Healthcare Timeline and How It Impacted Peer Reviewed Articles
Prev Chronic Dis. 2020; 17: E64.
Peer Reviewed
The Influence of Telehealth for Better Health Across Communities
Jane A. McElroy
iFamily and Community Medicine Department, Academy of Missouri, Columbia, Missouri
Tamara K. Day
2University of Missouri Wellness Care, University of Missouri, Columbia, Missouri
Mirna Becevic
3Section of Dermatology, University of Missouri, Columbia, Missouri
Abstract
Rapid spread of coronavirus affliction 2019 (COVID-nineteen) forced an abrupt shift in the traditional U.s. health care delivery model to see the needs of patients, staff, and communities. Through federal policy changes on telehealth, patient care shifted from in-person to phone or video visits, and wellness care providers reached out to patients most at run a risk for exacerbation of chronic illness symptoms. ECHO (Extension for Community Healthcare Outcomes), a videoconferencing peer learning application, engaged health care providers beyond Missouri in the treatment and direction of circuitous COVID-xix–positive patients. Re-envisioning health care in the digital age includes robust utilization of telehealth to enhance care for all.
Summary
What is already known on this topic?
The COVID-19 pandemic has forced many health care institutions to reconsider wellness care commitment mechanisms. Because of reimbursement restrictions, telehealth has been underutilized.
What is added by this report?
Capitalizing on existing infrastructure that supports digital connectivity through uptake of telehealth was vital to successfully reimagine rubber health intendance delivery. Removing a disquisitional barrier, reimbursement, supported telehealth.
What are the implications for public wellness practice?
Technologic advancements and policy changes can change wellness care delivery and have the potential to reduce disparities in admission to care and improve outcomes among the almost vulnerable populations.
Introduction
In December 2019, an infection acquired by a bat-origin novel coronavirus, severe acute respiratory syndrome coronavirus two (SARS-CoV-ii), was detected in Wuhan, Mainland china (1). Within less than 3 months, coronavirus disease 2019 (COVID-19), the disease caused past SARS-CoV-two, had spread beyond Cathay and worldwide. The World Health Organization declared COVID-19 a pandemic on March 11, 2020 (2). Equally of May 30, 2020, more than 1 million infections had been laboratory-confirmed in the United States with more than than 100,000 case fatalities (3). An estimated lxxx% of people infected with COVID-19 during this fourth dimension did not require hospitalization, and approximately 5% to 12% of hospitalized patients were admitted to intensive care units (3). Hospitalization rates were highest among adults anile 65 years or older, people with multiple chronic conditions, and men (iii). Among younger patients (18–49 y), obesity, underlying chronic lung disease (primarily asthma), and diabetes were the virtually prevalent chronic disorders (3). Because COVID-19 is a pandemic, the virus is expected to cause multiple waves of infection in hereafter months and to persist to cause seasonal outbreaks (2).
Patients exhibiting severe symptoms related to COVID-xix were urged to seek firsthand care; however, this was challenging for people in rural areas of the United States, who make up about twenty% (60 one thousand thousand residents) of the total population (4). Rural populations in the United States face up meaning challenges in accessing health care and have poorer health outcomes than urban or suburban populations, including higher rates of chronic disease, higher expiry rates, and delayed diagnoses for cancers and other diseases (5–7). These challenges are likely due to less accessible care related to lower rates of insurance; maldistribution of the wellness intendance workforce, particularly specialists; an older population; a greater proportion of patients with multiple comorbidities; and higher levels of socioeconomic demand (eight).
