key: cord-314028-sf8zt9r9 authors: esposito, susanna; voccia, emanuele; cantarelli, angelo; canali, andrea; principi, nicola; prati, andrea title: telemedicine for management of paediatric infectious diseases during covid-19 outbreak date: 2020-06-23 journal: j clin virol doi: 10.1016/j.jcv.2020.104522 sha: doc_id: 314028 cord_uid: sf8zt9r9 nan problems. to verify this hypothesis, a comprehensive paediatric infectious disease telemedicine programme at an urban academic medical centre in parma, emilia-romagna region, italy, was developed and activated on march 7, 2020. the academic hospital was directly connected to all the paediatric ambulatories that systematically followed the children in the community during the year. one paediatric infectious disease specialist coordinated the programme. a total of 36 primary care paediatricians of parma province who globally follow 30,000 children were enrolled. the service used telemedicine peripheral devices, apps for smartphones and broadband connections. telemedicine participants could connect for real-time interaction usually during the 4-hour/day period of primary care paediatrician activity in the ambulatory. evaluations of children generally began with a review of the available information that was discussed and, when possible, associated with a visual assessment of the child's overall appearance, respiratory pattern and behaviour. from march 7 to may 3, during the lockdown phase, 61 requests of telemedicine consultation (28, 45.9%, males; mean age ± standard deviation, 4.69 ± 3.22 years) to the paediatric infectious disease specialist in the hospital by the primary care paediatricians were made. a total of 55 (90.2%) paediatric problems that without telemedicine support could have led the patient to the emergency room of the hospital were solved in the community: 30 (54.5%) children with fever of unknown origin, 20 (36.4%) with skin rash, 3 (5.5%) with suspected primary immunodeficiency and 2 (3.6%) with acrocyanosis. in 6 out of 61 cases (9.8%), a medical visit was required because of skin rash (n=4, 66.7%) and acrocyanosis (n=2, 33.3%): in these cases nasopharyngeal swab was performed and resulted negative for sars-cov-2 using real-time polymerase chain reaction. none of the children needed further medical evaluation either in the community or in the hospital. this experience shows that during the covid-19 outbreak, the use of telemedicine for the management of paediatric infectious diseases permitted us to avoid hospital access j o u r n a l p r e -p r o o f in 90% of the cases, favouring reduction of the pressure on the hospitals. during the present covid-19 pandemic, telemedicine use has been promoted in some countries [2] [3] [4] . however, in the majority of the countries, despite a very large burden of covid-19, telemedicine was not included in the essential level of care granted by the national health system. our experience shows that telemedicine may be an easy and effective measure to solve many paediatric problems in the community during covid-19 outbreak, reducing emergency room visits. the activation of integrated software that can be used by paediatricians and parents from their mobile phone with the possibility to perform virtual visits and daily monitoring at home of patients with acute infections with respect to privacy law is advisable. none. andrea prati 4 , phd, for the parma covid-19 pediatric working group pediatric clinic, pietro barilla children's hospital, department of medicine and surgery virtually perfect? telemedicine for covid-19 online mental health services in china during the covid-19 outbreak a virtual care program for outpatients diagnosed with covid-19: a feasibility study rapid implementation of virtual clinics due to covid-19: report and early evaluation of a quality improvement initiative la tecnologia e l'innovazione per la lotta al key: cord-312947-ppc4w23a authors: spiess, philippe e.; greene, john; keenan, robert j.; paculdo, david; letson, g. douglas; peabody, john w. title: meeting the challenge of the 2019 novel coronavirus disease in patients with cancer date: 2020-04-23 journal: cancer doi: 10.1002/cncr.32919 sha: doc_id: 312947 cord_uid: ppc4w23a the alarming situation of the 2019 novel coronavirus disease (covid‐19) is contrasted by the limited efforts to curb the spread and impact of the disease among patients with cancer. this commentary proposes a simple 5‐part strategy plus rapidly expanded use of telemedicine to anticipate and deal with covid‐19 and, by extension, future epidemics in patients with cancer. cancer month 0, 2020 restrictions on telemedicine use, clinical trials be put into place for evaluating telemedicine's clinical effectiveness, overall costs of care, diagnostic accuracy, and real and perceived effects on patient confidentiality. expanding telemedicine faces 3 significant challenges. first, not all patients will have access to high-speed internet connections, and this must be addressed. 9 some of these clinical encounters will still be accomplished through phone conversations, with in-person clinical visits reserved for those with unresolved problems or without telemedicine connectivity. second, providers and patients who typically have not used telemedicine will have to be introduced and supported until they develop some facility. 10, 11 third, the us department of health and human services has exercised its authority granted under imminent bipartisan legislation emerging from congress, 12 and it will pay providers caring for medicare patients, waive or reduce copays, and allow for patients' care across state lines. with these regulatory changes, however, providers need to be reassured that these changes and future regulatory changes, such as eliminating the need to first conduct an in-person visit before telemedicine is used, will encourage expanded use of telemedicine among oncologists to reduce covid-19 infections today and improve access to care tomorrow. no specific funding was disclosed. philippe e. spiess reports that he is medical director of virtual health at moffitt cancer center. douglas g. letson reports consultancy work for stryker ortho outside the submitted work. john w. peabody is a professor at the university of california, provides strategic support to moffitt cancer center, and is the founder and president of qure healthcare, which is a health care measurement company that uses its trademarked tool, clinical performance and value, to reduce clinical practice variation, raise the quality of care, and lower the costs of health care for patients, providers, and payors. the other authors made no disclosures. cdc media telebriefing: update on covid-19 covid-19-navigating the uncharted estimated global mortality associated with the first 12 months of 2009 pandemic influenza a h1n1 virus circulation: a modelling study infection in cancer patients: a continuing association cancer patients in sars-cov-2 infection: a nationwide analysis in china congress must act to ensure telehealth can be used to combat the coronavirus the role of telemedicine in infectious diseases use of telemedicine technologies in the management of infectious diseases: a review telemedicine infectious diseases consultation and clinical outcomes: a systematic review quality attributes in telemedicine video conferencing overview for implementation of telemedicine services in a large integrated multispecialty health care system house passes $8.3 billion emergency coronavirus response bill key: cord-308873-73zv5ned authors: kim, hun-sung title: lessons from temporary telemedicine initiated owing to outbreak of covid-19 date: 2020-04-30 journal: healthc inform res doi: 10.4258/hir.2020.26.2.159 sha: doc_id: 308873 cord_uid: 73zv5ned nan to prepare clinical evidence in earlier telemedicine projects, various medical devices were used to check the patient's condition and provide medical treatment through videotelephony [5] [6] [7] [8] . for this reason, it is true that the earlier telemedicine projects concentrated on medical devices and platforms to check health conditions of patient [9, 10] . in a state of emergency such as covid-19 [11] , this temporary telemedicine will definitely help. however, in the case of acute and infectious diseases such as covid-19, the role of medical devices and platforms is ambiguous. clear diagnosis or monitoring at home is also practically impossible. in other words, telemedicine approved at this time is not the existing evidence-based telemedicine for the purpose of healthcare itself, but most instances are simply repeated prescriptions of drugs over the phone. in other words, it is difficult to say that it is a new technology-based telemedicine utilizing new technology. from the hospital's point of view, for telemedicine, it is necessary for a nurse to first call the patients to make a reservation prior to consultation. the medical staff must call the patient again for medical consultation and then help schedule the next outpatient visit. in this process, if elderly patients do not have a good telephone connection, the telephone consultation is not executed well, and there are many communication obstacles. in the case of the elderly, it is also difficult to be sure that the person who receives the telephone consultation is actually a registered patient, and it is necessary to confirm this. from the medical staff 's point of view, teleconsultation takes more time and labor than conventional face-to-face treatment. from the patient's point of view, it may be necessary to visit the pharmacy again in person after telephone consultation depending on the results. it is difficult for patients to take advantage of telemedicine's ability to provide care anytime, anywhere [6] . although it is temporary telemedicine, where only repeated prescriptions and simple comments are possible, patients have many expectations and requirements. patients unfamiliar with telemedicine will be more interested in taking prescriptions for repeated medications without visiting the hospital, rather than using telemedicine for the purpose of healthcare. unlike face-to-face medical treatment, which consists of inspection, palpitation, percussion, and auscultation, telemedicine consists only of inspection; hence, safety problems and accountability are inevitable (currently, temporary telemedicine is a telephone consultation, without inspection. moreover, the responsibility of safety is entirely that of the medical staff). for this reason, if the medical staff focuses only on repeated medications, they may miss a relatively severe symptom that masks acute illness. it will be difficult to distinguish covid-19 from the common cold by phone from the home of a patient who has symptoms of the common cold. therefore, there is a risk of delaying the patient's diagnosis or missing the opportunity for adequate initial treatment. further, service scenarios, legal reviews, scope of treatment and discretion of doctors, and insurance claims should be prepared in advance [12] . medical staff should not just blindly refuse telemedicine and only insist on face-to-face treatment. in any event, during the covid-19 outbreak, telemedicine must be accepted for a limited time to reduce face-to-face contact. unfortunately, even in the medical field, if we have had prior experience with telemedicine, or if we have been prepared accordingly for the introduction of telemedicine in advance [13] , we may be able to respond more flexibly in this outbreak of covid-19. repeated medication prescriptions to reduce in-hospital infections are also a big advantage of telemedicine. however, it is difficult to judge whether telemedicine should be adopted in the future based only on the experience of temporary telemedicine initiated during covid-19. rather, attributing an exaggerated meaning to telemedicine would only raise opposition to the adoption of telemedicine in the future. due to the sudden implementation of ill-equipped telemedicine, there are multiple concerns about poor operation. however, the time has come to seriously consider allowing remote medical care. i hope that this will be an opportunity to form a social infrastructure and consensus through the experience of temporary telemedicine adoption due to covid-19. the aspect of national policy is definitely the most important point. further, it is also expected that the medical field and patients need deep attention. no potential conflict of interest relevant to this article was reported. the covid-19 epidemic will the third wave of coronavirus disease 2019 really come in korea? case of the index patient who caused tertiary transmission of covid-19 infection in korea: the application of lopinavir/ritonavir for the treatment of co-vid-19 infected pneumonia monitored by quantitative rt-pcr ministry of health and welfare. temporary allowance of telephone consultation/prescription and proxy prescription ministry of health and welfare new directions in chronic disease management current clinical status of telehealth in korea: categories, scientific basis, and obstacles clinical examination component of telemedicine, telehealth, mhealth, and connected health medical practices smartphone sensors for health monitoring and diagnosis digital health technology and mobile devices for the management of diabetes mellitus: state of the art video consultations for covid-19 telemedicine: medical, legal and ethical perspectives virtually perfect? telemedicine for covid-19 key: cord-344258-19zzumqf authors: mustafa, s. shahzad; yang, luanna; mortezavi, mahta; vadamalai, karthik; ramsey, allison title: patient satisfaction with telemedicine encounters in an allergy/immunology practice during the covid-19 pandemic date: 2020-06-22 journal: ann allergy asthma immunol doi: 10.1016/j.anai.2020.06.027 sha: doc_id: 344258 cord_uid: 19zzumqf nan the use of telemedicine dates as far back as 50 years ago, when the university of 1 nebraska used interactive telemedicine to transmit neurologic examinations. 