Patient Perspectives on Using Telemedicine During In-Center Hemodialysis: A Qualitative Study.

Rationale & Objective: In the wake of the coronavirus disease 2019 (COVID-19) pandemic, the United States federal government expanded originating telemedicine sites to include outpatient dialysis units. For the first time, nephrology practitioners across the United States could replace face-to-face visits with telemedicine for patients receiving in-center hemodialysis. This study describes patients' perspectives on the use of telemedicine during in-center hemodialysis. Study Design: A qualitative study. Setting & Participants: Thirty-two patients from underserved populations (older, less educated, unemployed, persons of color) receiving in-center hemodialysis who used telemedicine with their nephrologist during the COVID-19 pandemic. Analytical Approach: Telephone semistructured interviews were conducted in English or Spanish. Transcripts were thematically analyzed. Results: We identified 6 themes with subthemes: adapting to telemedicine (gaining familiarity and confidence, overcoming and resolving technical difficulties, and relying on staff for communication); ensuring availability of the physician (enabling an immediate response to urgent medical needs, providing peace of mind, addressing patient needs adequately, and enhanced attention and contact from physicians); safeguarding against infection (limiting COVID-19 exposures and decreasing use); straining communication and physical interactions (loss of personalized touch, limited physical examination, and unable to reapproach physicians about forgotten issues); maintaining privacy (enhancing privacy and projecting voice enables others to hear); and supporting confidence in telemedicine (requiring established rapport with physicians, clinical stabilty of health, and ability to have in-person visits when necessary). Limitations: Interviews were conducted later in the pandemic when some nephrology care providers were using telemedicine infrequently. Conclusions: Patients receiving in-center hemodialysis adapted to telemedicine visits by their nephrologists in the context of the COVID-19 pandemic and observed its benefits. However, further considerations regarding communication, privacy, and physical assessments are necessary. Integrating telemedicine into future in-center hemodialysis care using a hybrid approach could potentially build trust, optimize communication, and augment care.

This study describes patients' perspectives on the use of telemedicine while receiving in-center hemodialysis during the coronavirus disease 2019 (COVID-19) pandemic. Data are derived from semistructured interviews with thirty-two patients from underserved populations (older, less educated, unemployed, persons of color). We identified 6 major themes including adapting to telemedicine, ensuring availability of the physicians, safeguarding against infection, straining communication and physical interactions, maintaining privacy, and supporting confidence in telemedicine. These findings suggest that patients receiving in-center hemodialysis adapted to telemedicine visits by their nephrologists in the context of the COVID-19 pandemic and observed its benefits. However, further considerations regarding communication, privacy, and physical assessments are necessary. Integrating telemedicine into future in-center hemodialysis care using a hybrid approach could potentially build trust, optimize communication, and augment care.

Patient-centered development of a bladder cancer survivorship care plan.

PURPOSE: This study aimed to develop a patient-centered survivorship care plan (SCP) for US military Veteran bladder cancer (BC) survivors in accordance with the National Academy of Medicine recommendation that survivors receive an SCP at treatment completion. BC, which differentially impacts older men, is a costly and highly recurrent cancer associated with invasive procedures and long-term surveillance. Veteran BC survivors may face challenges navigating the patient-to-survivor transition due to their age and comorbidities. METHODS: We conducted 20 one-on-one qualitative interviews and 2 focus groups with Veteran BC survivors to understand their preferences for information and support to inform SCP development. Data were analyzed using rapid analysis. RESULTS: Participants voiced concerns about BC's impact on their psychosocial functioning and quality of life. They suggested information on BC recurrences, recommended surveillance schedules, long-term side effects and healthy living, and how and when to seek help if a medical problem arises should be included on the SCP to help manage expectations and access key resources during survivorship. Although participants had varying needs, many recommended including information on supportive resources (e.g., support groups, peer support programs) to manage cancer-related anxiety. Participants also suggested including Veteran-centered information (e.g., Veterans' BC risk factors). CONCLUSION: We developed an SCP to help Veteran BC survivors navigate the transition from patient to survivor. Adapting an SCP to address specific needs of the Veteran population was an important step in supporting Veteran BC survivors. Future research should evaluate the potential effectiveness of this SCP at improving Veterans' health outcomes and healthcare experiences.