Missouri is a predominantly rural state. More than 97% of its country area is classified as rural, and from 30% to 37% of its population currently live in rural areas (nine,10). Enriquez et al reported that at least 50% of patients in their Missouri study had one or more chronic diseases, and that "patients with multiple chronic conditions were the norm" (11). These comorbid conditions among rural Missouri residents put them near at gamble of fatal complications from COVID-19, in particular those with predisposing conditions, such every bit diabetes, chronic pulmonary affliction, and hypertension (3). As cases of COVID-19 increased exponentially once the pandemic reached the U.s.a., clinicians and researchers became particularly concerned about its touch on on the nearly vulnerable rural and underserved people with chronic atmospheric condition. Our objective is to describe the multipronged approach used in Missouri to provide quick response to the COVID-19 pandemic forth with preliminary trend data, including disruptive technology applications that created an environs for widespread adoption of telemedicine.
Taking reward of the experiences of US coastal cities where the COVID-19 pandemic striking difficult and fast, an incident command team was created on March ix, 2020, at a tertiary referral infirmary organisation, University of Missouri Wellness Care (MU Wellness Care), serving a 25-canton, predominantly rural, catchment area. The team was co-led past the hospital's chief nursing officer and main medical officer because each profession brought a unique perspective. Policies were chop-chop implemented that profoundly reduced or suspended medical and surgical services to reserve personal protective equipment, reduced the clinical staff's COVID-19 exposure, limited the number of patients and visitors in hospital, re-deployed staff, and extensively expanded the telemedicine infrastructure.
In this commentary, we use telehealth as an umbrella term referring to telemedicine and other health-related virtual activities, such as distance continuing medical teaching, training, and patient portals. Telemedicine volition refer to providing medical intendance at a distance, which includes audio–video care or sound care simply.
Workforce Redeployment
The MU Health Intendance system had to reconsider the commitment of intendance, not simply for the expected deluge of COVID-xix–positive patients merely also the routinely sick patients. With the governor'southward stay-at-abode edict and fear of SARS-CoV-2 exposure, patients were reluctant to actively seek medical intendance or keep scheduled appointments. With these policies and behavior changes, a pregnant shift in nursing work duties and the way nurses provided care occurred, often in areas exterior normal clinical specialty areas. In response, nigh 50% of the i,836 patient care staff completed online rapid acute care orientation within 2 weeks of implementation to competently take on pivotal changes in work responsibilities.
On March 19, 2020, iii quick-care clinics located in grocery stores were airtight to redeploy advanced practice nurses to triage hundreds of patients who were calling with reports of respiratory disease (n = 1,368 through March 27, 2020). This strategy finer reduced the need for clinic or emergency section in-person visits while continuing to address patients' health care needs. During this same fourth dimension period, some redeployed nurses served as ambulatory care coordinators and identified patients most at risk for exacerbation of chronic affliction symptoms. Coordinators initially contacted these vulnerable patients (north = 750) by telephone but transitioned eventually to audio–video consultations, when possible. Intendance coordinators checked in with patients regarding their health and well-being and closely collaborated with the patient's master intendance provider to coordinate whatsoever necessary medical care. This repositioning of nurses to intendance for vulnerable populations was based on strong evidence-based enquiry in which nurse-led interventions in primary care accept been shown to meliorate health outcomes (12). This also harkened back to an era in which patients stayed at dwelling and the health intendance provider traveled to the patient. In this case, the traveling was virtual.
Adoption of Telehealth
To readily support virtual traveling within the US health intendance arrangement, the federal regime immune a more than robust use of telehealth services during this national emergency. Specifically, the Centers for Medicare and Medicaid Services (CMS) made a limited-fourth dimension change for allowable reimbursement for medical visits by expanding their definition to include telemedicine visits. The change was initially released on March 17, 2020, and fabricated retroactive to March half-dozen, 2020. CMS likewise relaxed the Health Insurance Portability and Accountability Deed (HIPAA) requirements for secure exchange sites by allowing the use of nonpublic-facing video applications (such as Skype or Zoom) and text-based applications (such as WhatsApp, iMessage) (xiii). Within 24 hours of CMS'south conclusion to support telemedicine visits, our MU Wellness Care arrangement had in place a structure to allow health care providers to use the engineering science for acoustic visits. The power of a large health intendance organization to make this happen nearly overnight was breathtaking and a reminder of our potential to respond to an imminent challenge or threat. With this change, health care providers took intendance of both new and established patients in their homes by telephone and video visits (ie, telemedicine visits) throughout the 25-county catchment expanse.