1 since that time, 2 despite advances in available technologies, and proven utility of telemedicine in 3 allergy/immunology (ai), 2,3 the uptake of telemedicine by ai physicians remains low. 4 with the 4 global spread of novel coronavirus disease 2019 (covid19) , ai physicians were abruptly forced 5 to change their mode of health care delivery. given the need for social distancing and exposure 6 mitigation, many practices quickly adapted to remote encounters from primarily in-person 7 care. 5 as it has become clear that the covid-19 pandemic will have long lasting consequences, 8 the emergence of telemedicine presents an opportunity for optimizing healthcare delivery in 9 our specialty. given the paucity of data on patient satisfaction with telemedicine, we aimed to 10 further characterize this understudied area. 11 we prospectively collected patient encounter data for the four-week period from april 12 13 -may 8, 2020 among four physicians at the rochester regional health (rrh) ai practice. the 13 appointment type (in-person, telephone, telemedicine) was tracked for all encounters, but only 14 telemedicine encounters were studied further. telemedicine encounters were completed using 15 the following third party vendors: epic warp (ehr, verona, wi), skype (palo alto, ca), facetime 16 (apple, cupertino, ca), and doximity (san francisco, ca) depending on patient preference. for 17 telemedicine encounters, the following were collected: number of new patient (np) 18 encounters, number of follow up (fu) encounters, patient gender, age, primary diagnosis, 19 biologic therapy or immunotherapy, and encounter completeness as determined by the 20 treating physician. patients evaluated by telemedicine were contacted by telephone within 21 seven days to answer three patient satisfaction questions (table 1) the covid-19 pandemic facilitated widespread adoption of telemedicine in ai practices. 47 despite the sudden change in the mode of healthcare delivery, our results show that patients 48 have been highly satisfied with these encounters. nearly 97% "agreed" or "strongly agreed" 49 that they were satisfied with their telemedicine encounter. these rates mirror similar work by 50 waibel et al and staicu et al that demonstrated 98% of patients were satisfied with a 51 telemedicine evaluation. 3,6 additionally, in our study, the majority of patients felt their 52 telemedicine encounter was as satisfactory as an in-person encounter, whereas only 12.8% of 53 patients disagreed with this sentiment. although telemedicine has been presently necessary for 54 social distancing to mitigate risk of exposure to covid-19, we hypothesize that going forward, 55 patients may continue to favorably view telemedicine due to its potential to save time and 56 improve access to specialty care. these benefits must be weighed against the advantages of an 57 in-person evaluation, including the sense of a more personable interaction, the ability to 58 perform a physical exam and order routine diagnostic testing. 59 importantly, our data shows that patients report high satisfaction with telemedicine 60 regardless of their primary diagnoses and type of evaluation (np versus fu). although nearly 61 half of the encounters were deemed to be incomplete by the treating physician, these 62 encounters still resulted in high patient satisfaction. although certain diagnoses in the field, 63 such as chronic urticaria, would seem better suited to a telemedicine evaluation, patients also 64 reported satisfaction with their evaluations for allergic rhinitis, food allergy, and asthma. these 65 findings could potentially be explained by patients accepting physician decision-making without 66 customary testing (i.e. spirometry for patients with asthma, or skin testing for evaluation of 67 food allergy), or expecting such testing at future visits. the high patient satisfaction also 68 supports that the clinical history remains the most important part of a medical evaluation, 69 whether it occurs in-person or via telemedicine. 70 we acknowledge that our cohort may be more accepting of telemedicine during the 71 covid-19 pandemic, and their responses may have been skewed by a desire to positively 72 review their personal physicians. one third of patients could not be reached for follow up, and 73 they may represent a subgroup who had a less positive experience with telemedicine. we also 74 acknowledge that our data is reflective solely of patient satisfaction and not patient outcomes. 75 however, previous data has shown that patient care outcomes are comparable with 76 telemedicine versus in-person visits, 7,8 and that telemedicine can result in cost-77 savings. 6 comparing video visits to telephone and in-person visits also would also have 78 strengthened our study. nevertheless, our data on telemedicine mirrors the high level of 79 patient satisfaction that has been previously reported. we urge a/i physicians to continue to 80 educate themselves on evolving telemedicine regulations and reimbursement unique to their 81 practice settings. 9 the uptake of telemedicine was hastened by the covid-19 pandemic, but it 82 is likely to be an important part of ai practices in the post pandemic era. telemedicine: a guide to assessing telecommunications in health care the 4 effects of telemedicine on asthma control and patients' quality of life in adults: a systematic 5 review and meta-analysis the use of telemedicine for penicillin the use of telemedicine by physicians: still the exception rather 9 than the rule appointment characteristics in an 11 allergy/immunology practice in the immediate aftermath of covid-19 restrictions outcomes from a regional synchronous tele-allergy 14 service telemedicine is as effective as in-person visits 16 for patients with asthma the uses of telemedicine to improve asthma control american telemed accessed 6/10/2020 key: cord-281796-sutgyaep authors: bluman, eric m.; fury, matthew s.; ready, john e.; hornick, jason l.; weaver, michael j. title: orthopedic telemedicine encounter during the covid-19 pandemic: a cautionary tale date: 2020-06-27 journal: trauma case rep doi: 10.1016/j.tcr.2020.100323 sha: doc_id: 281796 cord_uid: sutgyaep the covid-19 pandemic has necessitated increased use of telemedicine for diagnosis and management of musculoskeletal disorders. we describe the initial virtual/telemedicine encounter and management of a patient with knee pain initially diagnosed as gonarthrosis but that actually resulted from an impending pathologic fracture of the femur. definitive diagnosis and treatment occurred only after completion of the impending fracture. the multiple factors making telemedicine encounters challenging which contributed to this outcome are highlighted. orthopedists need awareness of these challenges and must take steps to mitigate the risk of complications possible with continued increased utilization of telemedicine during this pandemic and beyond. j o u r n a l p r e -p r o o f summary the covid-19 pandemic has necessitated increased use of telemedicine for diagnosis and management of musculoskeletal disorders. we describe the initial virtual/telemedicine encounter and management of a patient with knee pain initially diagnosed as gonarthrosis but that actually resulted from an impending pathologic fracture of the femur. definitive diagnosis and treatment occurred only after completion of the impending fracture. the multiple factors making telemedicine encounters challenging which contributed to this outcome are highlighted. orthopedists need awareness of these challenges and must take steps to mitigate the risk of complications possible with continued increased utilization of telemedicine during this pandemic and beyond. keywords: coronavirus, telemedicine, orthopedic surgery, delayed diagnosis, impending fracture telemedicine or virtual visits (vvs) refers to the treatment of various medical conditions without seeing the patient in person. encounters conducted over the phone without video imaging to j o u r n a l p r e -p r o o f no physical examination was possible because of the virtual nature of the encounter. three nonweight bearing radiographs of her right knee were evaluated as part of the encounter (figure 1 ). these demonstrated mild arthritic changes of the patellofemoral joint. no appreciable deformity was noted. a diagnosis of mild right knee arthritis was made. non-operative management including weight loss, nsaids and physical therapy to include a home exercise program was decided upon. on 13 apr 2020, the patient twisted her body while at home with a resultant fall, pain in her right thigh, and inability to stand. she was transported to our hospital by emergency services. in the emergency department, her right lower extremity was shortened and her thigh was tender to palpation but her integument and neurovascular exam were intact. radiographs of her right femur revealed a displaced, oblique subtrochanteric fracture through a lytic lesion ( figure 2 ). further history revealed that her prior thyroid cancer had metastasized to a rib that required resection. standard lab testing for patients with known skeletal metastases was initiated. she was admitted and a bone scan and skeletal survey was performed to ensure there were no other sites of impending fracture and to identify possible targets for radiation therapy. the patient underwent reduction and placement of a cephalomedullary device for fixation of the right femur ( figure 3 ). the surgery was un-eventful, and she tolerated it well. during the procedure, a biopsy of the contents of the lytic lesion within the right femur was performed and sent to surgical pathology for gross and microscopic histologic evaluation. this analysis confirmed the diagnosis of metastatic thyroid carcinoma (figure 4 ). radiation oncology was consulted to provide post-operative radiation therapy and medical oncology was consulted for consideration of postoperative chemotherapy. she was mobilized with physical therapy, and was able to walk with the aid of a walker at the time of discharge. in this case report, we illustrate numerous factors associated with a telemedicine visit that resulted in the delayed diagnosis of a skeletal metastasis. this case highlights many of the pitfalls possible with orthopeadic surgeons' use of this type of encounter. one obvious drawback to using telemedicine visits is the limitation placed in conducting a physical examination. telephonic-only visits are the most limited. these types of visits can detect certain components of the examination (e.g. affect) the patient's verbal communication. in some unusual circumstances, the physician may be able to evaluate audible findings (e.g. tendon crepitus). physical examinations through the video component of evisits are also limited, albeit less so than with telephonic encounters. evisits with orthopeadic encounters can certainly provide greater information but still prevent adequate examination of tissue character, temperature, sensory function, motor strength, differentiation of pain intensity and certain types of coordination. with both isolated telephonic encounters and evisits, there is a very limited ability to obtain synchronous supplemental imaging. for these