired with personalized storytelling, bridges the digital divide, making complex health information accessible to those with limited resources. This project offers translational suggestions for creating adaptable, human-centered platforms that boost digital health literacy and equity. Guided by user needs, these strategies support broader connected health goals, ensuring equitable access to health information and advancing public health outcomes.
Addressing Barriers to Social Determinants of Health: Using Telehealth to Facilitate Connections
Stephanie Punt PhD1, Mariana Rincon Caicedo MA2, Cordaris Butler MA2, Chase Koob BA3, Haley Bell BS3, Eve-Lynn Nelson PhD3
1University of Califorina Los Angeles 2University of Kansas 3University of Kansas Medical Center
Primary Email:spunt@mednet.ucla.edu
Background: While social determinants of health (SDoH) is an important piece of brain health equity, there has yet to be a consensus on assessing and addressing resources in communities. Telehealth ROCKS, a multidisciplinary team developed a service delivery program with community partners to address SDoH and health disparities in rural areas, primarily reliant on mining and factory industries. To date, this program has served 6,876 students across seven school districts and has served these families with a centralized assessment process through which community health workers (CHWs) can efficiently assess and address SDoH for students and their families. Community CareLink (CCL) is an online platform utilized by CHWs to document and assess SDOH gaps in rural communities. Specifically, the Arizona Self-Sufficiency Matrix was used to measure the extent to which these SDOH gaps are met across domains. Qualitative analyses were conducted to examine findings from the CCL platform.
Methods: Students were from diverse Background:s with a range of neurological and neurodevelopmental conditions. CHWs utilized Community CareLink (CCL), an online platform tailored for rural communities to document and track SDOH gaps. The Arizona Self-sufficiency Matrix assesses to what extent needs are being met across SDOH domains. Descriptive statistics, independent sample t tests, and qualitative analysis were conducted.
Results: Since its initial implementation in 2021, 606 students have been entered into the CCL platform. Students hail from a wide range of Background:s and have a wide range of psychiatric and developmental conditions. Reports are run as needed and are used in partnership with CHW partner sites to monitor families’ needs related to SDOH as they change over time. CCL data are used as evaluation measures and are valuable components of programmatic continuous quality improvement (CQI) efforts among CHW partner sites. CHWs reported benefiting from CCL by being able to observe their impact on their communities and utilizing the data to advocate for their communities with schools, boards, and other stakeholders. When asked about the CHW perspective and experience in utilizing this approach, one CHW said “The ultimate goal is allowing kids to be able to focus on school. I don’t want them to wonder why their clothes are too tight or why their stomachs growl, and they can’t focus on a math problem.” Ongoing addition of resources and improvement of the platform is conducted by CHWs.
Discussion: CCL is a novel and dynamic platform that was developed in response to observed needs to monitor and address SDOH in rural communities. It has been well received by CHWs and partner agencies. As the platform continues to expand, the process to connect students to resources will be streamlined, and data can be used to gather additional funding for communities in need. Future steps include building a closed-loop referral process to streamline referrals to other community agencies through the CCL platform, as well as strengthening the referral network for improved utilization. The evaluation process is a valuable one in understanding areas of improvement and also monitoring progress and remaining gaps in services. This approach could be a replicable, feasible, and a valuable resource for other geographic areas serving underserved populations.
Effect of State Medicaid Reimbursement Policies on Telehealth Visits in Community-based Clinics
Annie Larson PhD MPH1, Jose Escarce MD PhD2, Susan Ettner PhD3, Lucinda Leung MD PhD MPH3,4
1OCHIN 2David Geffen School of Medicine, University of California, Los Angeles 3Department of Medicine, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles 4VA Greater Los Angeles Healthcare System, Center for the Study of Healthcare Innovation, Implementation, & Policy
Primary Email:larsona@ochin.org
Background: In many health care settings, when telehealth is provided, it has primarily been video visits. Conversely, in community-based clinics and other low-income health care settings, when telehealth is provided, it is mostly audio-only visits. Changes in reimbursement policies for telehealth services, often temporary or informal laws, helped expand access to health care at the beginning of the public health emergency. Over the past several years, states began formally enacting these telehealth policies into law to avail audio-only services for those unable to receive care in-person or over video. This study sought to examine whether codification of Medicaid reimbursement for audio-only services or payment parity predicted greater numbers of telehealth encounters, including greater use of audio-only (versus video) visits, among primary care and behavioral health visits in safety-net clinics across 20 states.
