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  1. Hello! I am a DNP-FNP student at Robert Morris University in Pittsburgh, PA conducting a DNP project. My area of focus is on primary care provider perceptions of telemedicine before and during the COVID-19 pandemic. If you are a nurse practitioner and have been practicing in primary care for at least two years, manage adult patients, and utilize telemedicine in your practice before and during the pandemic, I invite you to participate in this anonymous survey. For more information and eligibility to participate in my project, visit the link below: https://www.questionpro.com/t/ASckVZlvRC If you have any questions, please contact me, Sabrina Platt, the primary investigator at skfst174@mail.rmu.edu.
  2. Due to the current global pandemic, telemedicine has become more relevant than ever in primary care. This external threat is forcing providers and patients to stay apart as a broader public health initiative to maintain the spread of COVID-19. This technology allows patients to receive care without the in-person contact. Under an emergency declaration in conjunction with the 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act, Medicare has temporarily broadened its access of telemedicine, delivering benefits to patients while containing community spread (Centers for Medicare & Medicaid Services, 2020). As more patients and providers adopt this healthcare delivery platform during this worldwide crisis, it has the potential to create a fundamental impact on the primary healthcare landscape. Telemedicine is widely embraced by specialty areas of medicine. Although there is an overall general increase of use of telemedicine in primary care, it is still not universally employed (Barnett et al., 2018). The volume of telemedicine claim lines has increased over 4,000 percent from March 2019 to March 2020 across the United States. While meaningful increases, wider implementation of telemedicine can improve patient outcomes, decrease chronic disease burdens, and ensure financial stability (American Medical Association, 2020). Furthermore, telemedicine has the opportunity to increase continuity of care between providers and patients as frequent follow-ups are easier to achieve. Primary care providers [PCPs] have limited access to telemedicine due to barriers put in place by Medicare and these barriers are only lifted in times of need (American Hospital Association, 2019). In March of 2020, Medicare has temporarily broadened access of telemedicine during this current public health crisis, which helps to alleviate the stress of the public health crisis on the healthcare system (Centers for Medicare and Medicaid Services, 2020). Primary Care Provider Response to Public Health Crises The literature demonstrates studies have been conducted to describe the response of PCPs to public health crises. Researchers found that PCPs experiences are crucial for improving future prepandemic planning, which is a relatively new phenomenon (Kunin et al., 2013). PCPs experienced lack of confidence dealing with new and potentially life-threatening disease. Additionally, PCPs faced other problems associated with performance of public health responsibilities including surveillance, reporting, and privacy concerns (Kunin et al., 2013). Tomizuka et al. conducted a cross-sectional study that surveyed physicians based on World Health Organization checklists and essential components of institutional preparedness (2013). The researchers describe the necessity of a business continuity plan, or a plan that provides guidance on how to provide essential practice functions, staffing modifications, and record keeping during times of a public health crisis; however, this contingency plan was not implemented, and, therefore, creating a disruption in the local healthcare system (Tomizuka et al., 2013). During public health crises, PCPs and nurses are required to implement unique clinical skills. Other researchers described how clinical decision-making skills were different on the frontlines of the public health crisis, since regular office visits were suspended to control the spread of the virus (Verhoeven et al., 2020). Many PCPs and nurses expressed concern about the continuity of regular care, communication barriers to patients, and concern that certain cases would be missed due to less information gathered over the phone (Verhoeven et al., 2020). Trends of Telemedicine Healthcare is moving from fee-for-service to a value-based approach, and telemedicine has the capability to respond to the changing landscape of delivery (American Hospital Association, 2019). Barnett et al., conducted a retrospective chart review to examine trends in telemedicine utilization within a large commercial health plan (2018). The researchers found that annual telemedicine visits among all members increased from 206 to 202,374 from 2005 to 2017, and a rapid increase in growth from primary care telemedicine in 2016 and 2017 after coverage for direct-to-consumer telemedicine expanded (Barnett et al. 2018). Patient Perception of Telemedicine Many studies have concluded that patient perception of telemedicine is overall positive. In one study, 99% of the patients reported being very satisfied with all telemedicine attributes, and the majority reported the telemedicine visit just as good as a traditional visit (Polinski et al., 2015). The researchers reported an overall high satisfaction with telemedicine experience and quality of care were important to patients. Convenience was a recurring theme of telemedicine visits (Polinski et al., 2015, Powell et al., 2017). Powell et al. examined patient experiences with video visits with their established PCPs and reported that participants even preferred video visits over in-person visits; however, some participants expressed the loss of physician-patient connection, although this was not significant (2017). Despite some patients experiencing the lack of a personal connection, most patients felt telemedicine empowered them to manage their health (Hanley et al., 2018) It has been shown that telemedicine has a necessary place during the pandemic. But the question remains ... ... once we go back to our “normal lives,” will telemedicine in primary care be here to stay?