visits, patients ideally obtain imaging just before the visit itself (e.g. one or a few days before) to allow accurate radiographic diagnosis. when patients are seen in-person in the orthopeadic clinic, they are easily sent back to radiology for repeat imaging for those studies that were inadequate or for supplementary studies to show expanded fields of view or non-standard views. in most cases, this option is not available for telephonic or evisits. some locales have services that provide mobile imaging at the home of the patient. [3] [4] [5] where available, these services can help improve the quality of the care. however, the imaging equipment such companies are able to bring to the patient's home is limited; specialized studies are not able to be performed. this limits the improvement in diagnostic capabilities. all patients are not able to use evisit technology. while smart phones are extremely common, the expertise to conduct a evisit is not universal. we have found that many geriatric patients have difficulty with evisit technology. in our case, had an evisit been possible, it may have tipped-off the treating surgeon to the true nature of the problem. in the hospital, when describing her "knee pain," she grabbed her thigh. this observation during an evisit may have led to further questioning or radiographs. a virtual visit algorithm: how to differentiate and code telehealth visits, evisits, and virtual check-ins characteristics of patients who seek care via evisits instead of office visits the rad-home project: a pilot study of home delivery of radiology services portable x-ray services becoming more common -reuters key: cord-323625-co5j8wwd authors: garcia, marcos vinicius fernandes; garcia, marco aurélio fernandes title: telemedicine, legal certainty, and covid-19: where are we? date: 2020 journal: j bras pneumol doi: 10.36416/1806-3756/e20200363 sha: doc_id: 323625 cord_uid: co5j8wwd nan in brazil, telemedicine activities were exceptionally authorized due to the recent coronavirus disease 2019 (covid-19), being valid only while the pandemic lasts. (1) the necessary regulation of telemedicine is still being discussed and was subjected to a presidential veto, on the grounds that the regulation of medical activities by means of telemedicine after the end of the current pandemic is a matter that should be regulated by law. (2) telemedicine has been a successful tool and was the major international technological innovation implemented during the pandemic (3) ; however, legal uncertainty on the topic is still common among health care professionals and institutions. (4) covid-19 spread across all continents in weeks, overcoming the ability of health care systems to test individuals, as well as to track and contain the disease. (5) telemedicine activities prevent close contact, decreasing the chance of infection with the covid-19 virus, accelerate the dissemination of accurate information by making teaching platforms available, and promote access to the opinions of experts in remote locations. (3) various countries severely affected by the pandemic have developed and implemented telemedicine platforms. the government of the chinese province of shandong, one of the most affected regions, established a comprehensive telemedicine program in march of 2020. the program has provided guidance on prevention and treatment directly to the patients, training for health care professionals, and remote consultation with specialists for medical staff in different locations. this platform has been a great success and a model for other chinese cities. (6) italy, however, encountered various barriers to telemedicine amidst a large number of critical patients and low availability of icu beds. the limited availability of large-scale telemedicine solutions, the heterogeneity of the tools available, the poor interconnection among telemedicine services operating in different locations, the lack of a multidisciplinary approach to the management of patients, and the absence of clear legal guidelines were factors that limited the wide use of telemedicine. (7) telemedicine is not a novelty in the world. the world medical association statement, also known as the tel aviv statement, one of the most important telemedicine documents worldwide, was created in 1999. (8) this phenomenon soon arrived in brazil. in 2002, the brazilian conselho federal de medicina (cfm, federal council of medicine) (9) formulated a resolution that defined what telemedicine service is, established the minimal infrastructure required, and addressed medical responsibilities and the registration of telemedicine service providers. this resolution remained dormant for 15 long years, but made sure that "telemedicine, even in a timid way, already existed and worked." (10) incredibly, cfm new attempt to regulate the topic resulted in the alleged ban on telemedicine nationally. between the end of 2018 and the beginning of 2019, cfm prepared resolution no. 2,227, (11) which introduced several innovations applicable to telemedicine and finally provided a robust legal framework for the provision of telemedicine services in brazil. according to the resolution, these would be the modalities of telemedicine: teleconsultation, teleinterconsultation, telediagnosis, telesurgery, telescreening, telemonitoring (or telesurveillance), teleorientation, and teleconsulting. the legal wording reinforced that each of the eight different modalities of telemedicine would deserve a different approach instead of establishing general rules for telemedicine as a whole. it is important to note that this resolution formally revoked the previous cfm resolution of 2002, and it would only come into force 90 days after its publication. resolution no. 2,227 (11) had a very short life because it was revoked even before it came into force. because of the immediate reaction of the medical community, cfm rushed to publish resolution no. 2,228, (12) which completely revoked resolution no. 2,227, (11) but expressly reestablished resolution no. 1,643. (9) therefore, an unusual legal confusion was created. if resolution no. 2,228 (12) had only revoked resolution no. 2,227, (11) with nothing else to add, the understanding would be that telemedicine was no longer authorized in brazil. however, by expressly reestablishing the validity of the 2002 resolution (9) on telemedicine, resolution no. 2,228 (12) did not effectively prohibit the practice of telemedicine in brazil. this resulted in a legal imbroglio. technically, resolution no. 1,643 (9) remains in effect today. this fact still generates doubts and uncertainties in the medical community and in the media; however, it is understood that cfm regulations have never prohibited telemedicine in brazil. this position is clear considering that the law of telemedicine and the subsequent brazilian ministry of health ordinance no. 467 (13) made it clear that telemedicine would be authorized in brazil. however, the code of medical ethics, (14) published in 2019, maintains the prohibition of prescribing treatment and procedures without the direct examination of the patient or by any other means of communication or mass media. therefore, even the greatest enthusiast of telemedicine would be reluctant to rely on the outdated and incomplete resolution no. 1,643. (9) it is evident that telemedicine needs to be properly regulated in order to become available after the end of the covid-19 pandemic. to this end, all interested parties in its approval should be convened to create an adequate legal framework for telemedicine activities. given the very favorable results of telemedicine obtained in a very short time in brazil and worldwide, it is natural to expect that there will be no setbacks, such as the prohibition of telemedicine services in brazil. telemedicine has become a critical component during the pandemic and improved the efficacy of health care services, multiplying the capacity of the health care system to cope with covid-19. we believe that telemedicine plays a fundamental role in defeating the pandemic and should not be considered just an option or a complement to react against a crisis. therefore, the dissemination of telemedicine is a path of no return. the regulation of telemedicine will be remembered as a historic landmark for the brazilian unified health care system in the future. artigos 1 e 2. diaŕio oficial da uniaõ subchefia para assuntos jurídicos. mensagem no. 191, de 15 de abril de 2020. diaŕio oficial da uniaõ virtually perfect? telemedicine for covid-19 a busca pela regulamentação da telemedicina covid-19 and health care's digital revolution the role of telemedicine during the covid-19 epidemic in china-experience from shandong province telemedicine during the covid-19 in italy: a missed opportunity? archived: statement on accountability, responsibilities and ethical guidelines in the practice of telemedicine conselho federal de medicina. resolução cfm no. 1.643/2002. diaŕio oficial da uniaõ. 26 de agosto de rio de janeiro: forense diaŕio oficial da uniaõ. 6 de fevereiro de conselho federal de medicina. resolução cfm no. 2.228/2019. diaŕio oficial da uniaõ. 6 de março de portaria no. 467. diário oficial da união resolução cfm no. 2.217, de 27 de setembro de mvfg and mafg were responsible for preparing the text, revising the references, and writing the final text. key: cord-316414-1dho7mmd authors: valentino, leonard.a.; skinner, mark w.; pipe, steven title: the role of telemedicine in the delivery of healthcare in the covid‐19 pandemic date: 2020-05-12 journal: haemophilia doi: 10.1111/hae.14044 sha: doc_id: 316414 cord_uid: 1dho7mmd on 11 march 2020, the world health organization declared the coronavirus disease 2019 (covid‐19) a pandemic. recently, hermans, et.al., outlined the challenges the covid‐19 pandemic pose for the bleeding disorders community (1). the general response to the pandemic has included increased measures focused on personal hygiene, social distancing, symptom monitoring, early diagnosis, patient isolation, shelter in place, and public health quarantine. accordingly, such measures have led to concerns over how to maintain access to haemophilia treatment products and to the specialized integrated care medical follow up within the haemophilia treatment centers (htcs). as part of the medical response to disasters such as a world‐wide pandemic, telemedicine has emerged as one proposed solution to address this type of global challenge (2). telemedicine may include a variety of technologies to securely deliver remote health care including: live (synchronous) videoconferencing, typically a two-way audiovisual link between a patient and an hcp in different locations; audio-only visits via patient portals and messaging technologies; remote patientmonitoring tools; and store-and-forward technologies that collect images and data to be transmitted at a later time (e.g., educational materials) 5 . these technologies offer several possible advantages including: the ability to quickly ask and receive answers to questions; more timely diagnosis and institution of treatment for some conditions such as stroke; patients have access to medical specialists as well as a general hcp; the possibility of enhanced patient privacy; reduced costs and increased convenience; and reduced need for physical contact limiting potential infectious exposures. the potential disadvantages of telemedicine include: the need for technical training on the part of the hcp and to some degree, the patient; the necessary equipment to conduct the tele-visit; the possibility of a reduction in continuity of care like the retail healthcare movement; and last but certainly, not the least of the disadvantages is the inability to conduct a physical examination 5 . while sustaining optimal care during a pandemic is challenging, we can draw on prior experience. in 2012, the nhf-mcmaster guidelines on care models for haemophilia management 6 suggested that an optimal integrated care model include a hematologist, a specialized haemophilia nurse, a physical therapist, a social worker and round-the-clock access to a specialized coagulation laboratory be part of the integrated care team. while it may seem daunting, there is significant precedent for remote care delivery in haemophilia management. the impact of telemedicine, outreach clinics and other remote care delivery systems as an alternative/add-on to integrated care was identified as a priority within the guidelines. in 2013, the us national hemophilia program coordinating center (nhpcc) conducted a survey of hemophilia treatment centers (htc) assessing