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.

Impact of the Early Phase of the COVID-19 Pandemic on Medical Student Well-Being: a Multisite Survey.

BACKGROUND: The COVID-19 pandemic drastically impacted medical student experiences. Little is known about the impact of the pandemic on student well-being and protective factors for burnout. OBJECTIVE: Assess US medical student burnout, stress, and loneliness during the initial phase of the pandemic, compare results to pre-pandemic data, and identify risk factors for distress and protective factors to inform support interventions. DESIGN: Cross-sectional survey of medical students conducted between May and July 2020. PARTICIPANTS: 3826 students from 22 medical schools. MAIN MEASURES: Burnout (MBI-HSS), stress (PSS-10), loneliness (UCLA scale), and student experiences. Compared burnout and stress to pre-pandemic studies (2010-2020). KEY RESULTS: Of 12,389 students, 3826 responded (31%). Compared to pre-pandemic studies, burnout was lower (50% vs. 52%, P = 0.03) while mean stress was higher (18.9 vs. 16.0, P < 0.001). Half (1609/3247) reported high (≥ 6/9) loneliness scores. Significant differences were found in burnout and stress by class year (P = 0.002 and P < 0.001) and race (P = 0.004 and P < 0.001), with the highest levels in second- and third-year students and Black, Asian, or other racial minority students. Students experiencing financial strain or racism had higher burnout and stress (P < 0.001 for all). Respondents with COVID-19 diagnoses in themselves or family members had higher stress (P < 0.001). Nearly half (1756/3569) volunteered during the pandemic, with volunteers reporting lower burnout [48% (782/1639) vs. 52% (853/1656), P = 0.03]. CONCLUSIONS: While stress was higher compared to pre-pandemic data, burnout was significantly lower. Higher burnout and stress among Black, Asian, and other racial minority students and those who experienced financial strain, racism, or COVID-19 diagnoses likely reflect underlying racial and socioeconomic inequalities exacerbated by the pandemic and concurrent national racial injustice events. Volunteer engagement may be protective against burnout. Schools should proactively support vulnerable students during periods of stress.

Telehealth Competencies in Medical Education: New Frontiers in Faculty Development and Learner Assessments.

Telehealth visits have become an integral model of healthcare delivery since the COVID-19 pandemic. This rapid expansion of telehealthcare delivery has forced faculty development and trainee education in telehealth to occur simultaneously. In response, academic medical institutions have quickly implemented clinical training to teach digital health skills to providers across the medical education continuum. Yet, learners of all levels must still receive continual assessment and feedback on their skills to align with the telehealth competencies and milestones set forth by the Association of American Medical Colleges (AAMC) and the Accreditation Council for Graduate Medical Education (ACGME). This paper discusses key educational needs and emerging areas for faculty development in telehealth teaching and assessment of telehealth competencies. It proposes strategies for the successful integration of the AAMC telehealth competencies and ACGME milestones into medical education, including skills in communication, data gathering, and patient safety with appropriate telehealth use. Direct observation tools in the paper offer educators novel instruments to assess telehealth competencies in medical students, residents, and peer faculty. The integration of AAMC and ACGME telehealth competencies and the new assessment tools in this paper provide a unique perspective to advance clinical practice and teaching skills in telehealthcare delivery.

Digitally Disconnected: Qualitative Study of Patient Perspectives on the Digital Divide and Potential Solutions.

