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Evidence for telemedicine's ongoing transformation of healthcare delivery since the onset of COVID-19: A retrospective observational study

Mandal, Soumik; Wiesenfeld, Batia; Mann, Devin; Lawrence, Katharine; Chunara, Rumi; Testa, Paul; Nov, Oded
BACKGROUND:The surge of telemedicine use during the early stages of the coronavirus-19 (COVID-19) pandemic has been well documented. However, scarce evidence considers the utilization of telemedicine in the subsequent period. OBJECTIVE:This study aims to evaluate utilization patterns of video-based telemedicine visits for ambulatory care and urgent care provision over the course of recurring pandemic waves in one large health system in New York City, and what this means for healthcare delivery. METHODS:Retrospective electronic health record (EHR) data of patients between January 1st, 2020, and February 28th, 2022 were used to longitudinally track and analyze telemedicine and in-person visit volumes across ambulatory care specialties and urgent care, as well as compare them to a pre-pandemic baseline (June to November 2019). Diagnosis codes to differentiate COVID-19 suspected visits from non-COVID-19 visits, as well as evaluating COVID-19 based telemedicine utilization over time, were compared to the total number of COVID-19 positive cases in the same geographic region (city-level). The time-series data was segmented based on change-point analysis and variances in visit trends were compared between the segments. RESULTS:The emergence of COVID-19 prompted an early increase in the number of telemedicine visits across the urgent care and ambulatory care settings. This utilization continued throughout the pandemic at a much higher level than the pre-pandemic baseline for both COVID-19 and non-COVID suspected visits, despite fluctuation in COVID-19 cases throughout the pandemic and the resumption of in-person clinical services. Utilization of telemedicine-based urgent care services for COVID-19 suspected visits showed more variance in response to each pandemic wave, but telemedicine visits for ambulatory care have remained relatively steady after the initial crisis period. During the Omicron wave, the utilization of all visit types including in-person activities decreased. Patients between 25 and 34 years of age were the largest users of telemedicine-based urgent care. Patient satisfaction with telemedicine-based urgent care remained high despite the rapid scaling of services to meet increased demand. CONCLUSIONS:The trend of increased use of telemedicine as a means of healthcare delivery relative to the pre-COVID-19 baseline has been maintained throughout the later pandemic periods despite fluctuating COVID-19 cases and the resumption of in-person care delivery. Overall satisfaction with telemedicine-based care is also high. The trends in telemedicine utilization suggest that telemedicine-based healthcare delivery has become a mainstream and sustained supplement to in-person-based ambulatory care, particularly for younger patients, for both urgent and non-urgent care needs. These findings have implications for the healthcare delivery system, including practice leaders, insurers, and policymakers. Further investigation is needed to evaluate telemedicine adoption by key demographics, identify ongoing barriers to adoption, and explore the impacts of sustained use of telemedicine on healthcare outcomes and experience.
PMID: 36103553
ISSN: 2561-326x
CID: 5336262

A framework for digital health equity

Richardson, Safiya; Lawrence, Katharine; Schoenthaler, Antoinette M; Mann, Devin
We present a comprehensive Framework for Digital Health Equity, detailing key digital determinants of health (DDoH), to support the work of digital health tool creators in industry, health systems operations, and academia. The rapid digitization of healthcare may widen health disparities if solutions are not developed with these determinants in mind. Our framework builds on the leading health disparities framework, incorporating a digital environment domain. We examine DDoHs at the individual, interpersonal, community, and societal levels, discuss the importance of a root cause, multi-level approach, and offer a pragmatic case study that applies our framework.
PMID: 35982146
ISSN: 2398-6352
CID: 5300232

The Impact of Telemedicine on Physicians' After-hours Electronic Health Record "Work Outside Work" During the COVID-19 Pandemic: Retrospective Cohort Study

