Telehealth Policy, Practice, and Education: a Position Statement of the Society of General Internal Medicine.

Telehealth services, specifically telemedicine audio-video and audio-only patient encounters, expanded dramatically during the COVID-19 pandemic through temporary waivers and flexibilities tied to the public health emergency. Early studies demonstrate significant potential to advance the quintuple aim (patient experience, health outcomes, cost, clinician well-being, and equity). Supported well, telemedicine can particularly improve patient satisfaction, health outcomes, and equity. Implemented poorly, telemedicine can facilitate unsafe care, worsen disparities, and waste resources. Without further action from lawmakers and agencies, payment will end for many telemedicine services currently used by millions of Americans at the end of 2024. Policymakers, health systems, clinicians, and educators must decide how to support, implement, and sustain telemedicine, and long-term studies and clinical practice guidelines are emerging to provide direction. In this position statement, we use clinical vignettes to review relevant literature and highlight where key actions are needed. These include areas where telemedicine must be expanded (e.g., to support chronic disease management) and where guidelines are needed (e.g., to prevent inequitable offering of telemedicine services and prevent unsafe or low-value care). We provide policy, clinical practice, and education recommendations for telemedicine on behalf of the Society of General Internal Medicine. Policy recommendations include ending geographic and site restrictions, expanding the definition of telemedicine to include audio-only services, establishing appropriate telemedicine service codes, and expanding broadband access to all Americans. Clinical practice recommendations include ensuring appropriate telemedicine use (for limited acute care situations or in conjunction with in-person services to extend longitudinal care relationships), that the choice of modality be done through patient-clinician shared decision-making, and that health systems design telemedicine services through community partnerships to ensure equitable implementation. Education recommendations include developing telemedicine-specific educational strategies for trainees that align with accreditation body competencies and providing educators with protected time and faculty development resources.

The Impact of the COVID-19 Pandemic on Internet Use and the Use of Digital Health Tools: Secondary Analysis of the 2020 Health Information National Trends Survey.

BACKGROUND: The COVID-19 pandemic increased the use of digital tools in health care (eg, patient portal, telemedicine, and web-based scheduling). Studies have shown that older individuals, racial/ethnic minority groups, or populations with lower educational attainment or income have lower rates of using digital health tools. Digitalization of health care may exacerbate already existing access barriers in these populations. OBJECTIVE: This study evaluated how use of digital tools to asynchronously communicate with clinicians, schedule appointments, and view medical records changed near the beginning of the pandemic. METHODS: Using 2020 Health Information National Trends Survey (HINTS) data, we examined internet use and 7 digital health technology use outcomes (electronic communication with a provider, electronic appointment scheduling, electronic test result viewing, patient portal access, portal use to download health records, portal use for patient-provider communication, and portal use to view test results). The HINTS surveyors designated surveys received after March 11, 2020, as postpandemic responses. Using weighted logistic regression, we investigated the impact of the pandemic after adjusting for sociodemographic traits (age, race/ethnicity, income, education, and gender), digital access (having ever used the internet and smartphone/tablet ownership), and health-related factors (insurance coverage, caregiver status, having a regular provider, and chronic diseases). To explore differences in changes in outcomes among key sociodemographic groups, we tested for significant interaction terms between the pandemic variable and race/ethnicity, age, income, and educational attainment. RESULTS: There were 3865 respondents (1437 prepandemic and 2428 postpandemic). Of the 8 outcomes investigated, the pandemic was only significantly associated with higher odds (adjusted odds ratio 1.99, 95% CI 1.18-3.35) of using electronic communication with a provider. There were significant interactions between the pandemic variable and 2 key sociodemographic traits. Relative to the lowest income group (

Assessing Medical Student Readiness to Navigate Language Barriers in Telehealth: Cross-sectional Survey Study.

BACKGROUND: The COVID-19 pandemic has greatly increased telehealth usage in the United States. Patients with limited English proficiency (LEP) face barriers to health care, which may be mitigated when providers work with professional interpreters. However, telehealth may exacerbate disparities if clinicians are not trained to work with interpreters in that setting. Although medical students are now involved in telehealth on an unprecedented scale, no educational innovations have been published that focus on digital care across language barriers. OBJECTIVE: The aim of this study is to investigate advanced medical students' confidence in caring for patients with LEP during telehealth encounters. METHODS: We administered a written survey to medical students on clinical clerkships at one US institution in August and September 2020. We assessed students' overall confidence in working with interpreters; confidence in performing 8 clinical tasks during in-person versus telehealth encounters; and frequency of performing 5 different clinical tasks with patients with LEP compared to English-speaking patients during in-person versus telehealth encounters. Wilcoxon signed-rank tests and chi-square tests were used to compare confidence and task performance frequency, respectively, for patients with LEP versus English-speaking patients during telehealth encounters. Students were also asked to identify barriers to care for patients with LEP. The free-response questions were qualitatively analyzed using open coding to identify key themes. RESULTS: Of 300 medical students surveyed, 121 responded. Furthermore, 72 students answered >50% of questions and were included in the analyses. Compared to caring for patients with LEP during in-person encounters, respondents were less confident in working with interpreters (P<.001), developing trust (P<.001), identifying agenda (P=.005), eliciting preferences for diabetes management (P=.01), and empowering patients in lifestyle modifications (P=.04) during telehealth encounters. During both in-person and telehealth encounters, approximately half of students (40%-78%) reported engaging less frequently in every clinical task with patients with LEP and this was as low as 22% (13/59) for some tasks. Students identified these key barriers to care for patients with LEP: time pressure, interpretation quality and access, technical difficulties, cultural differences, and difficulty with rapport building. CONCLUSIONS: Advanced medical students were significantly less confident caring for patients with LEP via telehealth than in person. Broader implementation of training around navigating language barriers is necessary for telehealth care, which has rapidly expanded in the United States. Our study identified potential key areas for curricular focus, including creating patient-centered agendas and management plans within the constraints of virtual settings. These developments must take place simultaneously with systems-level improvements in interpreter infrastructure to ensure high-quality care for linguistically diverse patients.

