ABSTRACT
BACKGROUND: COVID-19 forced health systems to convert to telemedicine almost overnight. In turn, systems, physicians, and leadership are interested in optimizing telemedicine care quality. Most investigations into telemedicine experiences have been singular snapshots of attitudes or competencies. A better understanding of longitudinal experiences will be necessary to inform ongoing integration of telemedicine into practice. We surveyed practicing physicians a year apart to examine their experiences before and after regular provision of virtual care. METHODS: Surveys were distributed May-Jul '20 (following the first COVID wave) and again in Mar-Jun '21 to internal medicine physicians practicing in free-standing and hospital-based outpatient practices in two distinct health systems: NYU Langone Health (private) and NYC Health + Hospitals (public). Of the 391 physicians who received a survey, 136 participants responded (35% response rate);111 responses contained complete data and were included in analyses. Items covered physician experiences with and attitudes towards tele-visits. For analyses, 4-and 5-point Likert scale items were dichotomized (Disagree v. Agree) or grouped into three item responses (More Difficult, Roughly the Same, Easier). Chi-square analyses were used to explore differences by site and assessment year to describe changes between survey periods. Items on attitudes toward the future of remote-based care were collapsed into a mean 'telemedicine acceptance' score. Regression models were run in order to identify which items are associated with telemedicine acceptance. RESULTS: Physicians reported less difficulty with: taking an appropriate history (49% in 2020, 33% in 2021, p=.015);maximizing patient adherence (33% in 2020, 19% in 2021, p=.028);maintaining patient relationships (31% in 2020, 25% in 2021, p=.009);and sharing information with team members (31% in 2020, 27% in 2021, p=.795) in the follow-up survey. They reported continued challenges with: building new patient relationships (75% in 2020, 77% in 2021, p=.075) and working collaboratively (38% in 2020, 41% in 2021, p=.794). On acceptance measures, physicians reported increased satisfaction with tele-visits over in-person visits (13% in 2020, 27% in 2021, p=0.006) and less worry over doing future tele-visits (45% in 2020, 31% in 2021, p=.027). Fewer physicians found telemedicine to be exhausting than previously reported (51% in 2020, 43% in 2021, p=.247). Mean acceptance scores were 2.41 for 2020 and 2.53 for 2021 (p=.130) (with 4 signifying full acceptance). The ability to establish relationships with new patients (B=0.145, p=.039) and take an appropriate patient history (B=0.154, p=.044) during televisits are associated with increased acceptance. CONCLUSIONS: Results suggest that telemedicine care improves for physicians over time following integration into practice and identify areas for ongoing training/improvement. Long-term follow-up can build a deeper understanding of the ongoing use of telemedicine.
ABSTRACT
BACKGROUND: Since the onset of the COVID-19 pandemic, healthcare systems have faced significant barriers to providing quality primary care, particularly as practices shifted to telemedicine modalities without established technical and educational frameworks for patients, teams, and clinicians. We created an iterative quality improvement project with Unannounced Standardized Patients (USPs) to explore variation in telehealth practices across three public ambulatory care clinics. METHODS: Clinical leadership designed two USP cases reflective of local patient populations and their common clinical needs. USPs portrayed either;(1) a 40-45-year-old Black male with hypertension, or (2) a 40-45-year-old Latina with an asthma exacerbation and hypertension. Both were vaccine hesitant. USPs evaluated visit workflow and clinician's communication skills across core domains (Table 1). After each visit, the USPs completed a behaviorally anchored checklist. Domain summary scores were calculated as mean percent marked “well done.” A t-test was used to compare scores across phases and cases. RESULTS: 60 visits (48 video, 12 audio-only) were conducted in two phases (May-August 2021;September-December 2021). Of the 24 USPs (18 calls, 9 texts) contacted prior to their visit, only 4 spoke directly to a care team member. 74% of USPs recommended the clinic. There were no significant differences in domain scores between phases or cases (Table 1). Most clinicians (82% in both phases) introduced the topic of the COVID-19 vaccine appropriately. Regarding screening, most providers asked about smoking (79%) and alcohol use (72%), but few screened for vaping (22%) or depression (4%). 70% of clinicians or care teams replied to a MyChart portal message that was sent by the USP to the care team after the visit. CONCLUSIONS: Findings highlight opportunities for system-based change to optimize telehealth care (particularly the integration of team members in previsit planning, standardized screenings, and patient follow-up). Data across phases indicate sustained need for quality improvement efforts;reviewing comparative data with clinic leadership will inform further evaluation of health systems and educational methods.