gaps in care and resources needed to support care 7 . compared to the previous survey there was a marked increase in those identifying geographical access as a technical assistance need. subsequently, one of four projects of national significance funded by the nhpcc evaluated how htcs could provide care remotely to rural areas using telemedicine 8 . the pilot study demonstrated a high level of patient satisfaction with the telemedicine approach and significant cost savings, both in terms of cost of travel and time away from work. while telemedicine outreach clinics have long existed and been utilized in a accepted article number of htcs to resolve geographical access challenges the pilot project results published in 2018 demonstrated that, while not without challenges, telemedicine is especially well-suited for patient s with chronic disorders such as hemophilia 8 . concerns raised with telemedicine have primarily been related to privacy and data protection due to the risk for inadvertent disclosure of sensitive information 9 . as part of the us national response to the covid-19 national public health emergency, the office for civil rights (ocr) has stated that it will not impose penalties on physicians using telehealth in the event of noncompliance with regulatory requirements as outlined in the health insurance portability and accountability act (hipaa) 10 . despite this change, it is important that hcps obtain consent from patients for the telemedicine visit. patient acceptance of, and satisfaction with, telemedicine has generally been favorable 5 . in one study examining the management of osteoporosis 11 , participants expressed comfort with the use of technology and believed that the quality of care was comparable to in-person visits. benefits included the convenience and a reduced burden of travel and costs. perceived barriers this study identified included lack of follow-up and compliance with recommended tests and studies. prior experience does not allow us to conclude that telemedicine can deliver outcomes similar to in-person clinical encounters. during the pandemic, telemedicine will be utilized to deliver both routine care and emergency management. in addition to clinical outcomes, it will be important to document and monitor patient-important outcomes e.g. impact on functional status along with feasibility and acceptability. we can anticipate many lessons applicable to future health care delivery will be learned during the pandemic. as noted by hermans, et al, within this rapidly evolving health care environment htcs must adapt to the new reality of telemedicine. however, ultimately clinical trials may be required to understand if telemedicine is to be a long-term and suitable alternative for in-person delivery of care for people living with bleeding disorders. the task for telemedicine providers will be to tackle these challenges head-on. we need more research demonstrating that telemedicine improves patient-centered outcomes and that it can do so efficiently -not just for individual encounters but at the population level, without leading to overuse 12 . in summary, in the context of a pandemic, telemedicine has the potential to increase convenience, improve access, improve patient safety and better manage costs, limiting exposures to patients and hcps while accepted article reducing the burden on healthcare facilities allowing them to deal with the sickest patients. in a more general sense, widespread implementation of telemedicine will not only enhance the direct care of patients with bleeding disorders but will enable more people, especially those living in underserved areas, to receive specialty hematology care 8 . with the recent trends in the healthcare marketplace seeing an increase in enrollment in high-deductible consumer-driven health plans, rewarding providers for value requires moving encounters to lower cost options while maintaining quality care delivery. the pandemic has catalyzed hcps and patients to try telemedicine at an unprecedented level 13 . how we embed the learnings from our experiences during the pandemic in the future delivery of care remains to be seen. however, there is little doubt that the way care is provided by hcps and sought by patients in the future will be transformed. telehealth will be a critical pillar enabling the cost-effective and safe provision of value-based care. telemedicine is a good option for patients and hcp's for situations where the medical care infrastructure remains intact and hcps are available to interact with patients to deliver care remotely 14 . the covid-19 pandemic: new global challenges for the hemophilia community the role of telehealth in the medical response to disasters global telemedicine implementation and integration within health systems to fight the covid-19 pandemic: a call to action telemedicine 2020 and the next decade barriers and facilitators that influence telemedicine-based, real-time, online consultation at patients' homes: systematic literature review nhf-mcmaster guideline on care models for haemophilia management expanding telemedicine to medical homes for comprehensive care delivery use of telehealth in the delivery of comprehensive care for patients with haemophilia and other inherited bleeding disorders telemedicine and european law civil rights, hipaa, and the coronavirus disease 2019 (covid-19) in: rights. ofc understanding patient experiences and challenges to osteoporosis care delivered virtually by telemedicine: a mixed methods study virtual visits--confronting the challenges of telemedicine telehealth visits are booming as doctors and patients embrace distancing amid the coronavirus crisis virtually perfect? telemedicine for covid-19 md national hemophilia foundation jd institute for policy advancement ltd this article is protected by copyright. all rights reserved key: cord-306293-miyc5kok authors: sherman, courtney b; said, adnan; kriss, michael; potluri, vishnu; levitsky, josh; reese, peter p.; shea, judy a.; serper, marina title: in‐person outreach and telemedicine in liver and intestinal transplant: a survey of national practices, impact of covid‐19 and areas of opportunity date: 2020-08-09 journal: liver transpl doi: 10.1002/lt.25868 sha: doc_id: 306293 cord_uid: miyc5kok little is known about national practices and use of in‐person outreach clinics and telemedicine in transplantation. we initially aimed to assess contemporary use of in‐person outreach and telemedicine in liver and intestinal transplantation in the u.s. we conducted a national survey of liver and intestinal transplant programs to assess use of outreach and telemedicine from january to march of 2019. given the coronavirus disease 2019 (covid‐19) pandemic, we distributed a second survey wave in april 2020 to assess changes in telemedicine use. of the 143 programs surveyed, the initial response rate was 51% (n=73) representing all 11 organ procurement and transplantation network (optn) regions and 29 states. pre‐covid‐19, a total of 42 (59%) surveyed programs had in‐person outreach clinics only while 12 (16%) programs in only 6 states used telemedicine. centers with higher median meld at transplant were more likely to utilize telemedicine (p=0.02). during the covid‐19 pandemic, among 55 of the 73 original responding programs (75%) from all 11 optn regions, telemedicine use increased from 16% to 98% and was used throughout all phases of transplant care. telemedicine utilization was very low prior to covid‐19 and has increased rapidly across all phases of transplant care presenting an opportunity to advocate for sustained future use. the initial response rate was 51% (n=73) representing all 11 organ procurement and transplantation network (optn) regions and 29 states. pre-covid-19, a total of 42 (59%) surveyed programs had in-person outreach clinics only while 12 (16%) programs in only 6 states used telemedicine. centers with higher median meld at transplant were more likely to utilize telemedicine (p=0.02). during the covid-19 pandemic, among 55 of the 73 original responding programs (75%) from all 11 optn regions, telemedicine use increased from 16% to 98% and was used throughout all phases of transplant care. telemedicine utilization was very low prior to covid-19 and has increased rapidly across all phases of transplant care presenting an opportunity to advocate for sustained future use. due to the coronavirus disease 2019 (covid-19) pandemic, access to care for transplantation has been compromised due to conservation of healthcare resources and concerns regarding spread of infection for immunocompromised patients.(1) telemedicine may improve access and quality of care, but previously was underutilized. (2, 3) herein we report data from a national survey conducted in 2019 to assess the now historical use of in-person outreach clinics and telemedicine in liver and this article is protected by copyright. all rights reserved intestinal transplantation. given the covid-19 pandemic, we conducted an abbreviated second wave of the survey to investigate differences in telemedicine use in the covid-19 era. we conducted a national survey of all liver and intestinal adult and pediatric transplant programs active in 2018 in unos to assess practice patterns of in-person outreach clinics and telemedicine from january to march 2019. surveys were administered using qualtricsxm (qualtrics, provo, ut), (supplement 1). we assessed the use of outreach clinics as well as live video and asynchronous telemedicine (e.g. electronic consultation by review of medical records or imaging studies), including the frequency of telemedicine, duration of use, phase of transplant care in which it was used, providing care across state lines, and reimbursement. we obtained a single response per center from a transplant provider aware of outreach and telemedicine practices at that center. the study received exempt status from the institutional review board at the university of pennsylvania. only centers that responded (n=73) to the initial survey were invited to complete the covid-19 follow-up survey. we assessed interval implementation and utilization of telemedicine since march 2020. given high clinical demands during the covid-19 pandemic, our follow-up survey asked targeted questions limited to: 1) use of synchronous telemedicine modality (live video, telephone, both), 2) type of provider using telemedicine, 3) phase of transplant care for which telemedicine was used. descriptive statistics including proportions as well as mean, standard deviation, median, interquartile range were calculated for categorical and continuous variables as appropriate. bivariate comparisons were conducted with wilcoxon rank sum tests and kruskal wallis for continuous as well as chi-squared or fisher's exact tests for categorical variables where appropriate. among the 61 centers that did not have telemedicine, 34 (56%) planned to use telemedicine "in the near future". among the 19 programs that did not have outreach, 13 (68%) planned to use in-person outreach clinics in the future and 7 (37%) planned for future telemedicine. detailed information on telemedicine use characteristics of the 12 centers with telemedicine pre-covid-19 is presented in supplemental table 2 . most centers started using telemedicine in the recent past; 9 (75%) in the past 1-3 years and 3 (25%) within one year of when the survey was conducted. telemedicine use was only noted in 6 states and in unos regions 2, 4, 5, 7 and 11 with accepted article most of these programs (42%) located in region 2 (supplemental figure 1) . pre-covid-19, telemedicine was reported to be reimbursed by payers in 7 (58%) centers and was delivered across state lines by 8 centers (67%). in the second wave of our survey (conducted the week of april 13 th , 2020), 55 of the 73 original programs (75%) responded after 3 attempts to reach transplant center staff. these programs represented all unos regions and 35 dsas. among these, 54 of 55 (98%) now used telemedicine (table 1, figure 1 ). transplant center, provider and care characteristics during the covid-19 pandemic are shown in table 1 . characteristics of transplant centers currently using telemedicine were similar to those that reported in-person outreach and/or telemedicine use during the first survey. with nearly universal telemedicine utilization among responding programs, telemedicine was used by 35 (65%) programs to conduct transplant evaluations, 32 (58%) for waitlist management, and 53 (98%) for post-transplant care. most centers (82%) used a combination of live video and/or telephone (supplemental table 2 ). in a 2019 national survey of liver and intestinal transplant programs, we identified a high uptake of inperson outreach clinics (71% of programs), whereas telemedicine utilization was low at 16%. during this period, we observed that telemedicine and in-person outreach were more often used in programs with higher mmat, however, use was not related to center volume or population density. patients living in less populated areas would arguably derive the most benefit from telemedicine but did have not enough access, highlighting issues of inefficiency and inequity. importantly, an updated survey conducted in the covid-19 era showed unprecedented shifts in care delivery with a nearuniversal uptake of synchronous telemedicine use given the temporary relief in regulatory and reimbursement barriers in this public health emergency.