Expanding Virtual Health Capabilities Into Trainee Health

ABSTRACT Virtual health and secure messaging gained newfound relevance in medicine during the coronavirus disease (COVID)-19 pandemic. For a military trainee health care clinic located on Joint Base San Antonio, the McWethy Troop Medical Clinic (TMC), implementation of virtual health and secure messaging services meant decreased risk of COVID-19 exposure for trainees and clinical staff. Through ongoing utilization, these services also made impacts to reduce loss of instruction time and improve access to care for the McWethy TMC trainee population. In defining the challenges, successes, and future implications for virtual health and secure messaging at the McWethy TMC, key lessons emerge for other military trainee clinics. The key concepts explored in this article are virtual health and secure messaging.

Use and impact of virtual primary care on quality and safety: The public's perspectives during the COVID-19 pandemic

Introduction With the onset of Coronavirus disease (COVID-19), primary care has swiftly transitioned from face-to-face to virtual care, yet it remains largely unknown how this has impacted the quality and safety of care. We aim to evaluate patient use of virtual primary care models during COVID-19, including change in uptake, perceived impact on the quality and safety of care and willingness of future use. Methodology An online cross-sectional survey was administered to the public across the United Kingdom, Sweden, Italy and Germany. McNemar tests were conducted to test pre- and post-pandemic differences in uptake for each technology. One-way analysis of variance was conducted to examine patient experience ratings and perceived impacts on healthcare quality and safety across demographic characteristics. Results Respondents (n = 6326) reported an increased use of telephone consultations ( + 6.3%, p < .001), patient-initiated services ( + 1.5%, n = 98, p < 0.001), video consultations ( + 1.4%, p < .001), remote triage ( + 1.3, p < 0.001) and secure messaging systems ( + 0.9%, p = .019). Experience rates using virtual care technologies were higher for men (2.4 ± 1.0 vs. 2.3 ± 0.9, p < .001), those with higher literacy (2.8 ± 1.0 vs. 2.3 ± 0.9, p < .001), and participants from Germany (2.5 ± 0.9, p < .001). Healthcare timeliness and efficiency were the dimensions most often reported as being positively impacted by virtual technologies (60.2%, n = 2793 and 55.7%, n = 2,401, respectively), followed by effectiveness (46.5%, n = 1802), safety (45.5%, n = 1822), patient-centredness (45.2%, n = 45.2) and equity (42.9%, n = 1726). Interest in future use was highest for telephone consultations (55.9%), patient-initiated digital services (56.1%), secure messaging systems (43.4%), online triage (35.1%), video consultations (37.0%) and chat consultations (30.1%), although significant variation was observed between countries and patient characteristics. Discussion Future work must examine the drivers and determinants of positive experiences using remote care to co-create a supportive environment that ensures equitable adoption and use. Comparative analysis between countries and health systems offers the opportunity for policymakers to learn from best practices internationally.

Socioeconomic Disparities in the demand for and use of virtual visits among senior adults during the COVID-19 pandemic: A cross-sectional study (Preprint)

