One year of child neurology telemedicine: a data-driven analysis of 14,820 encounters

Introduction Determining the long-term impact of telemedicine in care across the diagnostic and age spectrum of child neurology during the COVID-19 pandemic and with the re-opening of outpatient clinics. Methods An observational cohort study of 34,837 in-person visits and 14,820 telemedicine outpatient pediatric neurology visits between October 1, 2019 and April 9, 2021. We assessed differences in care across visit types, time-period observed, time between follow-ups, patient portal activation rates and demographic factors. Results 26,399 patients were observed in this study (median age 11.4 years [interquartile range, 5.5-15.9]; 13,209 male). We observed a higher proportion of telemedicine for epilepsy (ICD10 G40: OR 1.4, 95% CI 1.3-1.5) and a lower proportion for movement disorders (ICD10 G25: OR 0.7, 95% CI 0.6-0.8; ICD10 R25: OR 0.7, 95% CI 0.6-0.9). Infants were more likely to be seen in-person after re-opening clinics than by telemedicine (OR 1.6, 95% CI 1.5-1.8) as were individuals with neuromuscular disorders (OR 0.6, 95% CI 0.6-0.7). Racial and ethnic minority populations and those with highest social vulnerability had lower rates of telemedicine participation throughout the pandemic (OR 0.8, 95% CI 0.8-0.8; OR 0.7, 95% CI 0.7-0.8). Discussion Telemedicine implementation was followed by continued use even once in-person clinics were available. Pediatric epilepsy care can often be performed using telemedicine while young children and patients with neuromuscular disorders often require in-person assessment. Prominent barriers for socially vulnerable families and racial and ethnic minorities persist.

Remote Follow-up of Self-isolating COVID-19 Patients with a Patient Portal: Protocol for a Mixed-method Pilot Study (The Opal-COVID Study) (Preprint)

BACKGROUND Individuals diagnosed with COVID-19 are instructed to self-isolate at home. However, during self-isolation, they may experience anxiety and insufficient care. Some patient portals can allow patients to self-monitor and share their health status with healthcare professionals for remote follow-up, but little data is available on the feasibility of their use. OBJECTIVE This manuscript presents the protocol of the Opal-COVID Study which has four objectives: 1) assess the implementation of using the Opal patient portal for distance monitoring of COVID-19 patients self-isolating at home; 2) identify influences on the intervention’s implementation; and describe 3) service and 4) patient outcomes of this intervention. METHODS This mixed-method pilot study aims to recruit 50 COVID-19 patient participants tested at the McGill University Health Centre (MUHC, Montreal, Canada) for 14 days of remote follow-up. With access to questionnaires through the Opal patient portal smartphone app, configured for this study, patients will complete a daily self-assessment of symptoms, vital signs, and mental health, monitored by a nurse, and receive subsequent teleconsultations, as needed. Study questionnaires will be administered to collect data on sociodemographic characteristics, medical background, implementation outcomes (acceptability, usability, and respondent burden) and patient satisfaction. Coordinator logbook entries will inform on feasibility outcomes, namely, recruitment/retention rates and fidelity, as well as on the frequency and nature of contacts with healthcare professionals via Opal. The statistical analyses for Objectives 1 (implementation outcomes), 3 (service outcomes), and 4 (patient outcomes) will evaluate the effects of time and sociodemographic characteristics on the outcomes. For Objectives 1 (implementation outcomes) and 4 (patient outcomes), the statistical analyses will also examine the attainment of predefined success thresholds. As to the qualitative analyses, for Objective 2 (influences on implementation), semi-structured qualitative interviews will be conducted with four groups of stakeholders (i.e., patient participants, healthcare professionals, technology developers and study administrators) and submitted to content analysis, guided by the Consolidated Framework for Implementation Research to help identify barriers and facilitators of implementation. For Objective 3 (service outcomes), reasons for contacting healthcare professionals through Opal will also be submitted to content analysis. RESULTS Between December 2020 and March 2021, 51 patient-participants were recruited. Qualitative interviews were conducted with 39 involved stakeholders, from April to September 2021. Delays in the study process were experienced due to implemented measures at the MUHC to address COVID-19 but the quantitative and qualitative analyses are currently underway. CONCLUSIONS This protocol is designed to generate multidisciplinary knowledge on the implementation of a patient portal-based COVID-19 care intervention and will lead to a comprehensive understanding of feasibility, stakeholder experience, and influences on implementation that may prove useful for scaling up similar interventions. CLINICALTRIAL ClinicalTrials.gov identifier NCT04978233.