Methods: This retrospective study used electronic health record (EHR) data from the Accelerating Data Value Across a National Community Health Center Network (ADVANCE), a member of PCORnet® who provides a single instance of Epic EHR to community-based clinics across the US. Encounters from 433 primary care and 279 behavioral health community-based clinics from 04/01/2021-03/31/2023 were classified by encounter type (in-person/telehealth) and telehealth modality (audio-only/video). Legal research Methods: identified if and when states codified Medicaid reimbursement for audio-only services. Linear probability models predicted encounter type and, conditional on having a telehealth visit, telehealth modality. Our predictor of interest was a variable to describe audio-only telehealth policies and laws as having: (1) no reimbursement for telehealth, (2) reimbursement for telehealth, but no payment parity, or (3) reimbursement for telehealth, at parity. Models controlled for time and patient characteristics (sociodemographics, comorbidities, rurality, and broadband internet) and clinic fixed effects. Adults 18-64 years with a Medicaid insured primary care visit (733,625 patients) or behavioral health visit (97,987 patients) were included.
Results: The majority of community-based clinic primary care visits were in-person (67.4%), while 20.5% were audio-only and 12.2% were video telehealth visits. Behavioral health visits were closely split by modality: 33.5% were in-person, 32.7% audio-only telehealth, and 33.9% video telehealth. In both primary care and behavioral health care clinics, patients who were Black versus other racial groups, lived in rural communities, or lived in a neighborhood with less broadband access used in-person versus telehealth for their visit. Codification of Medicaid reimbursement for audio-only services resulted in a 4.8 percentage-point increase in telehealth (versus in-person) visits (P< 0.01) in primary care clinics while codification of Medicaid reimbursement at parity resulted in a 4.8 percentage-point increase in audio-only (versus video) visits (P=0.01). For behavioral health, codification of Medicaid reimbursement for audio-only telehealth at parity was associated with a 3.2 percentage-point increase in telehealth (versus in-person) encounters, but no significant effect on audio-only modality.
Discussion: Medicaid reimbursement for audio-only services had a small, if any, effect on encounter type or telehealth modality in both primary care and behavioral health care community-based clinics. While telehealth policies made access to primary care and behavioral health care services easier for some, barriers continue to exist. This is especially true for individuals who lack access to broadband internet/digital devices, digital health literacy, or prefer to not use video telehealth services. Reimbursement for audio-only telehealth services can help increase health care access for some patients, but other factors still need to be addressed. Additional research is needed to help understand what factors (whether patient, provider, or clinic) are driving patients to use which telehealth modality and whether the same quality of care can be provided through audio-only versus video telehealth.
Telehealth Utilization Patterns Among Patients with Multiple Chronic Conditions in Arkansas
1Tulane University 2University of Arkansas for Medical Sciences 3University of Alabama at Birmingham
Primary Email:bwalker6@tulane.edu
Background: Patients with multiple chronic conditions (MCCs) face care coordination challenges and poorer health outcomes. Outpatient telehealth may be an effective way to enhance MCC patient care given the need for multiple visits and specialists. This study seeks to describe telehealth utilization between 2013 and 2023 in Arkansas.
Methods: We utilized the Arkansas All-Payer Claims Database (APCD) to identify patients diagnosed with high-prevalence MCCs comprising diabetes with comorbid hypertension, hyperlipidemia, or asthma. We then measured telehealth utilization defined as any claim associated with a telehealth modifier code, a place of service code defining the service as occurring in the patient’s home, or remote patient monitoring. Finally, we created payer-specific (e.g., commercial or Medicaid) yearly measures of the number of any telehealth claims among MCC patients divided by the number of MCC patients for that year. Linear regression was used to measure the difference in utilized during the COVID-19 pandemic versus prior to the pandemic.