Lawrence, Katharine; Nov, Oded; Mann, Devin; Mandal, Soumik; Iturrate, Eduardo; Wiesenfeld, Batia
BACKGROUND:Telemedicine as a mode of health care work has grown dramatically during the COVID-19 pandemic; the impact of this transition on clinicians' after-hours electronic health record (EHR)-based clinical and administrative work is unclear. OBJECTIVE:This study assesses the impact of the transition to telemedicine during the COVID-19 pandemic on physicians' EHR-based after-hours workload (ie, "work outside work") at a large academic medical center in New York City. METHODS:We conducted an EHR-based retrospective cohort study of ambulatory care physicians providing telemedicine services before the pandemic, during the acute pandemic, and after the acute pandemic, relating EHR-based after-hours work to telemedicine intensity (ie, percentage of care provided via telemedicine) and clinical load (ie, patient load per provider). RESULTS:A total of 2129 physicians were included in this study. During the acute pandemic, the volume of care provided via telemedicine significantly increased for all physicians, whereas patient volume decreased. When normalized by clinical load (ie, average appointments per day by average clinical days per week), telemedicine intensity was positively associated with work outside work across time periods. This association was strongest after the acute pandemic. CONCLUSIONS:Taking physicians' clinical load into account, physicians who devoted a higher proportion of their clinical time to telemedicine throughout various stages of the pandemic engaged in higher levels of EHR-based after-hours work compared to those who used telemedicine less intensively. This suggests that telemedicine, as currently delivered, may be less efficient than in-person-based care and may increase the after-hours work burden of physicians.
PMID: 35749661
ISSN: 2291-9694
CID: 5282312

Reimagining Connected Care in the Era of Digital Medicine

Mann, Devin M; Lawrence, Katharine
The COVID-19 pandemic accelerated the adoption of remote patient monitoring technology, which offers exciting opportunities for expanded connected care at a distance. However, while the mode of clinicians' interactions with patients and their health data has transformed, the larger framework of how we deliver care is still driven by a model of episodic care that does not facilitate this new frontier. Fully realizing a transformation to a system of continuous connected care augmented by remote monitoring technology will require a shift in clinicians' and health systems' approach to care delivery technology and its associated data volume and complexity. In this article, we present a solution that organizes and optimizes the interaction of automated technologies with human oversight, allowing for the maximal use of data-rich tools while preserving the pieces of medical care considered uniquely human. We review implications of this "augmented continuous connected care" model of remote patient monitoring for clinical practice and offer human-centered design-informed next steps to encourage innovation around these important issues.
PMID: 35436238
ISSN: 2291-5222
CID: 5202102

Chinese Americans' Use of Patient Portal Systems: Scoping Review

Lawrence, Katharine; Chong, Stella; Krelle, Holly; Roberts, Timothy; Thorpe, Lorna; Trinh-Shevrin, Chau; Yi, Stella; Kwon, Simona
BACKGROUND:Electronic patient portals are increasingly used in health care systems as communication and information-sharing tools and show promise in addressing health care access, quality, and outcomes. However, limited research exists on portal use patterns and practices among diverse patient populations, resulting in the lack of culturally and contextually tailored portal systems for these patients. OBJECTIVE:This study aimed to summarize existing evidence on the access and use patterns, barriers, and facilitators of patient portals among Chinese Americans, who represent a growing patient population in the United States with unique health care and health technology needs. METHODS:The authors conducted a literature search using the PRISMA Protocol for Scoping Reviews (Preferred Reporting Items for Systematic Reviews and Meta-Analyses-ScR) for extracting articles published in major databases (MEDLINE, Embase, and PsycINFO) on patient portals and Chinese Americans. Authors independently reviewed the papers during initial screening and full-text review. The studies were analyzed and coded for the study method type, sample population, and main outcomes of interest. RESULTS:In total, 17 articles were selected for inclusion in the review. The included articles were heterogenous and varied in their study aims, methodologies, sample populations, and outcomes. Major findings identified from the articles include variable patterns of portal access and use among Chinese Americans compared to other racial or ethnic groups, with limited evidence on the specific barriers and facilitators for this group; a preference for cross-sectional quantitative tools such as patient surveys and electronic health record-based data over qualitative or other methodologies; and a pattern of aggregating Chinese American-related data into a larger Asian or Asian American designation. CONCLUSIONS:There is limited research evaluating the use patterns, experiences, and needs of Chinese Americans who access and use patient portal systems. Existing research is heterogeneous, largely cross-sectional, and does not disaggregate Chinese Americans from larger Asian demographics. Future research should be devoted to the specific portal use patterns, preferences, and needs of Chinese Americans to help ensure contextually appropriate and acceptable design and implementation of these digital health tools.
PMID: 35363153
ISSN: 2292-9495
CID: 5220062

The Need for Responsive Environments: Bringing Flexibility to Clinic Spaces

Chapter by: Lu, Daniel; Ergan, Semiha; Mann, Devin; Lawrence, Katharine
in: Construction Research Congress 2022: Computer Applications, Automation, and Data Analytics - Selected Papers from Construction Research Congress 2022 by
[S.l.] : American Society of Civil Engineers (ASCE), 2022
pp. 812-821
ISBN: 9780784483961
CID: 5312742