BACKGROUND: As telemedicine utilization increased during the COVID-19 pandemic, divergent usage patterns for video and audio-only telephone visits emerged. Older, low-income, minority, and non-English speaking Medicaid patients are at highest risk of experiencing technology access and digital literacy barriers. This raises concern for disparities in health care access and widening of the "digital divide," the separation of those with technological access and knowledge and those without. While studies demonstrate correlation between racial and socioeconomic demographics and technological access and ability, individual patients' perspectives of the divide and its impacts remain unclear. OBJECTIVE: We aimed to interview patients to understand their perspectives on (1) the definition, causes, and impact of the digital divide; (2) whose responsibility it is to address this divide, and (3) potential solutions to mitigate the digital divide. METHODS: Between December 2020 and March 2021, we conducted 54 semistructured telephone interviews with adult patients and parents of pediatric patients who had virtual visits (phone, video, or both) between March and September 2020 at the University of Chicago Medical Center (UCMC) primary care clinics. A grounded theory approach was used to analyze interview data. RESULTS: Patients were keenly aware of the digital divide and described impacts beyond health care, including employment, education, community and social contexts, and personal economic stability. Patients described that individuals, government, libraries, schools, health care organizations, and even private businesses all shared the responsibility to address the divide. Proposed solutions to address the divide included conducting community technology needs assessments and improving technology access, literacy training, and resource awareness. Recognizing that some individuals will never cross the divide, patients also emphasized continued support of low-tech communication methods and health care delivery to prevent widening of the digital divide. Furthermore, patients viewed technology access and literacy as drivers of the social determinants of health (SDOH), profoundly influencing how SDOH function to worsen or improve health disparities. CONCLUSIONS: Patient perspectives provide valuable insight into the digital divide and can inform solutions to mitigate health and resulting societal inequities. Future work is needed to understand the digital needs of disconnected individuals and communities. As clinical care and delivery continue to integrate telehealth, studies are needed to explore whether having a video or audio-only phone visit results in different patient outcomes and utilization. Advocacy efforts to disseminate public and private resources can also expand device and broadband internet access, improve technology literacy, and increase funding to support both high- and low-tech forms of health care delivery for the disconnected.

Clinician Perspectives on Telemedicine: Observational Cross-sectional Study.

BACKGROUND: Since the COVID-19 pandemic onset, telemedicine has increased exponentially across numerous outpatient departments and specialties. Qualitative studies examining clinician telemedicine perspectives during the pandemic identified challenges with physical examination, workflow concerns, burnout, and reduced personal connection with patients. However, these studies only included a relatively small number of physicians or were limited to a single specialty, and few assessed perspectives on integrating trainees into workflows, an important area to address to support the clinical learning environment. As telemedicine use continues, it is necessary to understand a range of clinician perspectives. OBJECTIVE: This study aims to survey pediatric and adult medicine clinicians at the University of Chicago Medical Center to understand their telemedicine benefits and barriers, workflow impacts, and training and support needs. METHODS: In July 2020, we conducted an observational cross-sectional study of University of Chicago Medical Center faculty and advanced practice providers in the Department of Medicine (DOM) and Department of Pediatrics (DOP). RESULTS: The overall response rate was 39% (200/517; DOM: 135/325, 42%; DOP: 65/192, 34%); most respondents were physicians (DOM: 100/135, 74%; DOP: 51/65, 79%). One-third took longer to prepare for (65/200, 33%) and conduct (62/200, 32%) video visits compared to in-person visits. Male clinicians reported conducting a higher percentage of telemedicine visits by video than their female counterparts (P=.02), with no differences in the number of half-days per week providing direct outpatient care or supervising trainees. Further, clinicians who conducted a higher percentage of their telemedicine by video were less likely to feel overwhelmed (P=.02), with no difference in reported burnout. Female clinicians were "more overwhelmed" with video visits compared to males (41/130, 32% vs 12/64, 19%; P=.05). Clinicians 50 years or older were "less overwhelmed" than those younger than 50 years (30/85, 35% vs 23/113, 20%; P=.02). Those who received more video visit training modalities (eg, a document and webinar on technical issues) were less likely to feel overwhelmed by the conversion to video visits (P=.007) or burnt out (P=.009). In addition, those reporting a higher ability to technically navigate a video visit were also less likely to feel overwhelmed by video visits (P=.02) or burnt out (P=.001). The top telemedicine barriers were patient-related: lack of technology access, lack of skill, and reluctance. Training needs to be focused on integrating learners into workflows. Open-ended responses highlighted a need for increased support staff. Overall, more than half "enjoyed conducting video visits" (119/200, 60%) and wanted to continue using video visits in the future (150/200, 75%). CONCLUSIONS: Despite positive telemedicine experiences, more support to facilitate video visits for patients and clinicians is needed. Further, clinicians need additional training on trainee education and integration into workflows. Further work is needed to better understand why gender and age differences exist. In conclusion, interventions to address clinician and patient barriers, and enhance clinician training are needed to support telemedicine's durability.