(3) during this second survey wave, our questions were targeted to characterize telemedicine utilization in response to the covid-19 pandemic; therefore, direct comparisons of pre-covid-19 and covid-19 era patterns are not feasible. we did not assess the rationale for in-person outreach and/or telemedicine. motivations for use of remote care strategies may include expanding access to transplant care, reducing patient accepted article travel and cost, attracting candidates to a transplant center and providing care via telemedicine when in-person visits are limited due to exposure risks during the covid-19 pandemic. we did not evaluate clinical outcomes, financial implications, or patient and provider satisfaction with these care delivery strategies. telemedicine has an emerging evidence base in transplantation, but most examples from the literature derive from integrated care systems such as the veteran affairs (va) due to regulatory and reimbursement barriers. for example, specialty care access network-extension for community healthcare outcomes (scan-echo) has demonstrated increased efficiency and access to specialty hepatology care, improved survival for patients with liver disease and reduced time from referral to initial liver transplant evaluation by a hepatologist and placement on the waitlist. the main barriers to widespread telemedicine adoption have not been related to technology, which is low-cost and easy to implement, but rather to arcane interstate licensing barriers and highly variable reimbursement (4). in our initial 2019 survey, only 7 programs using telemedicine (58.3%) were reimbursed with 2 of these being va programs. since the covid-19 pandemic, key legislative changes have occurred to make telemedicine a shortleveraging telemedicine technology serves two critically important functions: 1) allowing for continued patient care remotely during outbreaks while protecting patients, providers, and the community from exposure, and 2) expanding access and efficiency across the continuum of transplant care that can last well beyond the pandemic. however, barriers to implementation persist, including lack of digital literacy, potential disparities in technology access and use by patient age, race/ethnicity, and socioeconomic status.(5) moreover, telemedicine for new patients, symptomatic accepted article presentations, and serious illness conversations is not always appropriate. widespread judicious and optimal use of telemedicine has yet to be established. nonetheless, the future of telemedicine for transplantation is promising as long as it is viable from a financial and regulatory perspective. we urge transplant centers to advocate for policy changes at the local, state and federal levels in order to allow continued use of this essential healthcare delivery modality. this article is protected by copyright. all rights reserved organ procurement and transplantation during the covid-19 pandemic telehealth-based evaluation identifies patients who are not candidates for liver transplantation current and future applications of telemedicine to optimize the delivery of care in chronic liver disease telemedicine in liver disease and beyond: can the covid-19 crisis lead to action? addressing equity in telemedicine for chronic disease key: cord-310976-24b3c3a4 authors: parikh, neil r.; chang, eric m.; kishan, amar u.; kaprealian, tania b.; steinberg, michael l.; raldow, ann c. title: time-driven activity-based costing analysis of telemedicine services in radiation oncology date: 2020-10-01 journal: int j radiat oncol biol phys doi: 10.1016/j.ijrobp.2020.06.053 sha: doc_id: 310976 cord_uid: 24b3c3a4 purpose: health systems have increased telemedicine use during the sars-cov-2 outbreak to limit in-person contact. we used time-driven activity-based costing to evaluate the change in resource use associated with transitioning to telemedicine in a radiation oncology department. methods and materials: using a patient undergoing 28-fraction treatment as an example, process maps for traditional in-person and telemedicine-based workflows consisting of discrete steps were created. physicians/physicists/dosimetrists and nurses were assumed to work remotely 3 days and 1 day per week, respectively. mapping was informed by interviews and surveys of personnel, with cost estimates obtained from the department’s financial officer. results: transitioning to telemedicine reduced provider costs by $586 compared with traditional workflow: $47 at consultation, $280 during treatment planning, $237 during on-treatment visits, and $22 during the follow-up visit. overall, cost savings were $347 for space/equipment and $239 for personnel. from an employee perspective, the total amount saved each year by not commuting was $36,718 for physicians (7243 minutes), $19,380 for physicists (7243 minutes), $17,286 for dosimetrists (7210 minutes), and $5599 for nurses (2249 minutes). patients saved $170 per treatment course. conclusions: a modified workflow incorporating telemedicine visits and work-from-home capability conferred savings to a department as well as significant time and costs to health care workers and patients alike. since its initial detection, severe acute respiratory syndrome coronavirus 2 (sars-cov-2) has spread rapidly worldwide. 1 given the imperative to limit in-person contact, health systems have increased the use of telemedicine to reduce viral transmission, 2 supported in part by sweeping changes in regulation and reimbursement policies. 3, 4 however, as the pandemic evolves, it remains unclear what changes to clinic processes should be sustained, especially in regard to telemedicine efforts. time-driven activity-based costing (tdabc) is a tool for cost accounting, in which the continuum of care is mapped, with time spent and resource use (ie, personnel, space, equipment, and materials) associated with each step precisely quantified. 5 in this study, using a patient undergoing a 28-fraction treatment course as an example, we used tdabc to evaluate the overall change in resource use associated with transitioning to telemedicine in a radiation oncology department. tdabc was conducted from the departmental perspective with additional benefits to patients and employees calculated separately. in response to the sars-cov-2 outbreak, faculty and staff in a radiation oncology department at a large academic institution were encouraged to work from home, with physicians, physicists, and dosimetrists working remotely 3 days per week and nurses working remotely 1 day per week. the majority of new patient consultations, follow-up visits, and on-treatment visits (otvs) were converted from in-person visits to telemedicine encounters. to inform tdabc analysis, process maps were created for traditional in-person and telemedicine-based workflow processes to delineate differential care pathways and resource use (fig. 1 ). maps consisting of discrete steps were created for each phase of the care cycle, with mapping informed by interviews and surveys of personnel. equipment costs, space capacity, materials costs, and personnel costs were obtained from the department's financial officer. the capacity cost rate of each resource was determined by dividing the total annual cost for each personnel or piece of equipment by the practical capacity of the resource. personnel costs included salary, bonus, and fringe benefits but did not incorporate an employee's commute; therefore, in the telemedicine model, employee time saved by not commuting to work was assumed to solely benefit the employee. for processes completed remotely, the space was defined as a personal office with no associated space costs to the department; however, the equipment costs associated with purchase and installation of remote workstations were included in the employee's personal office. given a fixed-fee contract already set in place with the videoconferencing vendor, additional use of telemedicine services through this platform were not included in the analysis. costs of personal protective equipment and sars-cov-2 testing, specific to a global pandemic, were additionally excluded from this analysis, which focused on generally comparing resources used between traditional versus telehealth workflows. several steps in the traditional workflow were no longer necessary in a telemedicine workflow. during consultation and follow-up, telemedicine workflow no longer required a front office staff member to physically check in a patient (10 and 3 minutes during consultation and follow-up, respectively) or a nurse to print an after-visit summary (2 minutes). during each otv, telemedicine workflow no longer required a medical assistant to obtain vitals/weight (4 minutes) or a nurse on the last visit to print an after-visit summary (2 minutes). telemedicine workflow facilitated several steps to be performed remotely. for consultation and follow-up visits, patient interactions with nurses and physicians took place via telemedicine. otv encounters consisted of a telemedicine visit with the physician alone unless the patient was symptomatic or seen at physician request (w20%), in which both nurse and physician saw the patient in person. during treatment planning, except for the patient's plan being physically delivered to the phantom, all steps were converted to a remote workflow. in a survey of 10 nurses, average time spent in traditional in-person encounters during consultation, otv, and follow-up was 25.2, 16.2, and 13.9 minutes, respectively. in the telemedicine setting, average time spent during consultation and follow-up was 25.9 and 10.7 minutes, respectively. for each patient undergoing 28-fraction treatment, 6 otvs, and 1 follow-up visit, transitioning to telemedicine workflow reduced provider costs by $586 compared with the traditional workflow (table 1 )d comprising space/equipment ($347) and personnel ($239). the effect of modifying key model inputs, such as number of otvs and cost of nursing time, on savings from telehealth workflow is shown in figure 2 . from an employee perspective, assuming a 1-way commute of 27.1 minutes 6 to travel approximately 15 miles, the ability to work remotely for physicians/physicists/dosimetrists (3 days per week) and nurses (1 day per week) saves 7243, 7243, 7210, and 2249 minutes per year for each physician, physicist, dosimetrist, and nurse, respectively. considering each personnel type's capacity cost rate and a standard mileage allowance for vehicle wear/tear ($0.575/mile), 7 the annual amount saved was $36,718 per physician, $19,380 per physicist, $17,286 per dosimetrist, and $5599 per nurse (fig. 3) . from a patient's perspectivedincluding 2 fewer roundtrips to the department (given telemedicine consultation visit and follow-up visits)d232 minutes are saved throughout the entire course of treatment. accounting for because simulation and treatment require in-person interaction, most opportunities within radiation oncology to adapt to sars-cov-2 involve transitioning patient visits to telemedicine encounters and enabling work-fromhome solutions for employees. additional processes that have facilitated this change include increased use of patient portals to communicate with patients pre-encounter, training front office staff to educate patients on how to set up telemedicine on their devices, and replacing a paperbased survey on patient symptoms with electronic surveys. beyond the notable economic benefits generated from modified workflow, telemedicine touts benefits not explicitly included in this analysis. for employees, time saved may be reinvested in research or used for improved wellbeing. diminished waiting times associated with telemedicine visits are likely to improve provider and patient satisfaction alike. 