"We're Trained to Survive.": Veterans' Experiences Seeking Food Assistance.

PURPOSE: Food insecurity threatens veterans' health, yet little is known about their experiences seeking food assistance. Thus, we studied veterans' experiences as they navigated from food insecurity to food assistance. METHODS: We built a journey map using thematic analysis of interviews with 30 veterans experiencing food insecurity. FINDINGS: The map focuses on: (1) identifying contributing circumstances, (2) recognizing food insecurity, (3) finding help, and (4) obtaining assistance. Contributing circumstances included unemployment/under-employment, mental health challenges, and interpersonal violence. Veterans did not recall being screened for food insecurity. Military training also inhibited some veterans from recognizing their own food insecurity. Locating and accessing food assistance was a struggle. While many veterans applied for the Supplemental Nutrition Assistance Program, few qualified. Food pantries were a last resort. CONCLUSIONS: Opportunities to help veterans include (1) addressing contributing circumstances, (2) improving identification, (3) sharing knowledge of resources, and (4) reexamining sufficiency of food assistance programs.

Understanding patients' experiences during transitions from one electronic health record to another: A scoping review.

Objectives: Identify existing research on impacts of transitions between electronic health record (EHR) systems on patients' healthcare experiences. Methods: Scoping review. We searched MedLine, OVID, Embase, CINAHL, and PsycInfo databases for articles on patient experiences with EHR-to-EHR transitions. Results: Three studies met inclusion criteria. All three used validated surveys to compare patient satisfaction with care pre- and post-transition. The surveys did not include specific questions about the EHR transition; one study focused on patient perceptions of provider computer use. Satisfaction levels initially decreased following EHR implementation, then returned to baseline between six and 15 months later in two of three studies. Factors associated with changes in observed satisfaction are unknown. Conclusions: Patient experience has been given limited attention in studies of EHR-to-EHR transitions. Future research should look beyond satisfaction, and examine how an EHR-to-EHR transition can impact the quality of patients' care, including safety, effectiveness, timeliness, efficiency, and equity. Innovation: To our knowledge, this is the first literature review on EHR transitions that specifically focused on patient experiences. In preparation for a transition from one EHR to another, healthcare system leaders should consider the multiple ways patients' experiences with care may be impacted and develop strategies to minimize disruptions in care.

Maternal Anxiety and Empowerment in Pregnancies Complicated By Fetal Surgical Anomalies: A Mixed Methods Study.

INTRODUCTION: Fetal surgical anomalies cause significant anxiety. Following the diagnosis, prenatal counseling with shared decision-making occurs. Empowerment is an essential component of shared decision-making. The purpose of this mixed-methods study was to evaluate the association between patient empowerment with depression and anxiety among patients with fetal surgical anomalies. METHODS: An explanatory mixed-methods study was conducted at a large tertiary fetal center among patients with recently diagnosed surgical fetal anomalies from May, 2021 to May, 2022. Validated cross-sectional surveys were used to collect quantitative data regarding patient empowerment, depression, and anxiety. Univariate analysis was used to compare the association of maternal empowerment with depression and anxiety. Qualitative data was obtained from semistructured interviews to explore maternal anxiety and depression relative to the fetal diagnosis. Thematic analysis was performed to identify themes. RESULTS: Seventy-four patients were recruited for the quantitative study. Pregnancy-related empowerment score and patient empowerment score were significantly lower for expectant mothers with high anxiety (P < 0.01). Eighteen patients participated in qualitative interviews. Participants expressed significant anxiety related to their fetal diagnosis. Exacerbating stressors included social determinants, personal history of miscarriage, and changing family dynamics. CONCLUSION: Our results suggest there is an association between increased depression and anxiety with lower empowerment. These findings have important implications for prenatal counseling, as targeted interventions to improve psychosocial support to treat depression and anxiety might also improve empowerment.