A Study Protocol for Increasing Access to Smoking Cessation Treatments for Low-Income Minority Smokers

Background: Smoking rates among low-income patients are double those of the general population. Access to health care is an essential social determinant of health. Federally qualified health care centers (FQHC) are government-supported and community-based centers to increase access to health care for non-insured and underinsured patients. However, barriers to implementation impact adherence and sustainability of evidence-based smoking cessation within FQHC settings. To address this implementation barrier, our multi-disciplinary team proposes Mi QUIT CARE (Mile Square QUITCommunity-Access-Referral-Expansion) to establish the acceptability, feasibility, and capacity of an FQHC system to deliver an evidence-based and multi-level intervention to increase patient engagement with a state tobacco quitline.Methods: A mixed-method approach, rooted in an implementation science framework of RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance), will be used in this hybrid effectiveness-implementation design. We aim to evaluate the efficacy of a novel delivery system (patient portal) for increasing access to smoking cessation treatment. In preparation for a future randomized clinical trial of Mi QUIT CARE, we will conduct the following developmental research: (1) Examine the burden of tobacco among patient populations served by our partner FQHC, (2) Evaluate among FQHC patients and health care providers, knowledge, attitudes, barriers, and facilitators related to smoking cessation and our intervention components, (3) Evaluate the use of tailored communication strategies and patient navigation to increase patient portal uptake among patients, and (4) To test the acceptability, feasibility, and capacity of the partner FQHC to deliver Mi QUIT CARE.Discussion: This study provides a model for developing and implementing smoking and other health promotion interventions for low-income patients delivered via patient health portals. If successful, the intervention has important implications for addressing a critical social determinant of cancer and other tobacco-related morbidities.Trial Registration: U.S. National Institutes of Health Clinical Trials, NCT04827420, https://clinicaltrials.gov/ct2/show/NCT04827420.

Technology for Healthy Aging: Use of Electronic Communication among Older Adults

In the digital era, many electronic platforms have been established to facilitate patient-provider communication, such as e-mail, text messaging, and patient portal. The use of these electronic platforms is termed as electronic-communication (e-communication). E-communication has a variety of personalized healthcare functions, such as exchanging information, reviewing lab results, and facilitating patient engagement. However, little is known about the actual use of e-communication among older adults who are potentially major users of e-communication considering their high-level health care needs. Understanding their use of e-communication is critical in improving the application of e-communication in older adults. Using data from American Health Information National Trends Survey (HINTS2019-Cycle3; n=1,961; meanage =74.10, range=65-98), we explored: 1) the prevalence of e-communication use among older adults, and 2) factors affecting their use of e-communication. Variables were measured by self-reports. Weighted logistic regression with replicate weights provided by the HINTS was performed for data analysis. We found that 50% older adults reported the use of e-communication in the last year. Factors associated with higher likelihood of older adults’ e-communication use included younger age (OR=09.96, 95%CI=0.93-0.98, p<0.001), higher education (OR=4.82, 95%CI=2.32-10.02, p<0.001 for college graduate or higher), higher income (OR=1.58, 95%CI=1.05-2.38, p=0.030), comorbid conditions (OR=1.64, 95%CI=1.02-2.64, p<0.001), and having a regular provider (OR=2.06, 95%CI=1.31-3.22, p=0.002). This study provided nationally representative results demonstrating a great potential use of e-communication in older adults. Special attention is needed to focus on socially vulnerable older adults (e.g., those with older age, lower education and income, and having comorbidity).

Patient Portal Use Near the End-of-Life

Use of patient portals, personal health information websites linked to electronic health records, in seriously ill populations is unknown, as is use by caregivers. We described portal use patterns among adults with serious illness nearing end-of-life and their caregivers within Kaiser Permanente Colorado. Inclusion criteria were: 1) seriously ill patients (defined by KP’s “Care Group”), □18 years of age, who were registered for the portal, and died between 1/1/2016-6/30/2019; and 2) caregivers of these patients, □18 years of age, registered for a proxy account. Data included user characteristics and portal use metrics summarized monthly over the 12-month period prior to death. Models included an unadjusted linear trend of the days used by month using a generalized estimating equation Poisson model with a log link and an autoregressive correlation structure of order 1. We identified 6,517 seriously ill patients with portal registrations; 163 of these patients had proxy caregivers. Patient users were 77 years old, mostly frail and White, and caregivers were predominantly female. Average days of use among patients was 42.4 days and <1 day among their caregivers. Number of days used significantly increased by 0.7% per month from twelve months to one month prior to death (95% CI: 0.4%-1.0%; p-value <.0001) and peaked 3 months prior to the patient’s death. Average use was high in comparison to previous portal research and suggests that as the patient approaches death portal use increases. Future research should explore how portals may serve as indicators for identifying and addressing end-of-life care needs.