9 allowing personnel to work remotely is expected to reduce the risk of infection for health care workers. 2 additionally, this revised telemedicine workflow allows for a more flexible work environment, especially relevant to those caring for others at home. potential downsides of transitioning clinic visits to telemedicine encounters include being able to perform inperson clinical assessments less frequently and have less familiar physicians assessing patients in acute settings. this, however, may be mitigated by carefully deciding which patients during treatment are symptomatic enough to warrant face-to-face evaluation. due to a telemedicine encounter's dependence on internet connection, there are technical and privacy risks that must be addressed. lastly, efforts to ensure equity for vulnerable populations are required to ensure widespread implementation of telemedicine does not worsen health disparities. 10 this study has several limitations that warrant consideration. first, this study is based on processes/estimates of a single institution; consideration must be given to each institution's specific personnel, processes, and cost structure when incorporating this analysis. second, given limited long-term outcome data surrounding telemedicine use in radiation oncology, this study solely assesses resource use and not the effectiveness of such an approach. compared with a traditional workflow involving in-person visits, a modified workflow incorporating telemedicine visits and work-from-home capability confers provider savings of $586/patient, with number of otvs and cost of nursing time as the most important model inputs in the specific amount saved. additionally, this approach confers world health organization. coronavirus disease (covid-19) pandemic virtually perfect? telemedicine for covid-19 trump administration issues second round of sweeping changes to support u.s. healthcare system during covid-19 pandemic additional background: sweeping regulatory changes to help u.s. healthcare system address covid-19 patient surge time-driven activity-based costing average travel time to work in the united states by metro area irs issues standard mileage rates for 2020 average hourly and weekly earnings of all employees on private nonfarm payrolls by industry sector, seasonally adjusted patients' satisfaction with and preference for telehealth visits addressing equity in telemedicine for chronic disease management during the covid-19 pandemic key: cord-300620-scauefiv authors: gillespie, suzanne m.; handler, steven m.; bardakh, alex title: innovation through regulation: covid-19 and the evolving utility of telemedicine date: 2020-07-28 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.06.054 sha: doc_id: 300620 cord_uid: scauefiv nan a year ago, a group of amda leaders spent the day on capitol hill advocating for policy changes related to post-acute and long-term care (paltc) telemedicine. a main point of discussion was the need to revise the regulations governing payment for telemedicine visits in a way that would make it more feasible for paltc clinicians working with facilities to use telemedicine tools to care for residents. medicare payment for telemedicine physician visits has largely been to support rural nursing homes and limited to no more frequently than monthly regardless of medical necessity. these restrictions have made it very difficult for paltc clinicians to make the business case to include telemedicine into most clinicians' practice. telemedicine to date had largely been supported directly by nursing homes that arrange for afterhours and weekend coverage to manage changes of condition with the primary goals of reducing potentially avoidable emergency department visits and hospitalizations. telemedicine had also been frequently used for certain subspecialties including behavioral health, wound care diagnosis and management. one year later, as a result of rapid policy changes in response to the covid-19 pandemic, much has changed. rational changes in regulations guiding telemedicine in nursing homes and the need for thoughtful infection prevention have inspired a new opportunity for innovation and vision for how high-quality care can be accessed in nursing homes. many factors combine to make nursing homes an ideal venue for telemedicine. the population of patients in nursing homes has steadily increased in complexity, creating the need for timely and skilled acute and chronic care from clinicians with competency in paltc. in contrast to medical providers working in hospitals, emergency departments, and primary care practices, paltc clinicians may only be onsite in the nursing facility intermittently and rarely during nights and weekends. this translates into challenges around change of condition assessment and can contribute to misdiagnoses, delays in diagnosis, and overuse of emergency departments. paltc clinicians and medical directors have believed for many years that their patients would benefit from telemedicine tools to increase access. 1,2 a growing abundance of feasibility studies exploring the application of telemedicine in nursing homes has also supported the concept. in early 2019, amda's workgroup on telemedicine and technology published a white paper offering guidance to clinicians and facilities on the use of telemedicine to deliver medically necessary evaluation and management of change of condition for nursing home residents. 3 the paper reviewed the many research studies and published case reports that demonstrate the ability of telemedicine interventions to reduce avoidable emergency department visits and hospitalizations. in this issue of jamda, the gericare@north example also demonstrates the feasibility of deploying acute geriatric medicine consultation via telemedicine for a variety of routine and symptom-based concerns to nursing home residents in singapore. 4 the covid-19 pandemic has highlighted the need to provide timely access to high-quality medical care, especially to nursing home residents with new or worsening respiratory symptoms. the benefits of telemedicine allow for actual or suspected covid-19epositive residents to be treated in place when their care plan goals support this (ie, goal-concordant care). this concept, called forward triage, can allow for resident assessment in the nursing home using telemedicine to optimize survival and resources, while reducing the risk of community spread and limiting exposure of other health care personnel to covid-19. 5 in their march 2020 response to covid-19, the us center for medicare & medicaid services (cms) has essentially removed the biggest financial barriers to paltc clinicians providing telemedicine services in the nursing facility. in a sweeping interim final rule issued at the end of march, cms removed the once-a-month limitation for essentially, the agency suspended all face-to-face regulatory visit requirements and allowed them to be completed using telehealth tools. further, the agency announced that these visits will be paid at the same rate as a face-toface visit even if completed via telehealth. 6, 7 other codes that are now reimbursable are listed in table 1 . importantly, also removed was the limitation of telemedicine reimbursement for only rural nursing homes. regulations previously restricted reimbursement to rural nursing homes as originating sites (the location of the patient at the time the service is furnished via a telemedicine). under the public health emergency waiver, clinicians originating care for residents located in either rural or urban nursing homes can bill for eligible encounters delivered via telemedicine tools. paltc practitioners at the distant site who may furnish and receive payment for covered telemedicine services, also referred to as distal site practitioners, complete their billing documents with appropriate e&m codes, place of service where the service took place, and modifier 95 indicating a telemedicine visit. supplemental funding through the federal communications commission was also made available to health care centers seeking to expand their capacity to provide virtual care, further reducing barriers to telemedicine-based care. 8 governmental discretion to not enforce penalties for health insurance portability and accountability act (hipaa) violations on health care providers using telemedicine tools in good faith to deliver care during the covid-19 pandemic has allowed more health care providers to try using telemedicine tools without the burden of complex technology and program initiation costs. however, privacy concerns will likely resurface as we deal with the aftermath of the pandemic. in separate rulemaking just prior to the covid pandemic, the office of the national coordinator (onc) released a long-awaited interoperability final rule dealing with a plethora of issues including cybersecurity. there will be an ongoing need for the onc to address concerns about privacy and security as telehealth use expands. 9 for now, public health emergency waivers have enabled every paltc medical provider and facility to try adding telemedicine to their care delivery toolkit. telemedicine programs are reporting significant growth. health care's relationship with telemedicine has the opportunity to be forever changed as a result of the covid-19 global pandemic. during the pandemic, health systems across the united states have exponentially expanded care via telemedicine to nursing home residents. for example, at the university of rochester, between march and may 2020, telemedicine visits between the medical providers of our regulatory reform allow medicare payments to post-acute and long-term care clinicians for all skilled/nursing facility cpt e&m codes using telehealth allow medical necessity to dictate telemedicine visit frequency for subsequent care visits allow nursing homes to receive facility fees for all telemedicine encounters regardless of physical location expand billable telemedicine services for nursing home residents to include e-consultation and additional remote patient monitoring ensure payment parity between face-to-face and telemedicine care in medicare and third-party payors evaluate the impact of telemedicine on nursing home structure, process, and outcomes develop and assess the impact of paltc workforce competencies for both originating and distal site providers who use telemedicine tools on clinical outcomes refine and assess the use of telemedicine for forward triage on clinical outcomes evaluate how regulatory visits delivered by telemedicine vs face-to-face impact the quality of clinical care and provider or resident satisfaction technology collaborate with telemedicine service providers to develop cost-effective, low-bandwidth, accessible, and easy-to-use telemedicine technology work with cellular service and internet service providers to deliver high-speed, low-cost internet access, to support telemedicine and communication technologies in nursing homes collaborate with electronic medical record vendors to improve access to and documentation within various information systems during telemedicine visits increase the number of easy-to-use, low-cost health insurance portability and accountability act (hipaa) securityecompliant telemedicine tools available to post-acute and long-term care providers. cpt, current procedural terminology; e&m, evaluation and management. editorial / jamda 21 (2020) 1007e1009 geriatrics group that cares for residents of several nursing homes went from being a rare occurrence to the group completing approximately 250 telemedicine visits a week, representing about a third of the practice's nursing home encounters. the veterans health administration, a longstanding leader in adoption of telemedicine in health care, moved to create telemedicine access for nursing home residents in all of their community living centers. as we ride the momentum of change, it is important for us to continue to expand our understanding of how telemedicine tools are best used in care. the interconnected relationship between patient population, the reason for the medical visit, and the modality of telemedicine used needs to be further refined for us to deliver the highest-value care. many have hypothesized that telemedicine should not replace the face-to-face regulatory care visits and medically necessary visits that form the foundation of primary care in the nursing home. our experiences in covid-19 may change our perspective on that question. can we embrace the disruption of the pandemic and use it to drive other programmatic innovations in post-acute long-term care? as we move beyond the initial covid-19 storm to a new, improved way of providing care in nursing homes, strategic action is needed to more permanently resolve the issues that may limit our progress ( table 2 ). the integrated health network of eastern ontario has demonstrated the feasibility of using e-consultation for specialty care such as dermatology and infectious disease and identified perceived value with respect to timeliness, quality of care, and cost. 10 similarly, investigators in the amda telemedicine workgroup conducted a study of the perceived value of subspecialty telemedicine that showed that dermatology, geriatric psychiatry, and infectious disease were the specialties that paltc practitioners would consult the most if available. 