BACKGROUND The COVID-19 pandemic has limited the provision of in-person care and accelerated the need for virtual care. Older adults (65+) were one of the highest user groups of in-person health care services prior to the pandemic. Social-distancing guidelines and high rates of mortality from coronavirus infections among older adults made receiving in-person health care services challenging for older adults. The provision of virtual care technologies can help to ensure continuity of care and provide essential health care services during the pandemic to those in high-risk groups at contracting the COVID-19 coronavirus including older adults. It is also essential to understand and address potential socioeconomic, demographic, and health disparities in the demand for use of virtual care technologies among older adults. OBJECTIVE The objective of this study is to investigate socioeconomic disparities in the demand for and use of virtual visit during the COVID-19 pandemic among older adults in Canada. METHODS A cross-sectional web survey was conducted with 12,052 Canadians over the age of 16, selected from Leger’s LEO panel between July 14th to August 6th, 2021. Associations between socioeconomic factors and the demand for and use of virtual visits were tested using the χ2 tests and logistic regression models. Weighting was applied using the 2016 census reference variables to render a representative sample of the Canadian population. RESULTS Approximately 20% (n=2,303) of the survey sample were older adults above the age of 65. The proportion of older adults who expressed demand for telephone visit, video visits, and secure messaging were 69.6%, 49.2%, and 47.2%, respectively. The proportion of older adults in our sample who have used telephone visit in the past 12 months was 47.3%, 9.2%, and 8.4%, respectively. eHealth literacy was positively associated with use of telephone visits (OR 1.03, p=0.01), use of video visits (OR 1.04, p=0.00), and the use of secure messaging (OR 1.03, p=0.00). Income was negatively associated with the use of video visits (OR 0.65, p=0.03). Having no private insurance coverage was negatively associated with use of secure messaging (OR 0.73, p=0.04) but living in a rural community (OR 1.72, p=0.01) and being born outside of Canada (OR 1.50, p=0.03) were positively associated with the use of secure messaging. Education (OR 0.78, p=0.02) and being non-White (OR=0.54, p=0.02) were negatively associated with the use of telephone visits. CONCLUSIONS This study found that demand for and use of telephone visit services were more prevalent among older adults during the pandemic. Although demand for secure messaging and video visit is high, usage for these modalities remains low. The results highlight several socioeconomic factors that are associated with demand for virtual visits including language, community size, and health coverage.

Differences in Secure Messaging, Self-management, and Glycemic Control Between Rural and Urban Patients: Secondary Data Analysis

Background Rural patients with diabetes have difficulty accessing care and are at higher risk for poor diabetes management. Sustained use of patient portal features such as secure messaging (SM) can provide accessible support for diabetes self-management. Objective This study explored whether rural patients’ self-management and glycemic control was associated with the use of SM. Methods This secondary, cross-sectional, mixed methods analysis of 448 veterans with diabetes used stratified random sampling to recruit a diverse sample from the United States (rural vs urban and good vs poor glycemic control). Administrative, clinical, survey, and interview data were used to determine patients’ rurality, use of SM, diabetes self-management behaviors, and glycemic control. Moderated mediation analyses assessed these relationships. Results The sample was 51% (n=229) rural and 49% (n=219) urban. Mean participant age was 66.4 years (SD 7.7 years). More frequent SM use was associated with better diabetes self-management (P=.007), which was associated with better glycemic control (P<.001). Among rural patients, SM use was indirectly associated with better glycemic control through improved diabetes self-management (95% CI 0.004-0.927). These effects were not observed among urban veterans with diabetes (95% CI –1.039 to 0.056). Rural patients were significantly more likely than urban patients to have diabetes-related content in their secure messages (P=.01). Conclusions More frequent SM use is associated with engaging in diabetes self-management, which, in turn, is associated with better diabetes control. Among rural patients with diabetes, SM use is indirectly associated with better diabetes control. Frequent patient-team communication through SM about diabetes-related content may help rural patients with diabetes self-management, resulting in better glycemic control.

P133 ROBOTIC ASSISTED REINFORCED BIOLOGIC AUGMENTED REPAIR (REBAR) IN INGUINAL HERNIA: TWO-YEAR OUTCOMES

Aim The objective of this study is to identify two-year recurrence and complication rates using robotic assisted reinforced biologic augmented repair (ReBAR) in inguinal hernia repair. Material and Methods A retrospective review identified all robotic inguinal hernia repairs utilizing a reinforced biologic mesh performed by a single surgeon from May 2018 through May 2019. All repairs employed the robotic transabdominal preperitoneal (rTAPP) approach combined with the ReBAR technique. Patients with prior repairs and bilateral hernias were included. All patients were followed post-operatively using secure messaging to assess outcomes, including hernia recurrence and other complications. Results A total of 57 patients undergoing the rTAPP ReBAR were identified. Of these patients, there were 18 bilateral hernias repaired for a total of 75 inguinal hernia repairs. In addition, 5 of the hernias had previously been repaired. Two-year outcomes identified 1 recurrence (1.3%) at 345 days post-operatively and one complication of small bowel obstruction requiring takeback unrelated to the ReBAR. There were no complications of chronic groin pain or seromas in this cohort. Conclusions In conclusion, the two-year recurrence rate in this population of 75 inguinal hernias repaired using the robotic assisted ReBAR was 1.3%. With low recurrence and complication rates, the robotic assisted ReBAR technique appears to be a safe and durable option for inguinal hernia repairs.