Understanding Patients' Preferences and Experiences During an Electronic Health Record Transition.

BACKGROUND: The Department of Veterans Affairs (VA) has embarked on the largest system-wide electronic health record (EHR) transition in history. To date, most research on EHR-to-EHR transitions has focused on employee and system transition-related needs, with limited focus on how patients experience transitions. OBJECTIVE: (1) Understand patients' preferences for information and support prior to an EHR transition, and (2) examine actual patient experiences that occurred at facilities that implemented a new EHR. DESIGN: We used a two-step approach. We had discussions with geographically diverse patient advisory groups. Discussions informed semi-structured, qualitative interviews with patients. PARTICIPANTS: Patients affected by the EHR transition. MAIN MEASURES: We met with four patient advisory groups at sites that had not transitioned their EHR. Interviews were conducted with patients who received care at one of two facilities that recently transitioned to the new EHR. KEY RESULTS: Patient advisors identified key areas important to patients during an EHR transition. 1) Use a range of communication strategies to reach diverse populations, especially older, rural patients. 2) Information about the EHR transition should be clear and reinforce trustworthiness. 3) Patients will need guidance using the new patient portal. From the patient interviews, we learned if and how these key areas mapped onto patients' experiences. Patients at the sites that had transitioned learned about the new EHR through a variety of modalities, including letters and banners on the patient portal. However, their experiences varied in terms of information quality, leading to frustrations during and between healthcare encounters. Patient portal issues exacerbated frustrations. These raised concerns about the accuracy and security of the overall EHR. CONCLUSIONS: Maintaining clear communication across patients, local leadership, and providers throughout an EHR transition is essential for successful implementation. Patient-facing communications can set expectations, and help patients receive adequate support, particularly related to the patient portal.

Impact of the COVID-19 Pandemic on Medical Education during Inpatient Internal Medicine Rounds.

OBJECTIVES: Inpatient rounding is a foundational component of medical education in academic hospitals. The coronavirus 2019 (COVID-19) pandemic disrupted traditional inpatient rounding practices. The objectives of this study were to describe how Internal Medicine inpatient team rounding changed because of COVID-19-related precautions and the effect of these changes on education during rounds. METHODS: During February to March 2021, we conducted four virtual focus groups with medical and physician assistant students, interns, upper-level residents, and attending physicians at the Michael E. DeBakey Veterans Affairs Medical Center in Houston, Texas, and designed a codebook to categorize focus group commentary. RESULTS: Focus groups revealed that students believed that certain physical-distancing measures in place early on during the pandemic were ineffective and significantly limited their ability to evaluate patients in person. Residents described increased stress levels related to potential severe acute respiratory-coronavirus 2 exposure and limited time at the bedside, which affected their confidence with clinical assessments. Rounding-team fragmentation precluded the entire team learning from all of the patients on the team's census. Loss of intrateam camaraderie impaired the development of comfortable learning environments. CONCLUSIONS: This study evaluated Internal Medicine team member focus groups to describe how the COVID-19 pandemic affected medical education during rounds. Academic teaching programs can adapt the findings from this study to address and prevent pandemic-related gaps in medical education during rounds now and during future potential disruptions to medical education.

Unmet Needs and Coping Strategies of Older Underserved Veterans During the COVID-19 Pandemic.