11 similarly, many have called for reimbursement models to further expand reimbursement for telemonitoring and other telephonic-based care modalities. now is the time to quantify the cost, quality, and value of these types of clinical services. when we look back, years from now, what will paltc practitioners have learned about effective care delivery using telemedicine technology? hopefully, we will see 2020 as the turning point in our understanding of how to build effective, financially stable medical care models, that leverage telemedicine technology effectively to deliver the right care, at the right time, in the right place, to the right patient. perceived benefits, barriers, and drivers of telemedicine from the perspective of skilled nursing facility administrative staff stakeholders nursing home provider perceptions of telemedicine for reducing potentially avoidable hospitalizations standards for the use of telemedicine for evaluation and management of resident change of condition in the nursing home the nuts and bolts of utilizing telemedicine in nursing homesdthe gericare@north experience virtually perfect? telemedicine for covid-19 physicians and other clinicians: cms flexibilities to fight covid-19 long-term care nursing homes telehealth and telemedicine tool kit united states health and human services department. 21st century cures act: interoperability, information blocking and the onc health it certification program federal communications commission. covid-19 telehealth program the feasibility of using econsult in long-term care homes nursing home provider perceptions of telemedicine for providing specialty consults key: cord-334719-zl5mhuth authors: ohannessian, r. title: telemedicine: potential applications in epidemic situations date: 2015-09-30 journal: european research in telemedicine / la recherche européenne en télémédecine doi: 10.1016/j.eurtel.2015.08.002 sha: doc_id: 334719 cord_uid: zl5mhuth summary background telemedicine has several applications regarding different medical specialties or clinical situations. however, telemedicine as a potential tool during epidemics is not as well considered. methods in this paper, the application of telemedicine is conceptualised using five possible evidence-based epidemic situations. results the first situation corresponds to asymptomatic individuals, mainly home-based, living in an epidemic-affected location. the application of telemedicine would be through the use of teleconsultation for emergency medical dispatching and would occur when suspicious symptoms are detected by an individual. the second situation for the application of telemedicine is principally home-based and corresponds to the follow-up telemonitoring of asymptomatic individuals identified as case contacts. concrete applications of these concepts were used during the ebola virus disease outbreak in africa since 2014. the third situation links to symptomatic cases in need of isolation. examples include patients isolated in taiwan during sars epidemic in 2003 and h1n1 pandemic influenza in 2009, as well as h7n9 influenza infected patients in 2013 in china. the fourth situation involves tele-expertise when local medical resources do not have the technical expertise for the diagnosis or treatment of a patient and support is required from reference centres. the fifth situation corresponds to a healthcare facility under quarantine that would use telemedicine to keep taking care of patients that cannot access the facility, as it was the case in june 2015 in seoul during the middle east respiratory syndrome coronavirus epidemic. conclusion the use of telemedicine in epidemic situations has a high potential in improving epidemiological investigations, disease control, and clinical case management. however, since it is a recent application, further research would be needed to gain an improved understanding of how telemedicine could be applied in epidemic situations. it is a recent application, further research would be needed to gain an improved understanding of how telemedicine could be applied in epidemic situations. © 2015 elsevier masson sas. all rights reserved. télémédecine: épidémie ; cas groupé ; contrôle ; maladie à virus ebola ; santé globale contexte. -la télémédecine a de nombreuses applications selon les spécialités médicales et les situations cliniques. cependant, la télémédecine comme potentiel outil en situations épidémiques a été peu considérée jusqu'à présent. méthodes. -dans cet article, l'utilisation de la télémédecine en cas d'épidémies a été conceptualisée en fonction de cinq situations épidémiques différentes fondées sur les faits. résultats. -la première situation correspond au cas où la téléconsultation est utilisée avec une personne asymptomatique vivant à domicile dans une logique de régulation médicale d'urgence. la deuxième situation épidémique concerne l'utilisation de la télésurveillance pour le suivi régulier des personnes identifiées comme contacts de cas. de nombreuses applications mettant en pratique ces concepts ont été utilisées lors de l'épidémie de maladie à virus ebola en afrique depuis 2014. la troisième situation est en lien avec la nécessité d'isolation de patients malades et la réalisation de téléconsultations. ce fut utilisé notamment à taiwan en 2003 lors de l'épidémie de sras et en 2009 lors de la pandémie grippale à virus influenza h1n1, ainsi qu'en chine en 2013 pour des patients infectés par le virus influenza h7n9. la quatrième utilisation est la télé-expertise au cas où les ressources médicales locales ont besoin d'un support extérieur et d'une aide technique pour le diagnostic ou la prise en charge d'un patient. la cinquième situation correspond au cas où un établissement de santé serait en quarantaine et pourrait utiliser la télémédecine pour continuer à prendre en charge les patients ne pouvant accéder à l'établissement, comme ce fût le cas en juin 2015 à séoul pendant l'épidémie de coronavirus du syndrome respiratoire du moyen-orient. conclusion. -l'utilisation de la télémédecine lors de situations épidémiques a un intérêt pour améliorer les investigations épidémiologiques, le contrôle de la maladie, et la gestion médicale des cas. cependant, cette application de la télémédecine étant récente, des recherches supplémentaires seraient nécessaires afin d'obtenir une meilleure compréhension de la façon dont la télémédecine pourrait être utilisée en cas d'épidémie. © 2015 elsevier masson sas. tous droits réservés. telemedicine is often regarded as a way to improve the management of chronic diseases [1, 2] and assist emergency medicine [3, 4] . however, using telemedicine as a potential tool during epidemics is not as well considered. the objective of this paper is to conceptualize the use of telemedicine during epidemics using five possible evidence-based situations and associated concrete examples. the first situation corresponds to asymptomatic individuals, mainly home-based, living in an epidemic-affected location. the application of telemedicine would be through the use of teleconsultation with a remote medical service. the primary role of the application would be emergency medical dispatching and would occur when suspicious symptoms are detected by an individual. teleconsultation would be conducted using text, audio and/or video and would allow a personal risk assessment to determine whether the patient has a matched case definition or not. when symptoms match with the case definition, a secured transport would be issued and sent to the patient's location in order to safely transfer the patient to a referral treatment centre. when symptoms do not match with the case definition, the patient may be advised to seek a primary care physician. in 2014, during the ebola virus disease (evd) outbreak, the ministry of health in guinea set a national ebola hotline to respond to public health concerns and facilitate the referral of suspected cases to the isolation ward at donka hospital in conakry [5, 6] . similar hotlines were set up in liberia [7] and sierra leone as well [8] . furthermore, teleconsultation has been used in west africa through a free telemedicine mobile application allowing people to send free text messages to seek medical advice [9, 10] . doctors for this initiative were based in indonesia and nigeria and once symptoms were matched with case definitions, patients were advised to seek medical treatment. from october 2014 to may 2015 included, 6063 live chats concerning ebola occurred, with 20 suspicious cases detected. the second epidemic situation for the application of telemedicine is principally home-based and corresponds to the follow-up monitoring of asymptomatic individuals identified as case contacts. telemonitoring is managed through an auto-administered or hetero-administered online/mobile based questionnaire system. collected medical data are then sent to a contact tracing centre. this system could potentially be coupled with the contact geo-localisation to facilitate the monitoring process. in current practice, the contact's medical status is regularly monitored by an epidemiologist throughout the defined follow-up duration. with the use of telemonitoring, current practice may be improved. the advantages of telemonitoring would be increased time and human ressources as well as improving real-time data management and targeted intervention. in guinea, telemonitoring has been used since 2014 through the open source mobile platform application for contact tracing deployed by the united nations population fund (unfpa) [11, 12] . other examples of telemonitoring use during the evd epidemic include the smartphone mobile application tested in sierra leone in partnership with innovations for poverty action (ipa), the international medical corps, and the london school of hygiene and tropical medicine, and supported by the united nations mission for ebola emergency response (unmeer) [13] , as well as an integrated platform based on open data kit and form hub technology in nigeria [14] . furthermore, in western australia, in 2014, the concept of telemonitoring directed the development of an sms-based mobile application named ''ebolatracks'' for monitoring individuals returning from ebola-affected countries in africa. those potentially exposed to the virus were monitored via text message twice a day to identify the health status of patients, including their temperature. during the follow-up, 1108 messages were sent to 22 participants to solicit symptom information with a 91% return rate [15] . the third epidemic situation links to symptomatic cases in need of isolation, whether in a healthcare or home environment. the use of teleconsultation may reduce the exposure time between a healthcare worker and an infectious patient while still allowing a rigorous medical check-up process. when face-to-face consultations are required, the use of teleconsultation would not disturb clinical examinations and/or medical intervention. in an epidemic situation, the use of teleconsultation could thus provide a reduction in healthcare-associated infections and improve disease control. teleconsultations were used in taiwan in 2003 during the severe acute respiratory syndrome (sars) epidemic [16] concerning a hospital quarantined sars-affected patient [17, 18] , and in 2009 during the h1n1 influenza pandemic for home-quarantined patients [19] . teleconsultation was also used in china in 2013 with a h7n9 influenza infected patient hospitalised in beijing ditan hospital [20, 21] , and in the usa in 2014 at the biocontainment patient care unit in the nebraska medical center for an ebola-infected patient returning from west africa and confined to the isolation ward [22] . the fourth situation for the application of telemedicine in epidemic outbreaks involves tele-expertise. tele-expertise has potential when local medical resources do not have the technical