Policy Considerations To Ensure Telemedicine Equity.

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

System-Level Factors Associated With Telephone and Video Visit Use: Survey of Safety-Net Clinicians During the Early Phase of the COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic prompted safety-net health care systems to rapidly implement telemedicine services with little prior experience, causing disparities in access to virtual visits. While much attention has been given to patient barriers, less is known regarding system-level factors influencing telephone versus video-visit adoption. As telemedicine remains a preferred service for patients and providers, and reimbursement parity will not continue for audio visits, health systems must evaluate how to support higher-quality video visit access. OBJECTIVE: This study aimed to assess health system-level factors and their impact on telephone and video visit adoption to inform sustainability of telemedicine for ambulatory safety-net sites. METHODS: We conducted a cross-sectional survey among ambulatory care clinicians at a hospital-linked ambulatory clinic network serving a diverse, publicly insured patient population between May 28 and July 14, 2020. We conducted bivariate analyses assessing health care system-level factors associated with (1) high telephone adoption (4 or more visits on average per session); and (2) video visit adoption (at least 1 video visit on average per session). RESULTS: We collected 311 responses from 643 eligible clinicians, yielding a response rate of 48.4%. Clinician respondents (N=311) included 34.7% (n=108) primary or urgent care, 35.1% (n=109) medical, and 7.4% (n=23) surgical specialties. Our sample included 178 (57.2%) high telephone adopters and 81 (26.05%) video adopters. Among high telephone adopters, 72.2% utilized personal devices for telemedicine (vs 59.0% of low telephone adopters, P=.04). Video nonadopters requested more training in technical aspects than adopters (49.6% vs 27.2%, P<.001). Primary or urgent care had the highest proportion of high telephone adoption (84.3%, compared to 50.4% of medical and 37.5% of surgical specialties, P<.001). Medical specialties had the highest proportion of video adoption (39.1%, compared to 14.8% of primary care and 12.5% of surgical specialties, P<.001). CONCLUSIONS: Personal device access and department specialty were major factors associated with high telephone and video visit adoption among safety-net clinicians. Desire for training was associated with lower video visit use. Secure device access, clinician technical trainings, and department-wide assessments are priorities for safety-net systems implementing telemedicine.

The Abrupt Expansion of Ambulatory Telemedicine: Implications for Patient Safety.

The exponential growth of telemedicine in ambulatory care triggered by the COVID-19 public health emergency has undoubtedly impacted the quality of care and patient safety. In particular, the increased adoption of remote care has impacted communication, care teams, and patient engagement, which are key factors that impact patient safety in ambulatory care. In this perspective, we draw on a scoping review of the literature, our own clinical experiences, and conversations with patient safety experts to describe how changes in communication, care teams, and patient engagement have impacted two high priority areas in ambulatory safety: diagnostic errors and medication safety. We then provide recommendations for research funders, researchers, healthcare systems, policy makers, and healthcare payors for how to improve patient safety in telemedicine based on what is currently known as well as next steps for how to advance understanding of the safety implications of telemedicine utilization.

Clinician Experience with Telemedicine at a Safety-net Hospital Network during COVID-19: A Cross-sectional Survey

Objective. The COVID-19 pandemic prompted unprecedented expansion of telemedicine services. We sought to describe clinician experiences providing telemedicine to publiclyinsured, lowincome patients during COVID-19. Methods. Online survey of ambulatory clinicians in an urban safetynet hospital system, conducted May 28, 2020–July 14, 2020. Results. Among 311 participants (response rate 48.3%), 34.7% (n=108/311) practiced in primary/urgent care, 37.0% (n=115/311) medical specialty, and 7.7% (n=24/311) surgical clinics. A large majority (87.8%, 273/311) had conducted telephone visits, 26.0% (81/311) video. Participants reported observing both technical and nontechnical patient barriers. Clinicians reported concerns about the diagnostic safety of telephone (58.9%, 129/219) vs. video (35.3%, 24/68). However, clinician comfort with telemedicine was high for telephone (89.3%, 216/242) and for video (91.0%, 61/67), with many clinicians (92.1%, 220/239 telephone;90.9%, 60/66 video) planning to continue telemedicine after COVID-19. Conclusions. Clinicians in a safetynet health care system report great comfort with and intention to continue telemedicine after the pandemic, despite safety concerns and patient challenges.