The Digital Divide Amongst High-Need High-Risk Veterans

High-need high-risk (HNHR) veterans are medically complex and at the highest risk of hospitalization and long-term institutionalization. Technology can mitigate challenges these veterans have in accessing healthcare. Willingness to use technology as well as access and ability to use technology were assessed in this study. At the time of the survey, 2543 Miami VAHS veterans were listed as HNHR. 634 veterans ultimately completed the questionnaire, and 602 answered the “willingness to use video-visits” question. Of the 602 respondents, 327 (54.3%) reported they were willing for video-visits with the VA, while 275 (45.6%) were not. Those who were willing were significantly younger (P<0.001), with higher educational qualifications (P=0.002), and more health literate than those not willing (P<0.001). They were more also capable of using the Internet, more likely to use email and be enrolled in the VA’s patient portal, My HealtheVet (P<0.001). However, of the veterans who were willing, 248 (75.8%) had a device with video-capable technology. Those with video-capable technology were younger (P=0.004), more health literate (P=0.01), and less likely to be Black or African American (P=0.007). They were more capable of using the Internet, more likely to use email, and be enrolled in My HealtheVet than those without (P<0.001). Half of the respondents were willing for video-visits but a quarter of those willing lacked requisite technology, thereby making only about 41.2% of the respondents willing and video-capable. To minimize the digital divide, especially during the ongoing COVID-19 pandemic, targeted measures need to address these disparities in this vulnerable population.

Older Adults' Perceptions and Use of Patient Portals: A Comparative Analysis of Two Samples

Older adults can benefit from using patient portals. Little is known whether the perceptions and use of patient portals differ among diverse older adult populations. The aim of this study was to assess the difference in perceived usability of patient portals, self-efficacy for using patient portals, and patient portal use between two adult samples aged 65 years or older. One sample was recruited from a health care system, including hospitals and clinics (n = 174), and the other sample was recruited from nationwide communities (n = 126). Conducting a secondary data analysis using two survey datasets, this study performed a series of linear and ordinal logistic regression analyses. The health care system sample had a higher mean number of chronic diseases and proportion of recent hospitalization than the community sample. The health care system sample showed higher perceived usability, self-efficacy, and usage frequency of patient portals compared to the community sample. eHealth literacy was a significant predictor of perceived usability and self-efficacy. Perceived usability was another significant predictor of self-efficacy. Self-efficacy and health condition variables significantly predicted the more frequent use of patient portals. Compared to the health care system sample, the relationship between perceived usability and use of patient portals was stronger and significant in the community sample. These findings suggest that approaches for promoting patient portal use should consider personal characteristics and health conditions of diverse older adult populations. Future research needs to focus on assessing the impact of using patient portals on older adults’ health care outcomes.

Developing a web-based toolkit for new mothers about postpartum pelvic floor health in collaboration with a professional medical association

Background: Few electronic resources are available for new mothers with concerns about changes in their pelvic floorfollowing childbirth. Patients may struggle when seeking authoritative information regarding pelvic floor conditions online given the sensitivity of the topic as well as the inadvertent connection to obscene or demeaning content found online. A health sciences librarian partnered with the Motherhood and Pelvic Health Study, an interdisciplinary research group, to provide expert searching skills for a particularly challenging health condition that patients struggle to find useful information on.Case Presentation:A custom rubric was developed to evaluate existing information products, which included criteria for cultural sensitivity, conflicts of interest, and other red flags. This evaluation process enabled the research team to identify top-tier evidence-based materials that were culturally congruent. This collaborative evaluation process led to the creation of a web-based toolkit resource for new mothers concerned about changes in their pelvic floor. The toolkit connects women to pertinent information on a national health organization’s patient portal, supplemented by videos created by the team to serve as models of communication for women and health care providers. Conclusion:When developing a web-based resource, health sciences libraries can partner with research teams to find, evaluate, and disseminate information. Culturally congruent toolkits such as this one can improve access to health information and lead to improved health outcomes. To ensure that the information highlighted in toolkits is both culturally congruent and authoritative, research teams should form advisory committees and partner with relevant professional medical associations.