Results: Overall, the COVID-19 pandemic era was associated with an increase of telehealth utilization among commercial patients by 1.01 telehealth claims per MCC patient (95% CI: 0.39 to 1.62, p< 0.01) from a baseline value of less than 0.01. For Medicaid patients, the increase was 1.94 telehealth claims per MCC patient (95% CI: 1.00 to 2.89, p< 0.01) from a baseline value of less than 0.03. These Results: were driven by increases among patients with diabetes and asthma, whose experienced increases in utilization that are about 50% larger in magnitude than those with diabetes and hyperlipidemia or diabetes and hypertension.
Discussion: Variations in telehealth uptake among MCC patients suggest heterogeneity in its suitability and necessity. We will later evaluate whether telehealth use is associated with different levels of inpatient and emergency department utilization. We expect the findings to provide clarity on the suitability of telehealth use by MCC disease status.
Evaluation of Outcomes and Feasibility of Audio-Only Telehealth for Pediatric Surgery Patients: A Single Institution Experience
Savannah Walker MD1, Lindsay Rexrode BS1, Yueh-Yun Lin PhD1, Yunxi Zhang PhD1, Lincy Lal PhD PharmD2, Ying Zhang PhD1, Lindsey Kuiper PhD1, J. Michael Swint PhD2, David Sawaya MD1, Saurabh Chandra MD PhD1, Michael Morris MD1
1University of Mississippi Medical Center 2University of Texas School of Public Health Department of Management, Policy and Community Health
Primary Email:mmorrisjr@umc.edu
Background: During the COVID-19 pandemic, audio-only telehealth was implemented at the only tertiary care pediatric center in our state as a clinical adjunct to traditional in-person care to serve the predominantly rural and underserved population. While the application of telehealth within pediatric surgery for peri-operative clinical evaluation utilizing audio-visual platforms has previously demonstrated no significant differences in postoperative surgical outcomes compared with in-person assessment, the use of audio-only telehealth evaluations has not been investigated. In this study, we examine the outcomes of audio-only telehealth assessment of pediatric surgery patients compared to traditional in-person outpatient evaluation.
Methods: We conducted a retrospective matched cohort study of pediatric surgery patients <18 years-old undergoing in-person and audio-only telehealth outpatient evaluation at a single tertiary care pediatric center from August 2021 to April 2023. In-person and telehealth cohorts were balanced for age, sex, race, residence rurality, insurance type and pediatric comorbidity index (PCI) via 1:1 propensity score matching.
Results: 1,538 patients presented for outpatient pediatric surgical evaluation during the study period, with 22.2% (n=341) seen via audio-only telehealth. The majority of telehealth patients were male (57.8%), Black (50.4%), with Medicaid primary insurance coverage (61.3%); however, compared with the in-person cohort, telehealth patients were more often older (6.1 vs 5.7 years), White (39.9%. vs 34.2%) and had private insurance (35.5% vs 25.4%). Approximately one-half of telehealth patients were identified as residing in a rural area (48.4%), with a median driving distance of 70.3 miles (0 to 421). Post-matching, in-person surgery-related outpatient utilization within 30, 60, and 90 days after discharge of index surgery admission was lower in telehealth patients (Figure 1), with associated patient cost savings ($121.22 vs $227.15, p <0.0001). The surgery-related 30-day readmission rate for telehealth patients was 4.7% (n=16).
Discussion: The integration of audio-only telehealth evaluation within the care of peri-operative pediatric surgery patients holds promise for decreasing travel distances and patient costs without increased rates of post-operative surgery-related readmission. Additional investigation is warranted to further characterize the impact of and applications for audio-only modalities of telehealth in reducing health care disparities and enhancing access to pediatric surgical care.