ABSTRACT
BACKGROUND: Student health centers provide necessary care to university students, yet there is limited literature on efforts to standardize or improve quality of this care. When our urban student health center rapidly shifted to telemedicine-based care at the onset of COVID-19, we designed and deployed two unannounced standardized patient (USP) cases as part of a quality improvement project to assess, broadly, the impact of a new telemedicine workflow and common clinical activities. METHODS: In April and May of 2021, 12 primary care and 4 women's health clinicians conducted virtual visits with two distinct USP cases (N=32 visits, 2 per clinician). Cases included (1) a 21-year-old female requesting a birth control prescription with a positive PHQ-9 and (2) a 21-year-old gaymale who has questions regarding safe sex and vapes regularly. Clinicians were evaluated using two assessments: (1) a behaviorally anchored checklist completed by the USP covering the microsystem and the clinician's skills and (2) a systematic chart review of the electronic health record. RESULTS: Overall, 88% of USPs reported that they would recommend the clinic. Regarding the clinic workflow, 12 of 32 USPs reported receiving a previsit call (clinical protocol), 10 answered the calls and of those, 20% verified two patient identifiers. Between cases, there were significant differences in three domains (mean % well done). Information gathering was significantly higher for the depression case (84% vs. 48%;p=0.004), patient activation was higher for the sexual health case (53% vs 23%;p=0.027), and telemedicine skills were higher in the depression case (77% vs. 57%;p=0.015). Clinician performance was relatively low in case-specific education (depression: 28%, sexual health: 20%) and moderate in management/treatment plan (mean across cases: 66%), relationship development (64%), and education and counseling (65%). In a number of “gold standards of care” items identified by clinical leadership, less than half of clinicians met the target. In the depression case, 56% documented both PHQ-2 and PHQ-9 screenings, 0% screened for alcohol use and quantity, and 66% screened for relationship violence. In the sexual health case, 56% screened for vaping quantity and frequency. 63% counseled on PrEP. No providers completed any part of a physical exam besides commenting on appearance. CONCLUSIONS: Through USP visits and chart reviews, we identified variation in quality of communication skills and use of common screening protocols at this student health center during virtual visits. Health system standards previously integrated into in-person visits may have been lost in the transition to telemedicine care. Our results suggest opportunities exist for targeted improvement efforts that ensure quality virtual care for all students.
ABSTRACT
SETTING AND PARTICIPANTS: Clinician trainees across our health system, including: 1) 107 internal medicine faculty and residents who participated in workplace-based learning at public, private, and federal (Veterans Affairs) ambulatory practices, 2) 16 clinicians at our student health center, and 3) upwards of 250 medical students, residents, and newly-hired general internal medicine (GIM) faculty members from medicine, neurology, and pediatrics departments in our simulation center. DESCRIPTION: While core communication skills have always been at the forefront of medical trainee assessment, information on transference of those skills and integration of the in-person clinical workflow to the virtual care environment was limited prior to COVID-19. NYU Grossman School of Medicine (NYUSOM) implemented a telehealth improvement program across medical students, residents and faculty. In order to assess and improve our systems' ongoing telehealth practices, we employed three distinct educational methodologies across our health systems since March 2020: objective structured clinical exams (OSCEs) and announced (ASPs) and unannounced standardized patient (USPs). Cases were designed to target common, site-specific issues (i.e., hearing loss, COVID-19 vaccine hesitancy, social determinants of health, and sexual and mental health concerns). In line with previous work, all SPs were trained to use a standard behaviorally-anchored checklist to assess communication and telemedicine-specific skills over video visit ( Zoom or WebEx). USPs, professional actors who conduct visits unbeknownst to the clinician, were also trained to collect data on clinic functioning. EVALUATION: Summary reports on performance were provided to both clinical and education leadership and learners to identify future training needs. Data on telemedicine skills across all projects demonstrates room for improvement (mean % marked 'well done' across learners: 46% in the OSCE, 68% at the SHC, and 48% in the public clinics, respectively). Common telemedicine challenges included prompting the SP to adjust their video frame or remove distracting background noise. Most health systems conducted fewer screenings virtually than they did inperson (e.g., at the SHC only 41% and 6% of SPs were screened for alcohol and vaping, respectively;at the public clinics, 25% and 20% were screened for depression and vaping, respectively). Participant feedback reports highlight performance across core domains and provide resources for improvement. DISCUSSION / REFLECTION / LESSONS LEARNED: Our ongoing telemedicine training program demonstrates a highly scalable educational assessment methodology that can be leveraged to optimize common care practices. Data confirm that SPs, ASPs, and USPs can be used across the health care system in simulated and real-world scenarios to identify areas for intervention.