Using positive deviance to improve timely access in primary care

BackgroundImproving timely access in primary care is a continued challenge in many countries. We used positive deviance to try and identify best practices for achieving timely access in our primary care organisation in Toronto, Canada.MethodsSemistructured interviews were used to identify practice strategies used by physicians who successfully maintained a low third next available appointment (TNA) (positive deviants, n=6). We then conducted a cross-sectional survey to understand the prevalence of identified promising practices among all physicians (n=70) in the practice. We used χ2 testing to understand whether uptake of promising practices among survey respondents was different for those with a median TNA of 7 days or less vs a median TNA over 7 days.ResultsWe identified seven promising practice strategies used by positive deviants: adjusting the appointment template based on demand; reviewing the appointment schedule in advance; max-packing of visits; using phone, email and secure messaging; customising care for complex patients; managing planned absences; and involving the interprofessional team. 65 of 70 physicians responded to the survey on promising practices. Uptake of the promising practices was variable among survey respondents. In general, we found no association between uptake of promising practices and median TNA. One exception was that those with a median TNA of 7 or less were more likely to review the schedule in advance to potentially mitigate a visit using phone/email (62% vs 31%, p=0.0159).ConclusionPromising practices used by a small group of physicians (‘positive deviants’) to maintain good access were generally not associated with timely access among a larger sample of physicians in the practice. Our findings highlight the difficulty of untangling physician practice style and its contribution to timely access in primary care.

128 Evaluation of a Secure Messaging System for Children with Medical Complexity

Primary Subject area Complex Care Background The Connecting2gether (C2) platform is a secure online information-sharing tool that aims to improve care for Children with Medical Complexity (CMC) and their families. A key feature of C2 is secure messaging that enables parents to communicate with their child’s healthcare providers (HCPs) in an easy and timely manner. Objectives The objectives of this project are to (1) describe the usage of the secure messaging system; and (2) conduct a thematic comparative evaluation of the secure messaging tool, and email and phone calls. Design/Methods This study is a sub-component of a larger project investigating the overall feasibility and acceptability of the C2 platform. Parents of CMC were recruited from a tertiary level Complex Care program to use the C2 platform for a period of 6 months. Messaging data was extracted from C2 usage reports, and phone and email documentation was extracted from the patient’s electronic medical record. Codes were developed iteratively through comprehensive review of the C2 messages. Message, phone, and email data were then coded by two investigators using thematic analysis. Quantitative data from C2 usage reports were analyzed using descriptive statistics. Results Thirty-four parents and 90 care team members, including HCPs, family, and patient information coordinators were registered on the platform. 4027 messages were exchanged on C2. On average, parents sent 33.4 messages and received 66.4 messages on C2. Of all messages on C2, 32.6% were related to comments, questions, and concerns about the platform itself and its features. Figure 1 demonstrates the thematic content of messages related to care, and highlights the differences in messaging content between the 3 forms of communication. Email and phone content focused primarily on clinical care whereas C2 messaging content also emphasized other aspects of care including education, provision of resources, and personal support. Conclusion This study demonstrates the role that a secure messaging system can have for parents of CMC in being active members of their child’s care. Phone and email were mostly used to discuss medications or clinical issues, whereas C2 enabled the discussion of the patient as a whole. The use of secure messaging can therefore complement other forms of communication between providers and families, instead of replacing them. Further research is needed to understand clinical outcomes associated with the use of secure messaging in order to understand its role in improving patient care and overall caregiver and provider experience.

Patient Portals: Objectives, Acceptance, and Effects on Health Outcome – A Scoping Review of Reviews

Patient portals provide patients access to their electronic health record and other functions as secure messaging. For over a decade, more and more patient portals are developed for various settings. The aim of this scoping review of reviews is to systematically search the literature for existing reviews to provide an overview of patient portals’ objectives, acceptance and effects on outcome. We followed the PRISMA Statement and its extension for scoping reviews, and searched for articles published in 2011–2021. The 19 included articles were considerably heterogeneous concentrating on health outcome or patient portal facilitators and barriers.