PAMS - A Personalized Automatic Messaging System for User Engagement with a Digital Diabetes Prevention Program

Chapter by: Rodriguez, Danissa V.; Lawrence, Katharine; Luu, Son; Chirn, Brian; Gonzalez, Javier; Mann, Devin
in: Proceedings - 2022 IEEE 10th International Conference on Healthcare Informatics, ICHI 2022 by
[S.l.] : Institute of Electrical and Electronics Engineers Inc., 2022
pp. 297-308
ISBN: 9781665468459
CID: 5349202

Building Virtual Health Training Tools for Residents: A Design Thinking Approach

Lawrence, Katharine; Cho, James; Torres, Christian; Alfaro-Arias, Veronica
The COVID-19 pandemic drove a rapid transition to virtual care experiences for graduate medical trainees. Core training competencies have expanded to incorporate virtual contexts, however there is limited knowledge of the optimal design of virtual care training tools for learners. In this study, we describe the application of a Design Thinking approach to the identification and co-design of novel training tools to support residents and precepting attending physicians in virtual ambulatory care practice. We applied the model of "Empathize, Define, Ideate, Prototype, and Test" via a mixed methods approach to (1) explore the needs, preferences, and concerns of Internal Medicine residents and outpatient precepting attendings regarding virtual ambulatory care training environments, and (2) evaluate, prototype, and test potential training tools. Eleven residents and eight attending physicians participated. Identified learner needs and problem areas included: improving virtual visit technical skills; acquiring virtual communication skills; adapting to the loss of shared in-person learning space and optimizing virtual learning environments; remediating non-virtual procedural competencies; and educating on new documentation requirements. Key solution areas included: virtual precepting support tools; digital information and education dissemination tools; and strategies for management of technical issues. Several prototypes were proposed, with a single tool (a virtual preceptor tip sheet) deployed in clinical practice. Residents found the workshop program improved their understanding of Design Thinking and its relevance to healthcare. Ultimately, Design Thinking can be deployed to engage medical trainees and precepting attendings in the effective development of novel educational tools for the virtual care learning environment.
PMID: 35770138
ISSN: 2673-253x
CID: 5281252

Development of a computer-aided text message platform for user engagement with a digital Diabetes Prevention Program: a case study

Rodriguez, Danissa V; Lawrence, Katharine; Luu, Son; Yu, Jonathan L; Feldthouse, Dawn M; Gonzalez, Javier; Mann, Devin
Digital Diabetes Prevention Programs (dDPP) are novel mHealth applications that leverage digital features such as tracking and messaging to support behavior change for diabetes prevention. Despite their clinical effectiveness, long-term engagement to these programs remains a challenge, creating barriers to adherence and meaningful health outcomes. We partnered with a dDPP vendor to develop a personalized automatic message system (PAMS) to promote user engagement to the dDPP platform by sending messages on behalf of their primary care provider. PAMS innovates by integrating into clinical workflows. User-centered design (UCD) methodologies in the form of iterative cycles of focus groups, user interviews, design workshops, and other core UCD activities were utilized to defined PAMS requirements. PAMS uses computational tools to deliver theory-based, automated, tailored messages, and content to support patient use of dDPP. In this article, we discuss the design and development of our system, including key requirements and features, the technical architecture and build, and preliminary user testing.
PMID: 34664647
ISSN: 1527-974x
CID: 5043192

Preferences and patterns of response to public health advice during the COVID-19 pandemic

Nov, Oded; Dove, Graham; Balestra, Martina; Lawrence, Katharine; Mann, Devin; Wiesenfeld, Batia
With recurring waves of the Covid-19 pandemic, a dilemma facing public health leadership is whether to provide public advice that is medically optimal (e.g., most protective against infection if followed), but unlikely to be adhered to, or advice that is less protective but is more likely to be followed. To provide insight about this dilemma, we examined and quantified public perceptions about the tradeoff between (a) the stand-alone value of health behavior advice, and (b) the advice's adherence likelihood. In a series of studies about preference for public health leadership advice, we asked 1061 participants to choose between (5) strict advice that is medically optimal if adhered to but which is less likely to be broadly followed, and (2) relaxed advice, which is less medically effective but more likely to gain adherence-given varying infection expectancies. Participants' preference was consistent with risk aversion. Offering an informed choice alternative that shifts volition to advice recipients only strengthened risk aversion, but also demonstrated that informed choice was preferred as much or more than the risk-averse strict advice.
PMID: 34737373
ISSN: 2045-2322
CID: 5038432