Before the COVID-xix pandemic, reimbursement guidelines were an effective barrier to telemedicine use for both main and specialty care with less than one% of rural Americans using telehealth and few wellness care providers embracing information technology (xiv,15). In our MU Wellness Care system of selected specialties — family and community medicine, internal medicine, cardiology, and specialty medicine — no telehealth visits happened before March 2000 (Figure). Our visits peaked in Apr with almost 90% of visits happening through telehealth. With the lifting of the governor'south stay-at-home edict and opening of clinics, for the month of May the percentage of telehealth visits and the percentage of cancelled appointments reverted to March levels (Figure). In reviewing the 2019 appointment data, May had a higher volume of appointments than February through April. An opposite pattern for the same fourth dimension flow was observed in 2020; May had the everyman book of appointments. This leads us to conclude that the appointment trends we are observing are not associated with seasonality. We attribute a lower number of appointments in May and higher number of cancellations to the continued public wellness response to the COVID-nineteen pandemic. Unfortunately, engagement cancellation data were not collected on type of visit so we do not have insight into whether telehealth versus in-person visits were more likely to be cancelled.
Per centum of ambulatory patients who had in-person clinical, cancelled, and telehealth visits for family medicine, internal medicine, cardiology, and medical specialty, February–May, 2020. The denominator for in-person visits and telehealth visits is in-person plus telehealth visits. The denominator for cancelled appointments is all visits plus cancelled visits.
| Status of Dispensary Visit, % | February | March | April | May |
|---|---|---|---|---|
| In-person visits | 100 | 71 | 13 | 72 |
| Cancelled appointments | 23 | 89 | 85 | 21 |
| Telehealth visits | 0 | 29 | 87 | 28 |
For connectivity, some other rapid change was CMS adjustment audio-simply with sound–video telemedicine intendance on April 30, 2020, retroactive to March 6, 2020. Originally sound-only visits were reimbursed at about i-third the rate of audio–video visits (16). For patients who experienced poor connectivity, this disparity in reimbursement had the potential to affect care and widen the gap in medical care for vulnerable populations. Missouri is ranked fortieth among states on the digital divide index; this score is derived past using both broadband access and broadband adoption as well as socioeconomic factors (17). The presence of any broadband in households within our 25-canton service area ranges from 60% to 82%. The literature on the telehealth divide between rural and urban areas shows that the quality of broadband access affects the use of telehealth (18,nineteen), although some disparities are narrowing (18). Besides connectivity, other factors influence the ability to use telehealth. In preliminary data using family medicine encounters over a one-month period (March 17–Apr 16, 2020), telemedicine services with audio–video visits were markedly less likely to exist among older, black, Medicaid-insured, or self-pay patients. Schmeida and McNeal plant that among demographic groups less likely to take net access at home, including the poor, older patients, Latinos, and Blacks, express net access could affect the way they used the cyberspace for telehealth and/or searched for health care–related information online (18).
Our MU Wellness Care system sent a patient feel survey to all who had a telehealth visit from March 19, 2020, to June 3, 2020 (N = 4,183), and 25% responded. Half were asked the question, "Was your telehealth visit as good as an in-person engagement?" to which 33% gave a positive response. The other one-half were asked, "Was it easy to land concerns and ask questions through telehealth?" to which 56% gave a positive response. Going forward, re-envisioning health care in the digital historic period in which health care providers are reimbursed for time spent with the patient well-nigh shifts the driver from insurance companies to patients and wellness intendance providers to determine what a health intendance visit looks like and to document access disparities, such equally connectivity, privacy, and digital literacy. Therefore, more immediate and urgent action is needed to accost these disparities for equitable health intendance in the adoption of telehealth.