INTRODUCTION: The COVID-19 pandemic has had profound impacts on people with diabetes, a group with high morbidity and mortality. Factors like race, age, income, Veteran-status, and limited or interrupted resources early in the COVID-19 pandemic compounded risks for negative health outcomes. Our objective was to characterize the experiences and needs of under-resourced Veterans with type 2 diabetes during the COVID-19 pandemic. METHODS: We conducted semi-structured qualitative interviews (March through September 2021) with U.S. military Veterans with diabetes. Transcripts were analyzed using a team-based, iterative process of summarizing and coding to identify key themes. Participants included Veterans (n = 25) who were mostly men (84%), Black or African American (76%), older (mean age = 62.6), and low-income (<$20 000/year; 56%). Most participants self-reported moderate (36%) or severe (56%) diabetes-related distress. RESULTS: Shutdowns and social distancing negatively impacted Veterans' social, mental, and physical health. Veterans reported feeling increased isolation, depression, stress, and unmet mental health needs. Their physical health was also negatively affected. Despite pandemic-related challenges, Veterans adapted with new technological skills, appreciating their families, staying active, and relying on their religious faith. CONCLUSIONS: Veterans' experiences during the pandemic revealed the importance of social support and access to technology. For those without social support, peer support could protect against negative health outcomes. Emergency-preparedness efforts for vulnerable patients with type 2 diabetes should include raising awareness about and increasing access to technological resources (eg, Zoom or telehealth platforms). Findings from this study will help tailor support programs for specific populations' needs in future health crises.

Impact of Telemedicine on Prenatal Counseling at a Tertiary Fetal Center: A Mixed Methods Study.

INTRODUCTION: COVID-19 spurred an unprecedented transition from in-person to telemedicine visits in March 2020 at our institution for all prenatal counseling sessions. This study aims to explore differences in demographics of expectant mothers evaluated pre- and post-telemedicine implementation and to explore the patient experience with telemedicine. METHODS: A mixed methods study was completed for mothers with a pregnancy complicated by a fetal surgical anomaly who visited a large tertiary fetal center. Using medical records as quantitative data, patient information was collected for all prenatal visits from 3/2019 to 3/2021. The sample was grouped into pre- and post-telemedicine implementation (based on transition date of 3/2020). Univariate analysis was used to compare demographics between the study groups. Statistical significance was defined as P < 0.05. Eighteen semi-structured interviews were conducted from 8/2021 to 12/2021 to explore patients' experiences. Line-by-line coding and thematic analysis was performed to develop emerging themes. RESULTS: 292 pregnancies were evaluated from 3/2019 to 3/2021 (pre-telemedicine 123, post-telemedicine 169). There was no significant difference in self-reported race (P = 0.28), ethnicity (P = 0.46), or primary language (P = 0.98). In qualitative interviews, patients reported advantages to telemedicine, including the convenience of the modality with the option to conduct their session in familiar settings (e.g., home) and avoid stressors (e.g., travel to the medical center and finding childcare). Some women reported difficulties establishing a physician-patient connection and a preference for in-person consultations. CONCLUSIONS: There was no difference in patient demographics at our fetal center in the year leading up to, and the time following, a significant transition to telemedicine. However, patients had unique perspectives on the advantages and disadvantages of the telemedicine experience. To ensure patient centered care, these findings suggest patient preference should be considered when scheduling outpatient surgical counseling and visits.

Effects of Sex, Race, and Education on the Timing of Coming Out among Lesbian, Gay, and Bisexual Adults in the U.S.

Sexual identity formation or "coming out" as lesbian, gay, or bisexual (LGB) involves a complex process including both private realization and public disclosure. Private realization refers to the process through which an individual becomes aware of their LGB identity, whereas public disclosure reflects when an individual discloses their identity to another person. Sex, race, and class affect the timing of these processes across the life course. While extant research has identified the bivariate nature of these processes, we took a multivariate approach to understand the timing of these sexual identity milestones from a life-course perspective. Using data from the Pew Research Center's 2013 Survey of LGBT Adults (n = 1136), we considered how the timing of private realization and public disclosure of LGB identity is a sexed, racialized, and classed experience. The sample consisted of lesbians (n = 270), gay males (n = 396), bisexual females (n = 342), and bisexual males (n = 127). Results indicated that females uniformly realized and disclosed their identities at later stages in the life course, whereas individuals with at least some college education came out during their prime college-age years. We also found variation in timing between private realization and public disclosure for Black respondents, but not other racial groups. These findings provide insight into how organizations can develop specific programs that allow LGB individuals to safely explore their sexuality and provide support over the life course.