  3. A recent study published in Pediatrics found that children with acute respiratory infections (ARIs) were more likely to receive antibiotics during a direct-to-consumer (DTC) telemedicine provider visit compared to those who visited their primary physician or urgent care center. Also, children were less likely to receive antibiotic care that followed clinical guidelines when the antibiotic was prescribed during a DTC telemedicine visit. The lead study author, Kristen Ray, MD, MS, raised concerns around the inappropriate use of antibiotics. Concerns include the potential side effects of antibiotic use and contributing to antibiotic resistance through overprescribing. DTC Telemedicine Use Growing There are several factors driving the rapid increase of DTC telemedicine use among children. The convenience factor is a big draw for busy parents, who are able to connect with a physician with their smartphone, tablet or other device capable of audio or audio-video conferencing. Adding to the convenience is the large number of commercial companies offering DTC telemedicine services. Also, millions of children now have access to DTC telemedicine with 96% of large business insurance plans offering coverage to their employees and families. Quality of Care Concerns There is limited evidence regarding the quality of care pediatric patients receive when utilizing a DTC telemedicine provider. However, there are significant differences in providing care to children through telemedicine when compared to adults. Children often have difficulty describing their symptoms, therefore, there is increased reliance on the physical assessment in gathering patient data. Providing services to pediatric patients requires knowledge and understanding of evidence based treatment guidelines. Children also have a higher need for guideline-concordant antibiotic management at physician visits. Study Methods The researchers examined 2015-2016 claims data from a large single commercial insurer providing coverage for approximately 4 million children. The insurer also had contracts with a national DTC telemedicine company. The study group included children, ages 0 to 17, who received a diagnosis of acute respiratory infection (ARI) during an urgent care, primary care or DCT telemedicine provider during their initial visit. The quality of antibiotic management of ARI for 4604 children diagnosed during DTC telemedicine visits was compared to 485,201 children diagnosed during primary care visits and 37,408 in urgent care visits. The researchers analyzed the data to determine if prescribed antibiotic therapy was appropriate or inappropriate for the patient’s condition. Antibiotic therapy was considered “appropriate” treatment in the following ARIs: Sinusitis Pneumonia Streptococcal pharyngitis Acute otitis media Antibiotic therapy was considered “inappropriate” treatment in the following diagnosis: Viral upper respiratory infections Bronchiolitis Viral pharyngitis Serous otitis media Study Findings The analysis revealed antibiotics were prescribed for 52% of children in DTC telemedicine visits compared to 42% in urgent care centers and 31% in primary care provider visits. Antibiotics were appropriately prescribed in 59% of the telemedicine visits, 67% in urgent care and 78% in primary care provider visits. Antibiotics were inappropriately prescribed, primarily in cases of viral infections, in 56% of telemedicine visits compared to 67% of urgent care and 20% of primary care visits. Limits of DTC Telemedicine The researchers provide a discussion on potential reasons for increased antibiotic prescribing and lowered use of guidelines in DTC telemedicine visits. Visits do not allow the same level of physical assessment as a face-to-face visit. Technology is more limited compared to other types of telemedicine and more likely to have connection or sound issues. Lack an established relationship and no access to the patient's medical record. Provider may not have expertise specific to pediatrics The study authors write “Together, these issues may increase clinical uncertainty during pediatric DTC telemedicine visits, prompting physicians to prescribe antibiotics ‘just to be safe.’”. Study Limitations The authors identified several limitations in the study’s data analysis. Lack of additional demographic or clinical data, therefore, could not account for variables that could have influenced prescribing (race, severity of illness, time constraints or family expectations). Analysis limited to a specific health plan and a single DTC telemedicine vendor Conclusion Telemedicine has a valuable place in healthcare delivery and its contribution will continue to grow. The technology allows pediatric patients in remote, rural and underserved communities to have greater access to care and specialty consultation. However, the study results do raise the question of limits of telemedicine in diagnosing ARIs and adequately manage antibiotic therapy in pediatric patients. What do you think? Read the full article here.