Virtual Collaborative Learning Network
Across the local response to the pandemic, a statewide response (Show-Me Repeat) was initiated past using Missouri Telehealth Network'south Extension for Community Healthcare Outcomes infrastructure. The Show-Me Echo uses confusing innovation technologies, such as videoconferencing applications, and is dissimilar from traditional telehealth. It is centered on case-based learning, wellness care provider development and retentivity, and efficiency. Although successfully adopted in astute intendance medicine and nonmedical applications, this model is primarily used to increment capacity of wellness intendance providers to care for patients with chronic diseases and targets rural, isolated, and underserved communities (xx). Since its inception in Missouri, over 27,000 learners (medical doctors, doctors of osteopathy, nurse practitioners, physician assistants, wellness educators, and others) take attended sessions representing near every canton in Missouri. The existing infrastructure of this provider-facing technology was immediately expanded to create 2 new ECHOs: COVID-nineteen Repeat and Telemedicine ECHO.
COVID-19 ECHO, launched on March 23, 2020, supports health intendance professionals, especially those practicing in rural and isolated areas, with weekly meetings of didactic presentations focused on testing, triage, and other State updates, with more 2,700 attendees every bit of May 26, 2020. De-identified case presentations were used for learning through a guided practise model, focusing specifically on patients with chronic conditions and COVID-19 infection or risk of infection. In improver to these weekly sessions, COVID-xix–related topics were incorporated into other regular ECHO sessions, such as asthma, kidney disease, autism, and oral wellness, thereby substantially expanding the learning and networking opportunities among wellness care providers. A benefit of Echo learning is the evolution of a network of professional colleagues that encourages informal advice outside of regular sessions. The spread of COVID-19 has caused fright and dubiousness among the public and concerns among health intendance professionals about their responsibilities to practice medicine while balancing their need to protect their families. The Echo virtual collaborative network provides an ideal environment for reducing a sense of isolation amongst rural health care providers.
To support a growing number of novice health care providers using telemedicine and in response to popular demand, Telemedicine Repeat was initiated on Apr xiv, 2020. Telemedicine Echo is a collaboration of the University of Missouri, Missouri Telehealth Network, and the Heartland Telehealth Resource Centre serving Missouri, Kansas, and Oklahoma. Telemedicine Repeat has provided didactic presentations on numerous topics, such as legal and regulatory issues, policy changes, billing and reimbursement, privacy, and security. The plan has had more than than 300 attendees as of May 26, 2020. Case presentations of patients with acute and chronic conditions included best practices for treatment and care management using telemedicine. Although many institutions, nudged by the COVID-nineteen pandemic, have adopted this technology, there is all the same an art to this type of run across. As Telemedicine Repeat demonstrated, practicing wellness care professionals benefited from expert telemedicine support. Information technology is likely that medical schools and residency programs will supplement their curricula on patient encounters to include telehealth visits, if it is not already included. As telemedicine becomes more than usually used, this platform can be extended to monitor those with influenza-like affliction and COVID-nineteen–like symptoms as well as help in the management of multiple chronic diseases, as demonstrated by our Italian colleagues (21).
Implications for Public Health
The success of MU Wellness Intendance's rapid adjustment and response to the COVID-xix pandemic lies in its dedicated workforce, strong collaborative learning network, expertise in rural health, and robust telehealth infrastructure. One annotate fabricated by leadership on the COVID-nineteen response squad was the unwavering willingness of nurses and other health care workers to go where they were needed. This specially epitomized the dedication and professionalism of nurses and health care professionals. Innumerable stories in the media abound of nurses filling in gaps created by new policies, such as restriction on visitors to hospitalized patients and being that hospitalized patient's touchstone. Every bit the COVID-nineteen start moving ridge passes, the health care workforce, including nurses, can continue using telehealth successfully, and its use has been extended to departments and specialties that had never implemented telehealth before the pandemic. One of our gynecologic oncologists began using telemedicine subsequently COVID-19 policies were enacted. He remarked that he plans on continuing telemedicine encounters for enhanced patient-centered care and that telemedicine provided more comprehensive family date. All family members participated in a telemedicine visit, asked questions, heard his responses, and understood the handling program and prognosis. Our oncologist felt the telemedicine encounter allowed the extended family to actively participate in the patient's cancer journey. Without COVID-19's disruption of the condition quo of health care, it is unlikely that this example of re-envisioning the practice of health care would have occurred.
The design of delivering health care continues to adjust to medical, economic, and cultural changes. Before the centre of the twentieth century, few hospitals existed, and the health system enterprise, including health insurance, was nonexistent (22). Doctors traveled to their sick patients' homes, provided limited treatment options, and were paid a pocket-sized out-of-pocket fee. Pivotal advances in scientific medical knowledge dramatically inverse the landscape of medicine. The evolution from health care providers equally generalists who provided all care for their patients to health care providers who refer their patients to specialists is complicated, merely most consider that the tipping point in this change began in the post-Earth War Ii era (23). Currently, approximately 30% of younger patients (≤64 y) are referred to specialty care, and among older patients (≥65 y), referral to specialists average ii per person per year (24). In the initial response to the COVID-19 pandemic, express referrals for specialty care as well as engagement cancellations by health care providers for established patients and patients opting to not seek routine care were the norm, leaving a grouping of patients temporarily afloat (Figure). Similarly, only as engineering science, such as the invention of the phone and automobiles, shaped health care by reversing the traveler — the patient coming to see the physician rather than physician going to the patient — confusing technology in the COVID-19 era with focused attention to addressing disparities faced by some can reshape health intendance, specially for rural patients and patients with multiple comorbidities.
The Establish for Healthcare Improvement's new quadruple aim to optimize health system operation includes improving population health, lowering costs, and improving patient experience (25). The 4th aim is often cited equally finding joy in work or elevating health equity (25). These aims may exist achieved through a more than robust inclusion of telehealth. However, a critical factor for success requires thoughtful supportive interventions to ameliorate reported disparities in telehealth adoption. In the COVID-xix era, informal conversations with health intendance providers nigh telemedicine, from main intendance to oncology to endocrinology, suggest mixed reactions to virtual visits through telemedicine. Some providers have reverted back to the sometime ways whereas others have embraced this change.
Further exploration could identify factors, including barriers, associated with apply of telehealth from both the health care provider's and the patient's perspective. Every bit long as the CMS policy change for reimbursement remains, a telemedicine visit tin can be an pick between patient and health care provider, and therefore by default create an environment of patient-centered care.
The pandemic crisis has tapped into America'southward strengths — our ability to summon unity and collective confidence when facing a nationwide claiming. For telehealth, many of the restrictions have been lifted, namely HIPAA compliance, licensing restrictions, and reimbursement differences by blazon of visit, with the hope that these volition be permanently lifted. Although telemedicine has been integrated into daily clinical practise in responding to the public health emergency, barriers to telemedicine and issues surrounding associated health disparities should non be neglected. Telehealth alone is not a panacea for better wellness care, and information technology behooves researchers, providers, and educators to explore artistic solutions for optimal wellness care for all, particularly among vulnerable populations. Undoubtedly, a concerted effort by government agencies, organizations, and community volunteers will be needed to ensure effective admission to improved health intendance, both for high-technology and low-technology solutions.
Acknowledgments
The authors accept no conflicts of interest to report. No copyrighted material was used in this article.
Footnotes
The opinions expressed past authors contributing to this journal do non necessarily reflect the opinions of the U.S. Department of Health and Human being Services, the Public Wellness Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions.
Suggested citation for this article: McElroy JA, Day TM, Becevic M. The Influence of Telehealth for Ameliorate Health Beyond Communities. Prev Chronic Dis 2020;17:200254. DOI: https://doi.org/10.5888/pcd17.200254.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7380287/
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