  4. On April 12. 2019, President Trump and the Federal Communications Commission (FCC) Chairman announced a plan to hold a third Fifth Generation Wireless Technology (5G) spectrum auction in the latest effort to make more mobile spectrum available in the United States. A plan to spend $20 billion was also announced to expand broadband access to rural areas currently without it. This evolution of mobile technology will provide a much faster connection, be more responsive and allow more data to be transferred. We could experience downloads as much as 10 to 20 times faster than current 4G technology. What does this mean to healthcare? The advent of 5G bring exciting possibilities in the ability to provide more personalized care with improved access to services. Making Homecare A Viable Option An increasing number of people would prefer being treated at home instead of dealing with long wait times and the high cost of hospitals. In addition, Medicare patients over the age of 65 experience a 14.9% rehospitalization rate in the United States. Home health services will experience a growth with 5G technology and move forward with making homecare a viable option for healthcare. 5G will offer the following improvements in home care services: Wearable medical devices 5G technology will improve nurse and physician ability to monitor patients in real time. This will allow emergencies or abnormalities to be reported without delay. Research has shown patients are more engaged with their own health when using medical wearables for remote monitoring. Wearables have also been predicted to decrease hospital costs by 16% over the next 5 years. Imagine the impact of more efficient and effect data-generating tools. The ability to identify the first sign of illness will allow early interventions, including consults, to be implemented- reducing complications. Remote monitoring has been limited by slow network speeds and unreliable connections and 5G will increase consistency and confidence in the ability to monitor real-time patient data. Expanding telemedicine A study by Market Research Future found the telemedicine market is expected to grow at a rate of 16.5% from 2017 to 2023. The study determined the demand increase is attributed to the need for telemedicine in rural areas and a rise in government initiatives to improved access to care in rural communities. 5G technology will support mobile telemedicine appointments, including access to specialist and better healthcare collaboration. Quick Transmission of Large Imaging Data Imaging machines (i.e. MRIs, PET scanners) typically use very large files that are sent to a specialist for review and interpretation. If the network is low on bandwidth, the transmission of these files can be delayed or even not sent. For patients being treated outside of an acute care or surgical setting (outpatient clinics), slow data transmission can further delay diagnosis and treatment. Previous imaging studies are often needed for comparison to ensure implementation of appropriate treatment plan. 5G downloads could be 10 to 20 times faster than current technology and providers would reduce wait times to see more patients in the same amount of time. Bridging Language Barriers It is often a challenge for a person whose first language is not English to communicate vital health information. Informing healthcare providers of allergies and health history is essential for determining appropriate care. Additionally, these patients may not fully understand diagnosis, medication regime or instructions for follow-up care. Translation services for less common languages are typically centralized and not available on-site. Video services are available for translation, but network capabilities limit this technology, especially in rural areas. 5G will improve the network speed to make video translation services more reliable and accessible. Making Remote Medicine Possible Emergency medicine is typically based on a “patient-to-hospital” practice. Emergency care outcomes in critical situations, such as cardiac arrest, stroke, trauma) are dependent on prompt access to care. 5G would introduce a new set of tools to first responders for faster emergency care. For example: Alerting emergency departments of EMS estimated arrival time with great accuracy Sending in advance ECG, patient data and imaging that would allow the ED to be prepared with proper equipment and staff with patient arrival Potential for live link to ER doctors or specialists through 4K body cameras to help assess, treat and prepare patient for transfer Access in rural areas to augmented reality tools allowing EMTs or general practitioners to follow guided steps in performing critical care. This article highlights only a few improvements 5G will bring to the access and delivery of healthcare. With reliable and high-bandwidth networks, healthcare providers can improve quality of care and the patient experience. Additionally, rural communities will benefit with easier access to specialist and timely diagnosis. What other benefits, such as better protected health information, are you looking forward to experiencing with 5G technology? Resources: Federal Communications Commission. (2018, September 28). The FCCs 5G fast plan. [Press release]. Healthcare IT News. (2018). The journey to 5G. Verizon.