expertise for the diagnosis or treatment of a patient and when support is required from reference centres. tele-expertise is primarily useful in healthcare settings of primary and secondary care levels. the four situations are modelled in fig. 1 . the fifth situation corresponds to a healthcare facility under partial or complete quarantine that would use telemedicine to keep taking care of patients that cannot access the facility. in june 2015, the samsung medical center in seoul (south korea) was allowed to use teleprescriptions while being under quarantine [23, 24] due to the middle-east respiratory syndrome (mers) coronavirus epidemic [25, 26] . telemonitoring and teleconsultations could also have been used for patients that were not allowed to be admitted into the hospital. the use of telemedicine in epidemic situations has a high potential in improving epidemiological investigations, disease control, and clinical case management, while allowing the global health community to support local caregivers. further research would be needed to gain an improved understanding of how telemedicine could be applied further in epidemic situations. the empirical foundations of telemedicine interventions for chronic disease management using telemedicine to improve chronic disease monitoring systematic review of telemedicine applications in emergency rooms telemedicine in the intensive care unit: its role in emergencies and disaster management statement on the 1st meeting of the ihr emergency committee on the 2014 ebola outbreak in west africa busting the myths about ebola is crucial to stop the transmission of the disease in guinea community perspectives about ebola in bong, lofa and montserrado counties of liberia: results of a qualitative study. final report sierra leone: western area surge combats ebola pro-actively accessed online innovation et de l'économie numérique. des applications mobiles au service de la lutte contre le virus ebola. proxima mobile international telecommunication union. guinea ebola contact tracing application mobile app promises to speed ebola response in guinea reducing ebola virus transmission: improving contact tracing in sierra leone innovative technological approach to ebola virus disease outbreak response in nigeria using the open data kit and form hub technology ebolatracks:. an automated sms system for monitoring persons potentially exposed to ebola virus disease fact sheet: basic information about sars telemedicine application in sars case consultation the telemedicine and teleconsultation system application in clinical medicine quarantine and transportation of patients using a telemedicine system for patients with a/h1n1 infection human infection with influenza a(h7n9) virus in china-update importance of telemedicine in communicable disease preparing for ebola: what u.s. hospitals can learn from emory healthcare and nebraska medical center mers infections in s. korea rise to 145, samsung hospital closed world health organization. who statement on the ninth meeting of the ihr emergency committee regarding mers-cov telemedicine becoming hot issue in mersstricken korea npad accuses government of favoritism to samsung hospital the author thanks ms. sarina yaghobian. the author declares that he has no conflicts of interest concerning this article. key: cord-333003-t1lo5jpv authors: said, mena; ngo, victoria; hwang, joshua; hom, david b. title: navigating telemedicine for facial trauma during the covid‐19 pandemic date: 2020-07-09 journal: laryngoscope investig otolaryngol doi: 10.1002/lio2.428 sha: doc_id: 333003 cord_uid: t1lo5jpv importance: the covid‐19 pandemic is changing how health care providers practice. as some telemedicine and telecommunication support tools have been incorporated into the otolaryngology practice in response to safety and access demands, it is essential to review how these tools and services can help facilitate facial trauma evaluation during a time when clinical resources are limited. objective: to review applications of telemedicine for the evaluation of facial trauma to better direct utilization of these methods and technologies during times of limited access to clinical resources such as the covid‐19 pandemic. methods: a systematic review was conducted using pubmed, embase, and web of science. results: after screening 158 titles and abstracts, we identified 16 eligible studies involving facial trauma evaluation using telemedicine. telemedicine opportunities for facial trauma evaluation have the potential to be developed in the areas of multidisciplinary remote consultations, facial trauma triage, patient engagement, and postoperative follow‐up. conclusion: the covid‐19 pandemic is posing obstacles for both providers and patients in the delivery of health care at a time of limited clinical resources. telemedicine may provide a potential useful tool in the evaluation and triage of facial injuries and patient engagement. facial trauma remains a significant morbidity of concern as patients continue to enter the emergency room from falls, assaults, or accidents. [6] [7] [8] evaluation of acute facial injuries requires considerable provider-patient interaction as the thorough examination process guides successful treatment. risk of cross infection increases during patient evaluations and head/neck surgeries, especially when clinicians come in close contact with the anatomical nasal and oral mucosa areas where the virus can thrive. 6 opportunities for technology-based clinical evaluations are much needed. telemedicine, according to the institute of medicine (iom), is the "use of electronic information and communications technologies to provide and support health care when distance separates participants." 9 often used interchangeably with the broader medicare term, telehealth, telemedicine has the potential to improve communication in otolaryngology, save time, and aid in diagnosis. 10 other than routine telephone follow-up calls, few otolaryngologists utilized telemedicine in their practice 20 years ago. 11 as technologies developed and internet access improved over the years, however, some physicians envisioned telemedicine's practical potential for facilitating medical care, such as implementing tele-tools for consultation to the underserved, proctored surgery, treatment, education, and research. 11, 12 early adoption in telemedicine for otolaryngology began in rural areas alongside the improvement of otologic image quality. 13 today, in light of this unprecedented time during the covid-19 pandemic, telemedicine has become more relevant to give patients the supportive care they need and at the same time reduce exposure risks to other patients and clinicians. with the increased adoption of telemedicine in otolaryngology practice and growing concern for subsequent "waves" of infection, we review the literature in regard to the applications of telemedicine in the evaluation of facial trauma. a systematic review was conducted in pubmed, embase, and web of science using the search terms: "telemedicine," "telehealth," "remote monitoring," "virtual visit," "virtual consultation," "facial trauma," "facial," "facial injury," "face trauma," and "face injury." supplementary appendix a: search strings. the search was limited by dates between june 1, 1997 and april 30, 2020. this review followed the preferred reporting items for systematic reviews and meta-analyses (prisma) guidelines. 14 titles, abstracts, and selected articles were independently assessed by three authors (m.s., j.h., and v.n.). the population of interest was patients who experienced facial trauma and received a clinical evaluation. we took into consideration all modalities of telemedicine or telehealth application, in addition to any medical tool that may potentially serve as a telemedicine application. we read original peer-reviewed research studies on the population of interest. included were randomized controlled trials (rct), non-rcts, case-control studies, cohort studies, cross-sectional studies, case series, case reports, and qualitative research studies. we also added additional sources through reference review. excluded were narrative reviews, articles without full-text access, and non-english language articles. we also excluded intervention studies that did not have a telemedicine approach. disagreements and discrepancies between reviewers were discussed and resolved through consensus. a total of 257 references were identified in the database search, of which 158 were considered eligible for inclusion based on the assessment of title and abstract. upon full article review, 16 original peer reviewed research articles were selected for final inclusion ( figure 1 ). due to the heterogeneity in research methodology and populations studied, formal meta-analysis was not conducted. instead, we present a narrative synthesis of the results for the key domains of facial trauma evaluation using telemedicine. table 1 shows the distribution of included articles across different domains of telemedicine. this review found telemedicine technologies functioning as facilitators to facial trauma assessment, monitoring, treatment, and/or follow-up. the majority of articles (88%; 14/16) mentioned some form of assessment, which included using telemedicine tools to aid in diagnosis, triage, and referrals. telemedicine technologies were described to be either store-and-forward, live interactive, remote monitoring, and/or mobile health application/device (table 1 ). teleradiology was utilized in the evaluation of patients with facial trauma. [15] [16] [17] [18] [19] brucoli et al 15 out of 176 patients with "possible" surgical indications, 27 were offered surgery. of note, the indication for surgical intervention for naso-orbital-ethmoid fractures was underestimated using teleradiology. teleradiology allowed for accurate triaging of patients with orbitozygomatic maxillary complex, orbital wall, mandibular, maxillary, nasal, le fort, frontal sinus, and dentoalveolar fractures. 15 jacobs et al. 16 highlighted the value of image quality through a prospective study comparing radiographic findings, diagnosis, confidence of read, and assessment of image quality of 20 facial plain radiographs. these preselected, plain radiographs, with and without mandibular and zygomatic fractures, were presented to eight oral maxillofacial surgery (omfs) and eight emergency medicine (em) physicians to interpret. omfs physicians using plain radiographs had the highest sensitivity (100%) and specificity (84%) for diagnosis of fractures, followed by the em physicians using plain radiographs (90% sensitivity, 77% specificity, respectively), then omfs with telemedicine images (86% sensitivity, 80% specificity, respectively). rates of diagnosis were similar between omfs utilizing telemedicine and em physicians utilizing plain radiographs. telemedicine images were associated with lower image quality ratings, lower sensitivity, and lower confidence of diagnosis. although a powerful adjunctive tool for the diagnosis of facial fractures, teleradiology must be used in conjunction with clinical information and with a strong emphasis on image quality. 16 in a case report, millesi et al. 17 telementoring shown with the mitsuno et al. 18 study, was also highlighted in the chiao et al. 19 case report describing a telemedicine demonstration where a comprehensive examination of the eye with ultrasound was conducted by minimally-trained crew members in space using reference cards, and real-time guidance from a remote radiologist. this remote guidance yielded ocular images of diagnostic quality that could guide remote decision-making-suggesting possible applications in craniofacial trauma patients with a remote expert guiding a responder in image acquisition. 19 the evaluation of traumatic facial skin wounds was explored with telemedicine tools. [20] [21] [22] van dillen et al. 20 two studies explored the potential for using telemedicine tools to engage the patient in participating in their own facial trauma evaluation and follow up. 22, 28 moumoulidis et al. 28 conducted a prospective single center study (n = 25) to assess the use of mobile phone photographs in diagnosing nasal fractures. patients were asked in a questionnaire to judge their own perceived nasal shape change. they were also asked to take photographs of their nose and face with a mobile phone, to be reviewed by a clinician, to determine the presence of a fracture and indication for surgery. the same clinician then conducted an in-person clinical assessment to compare results. the camera assessment failed to identify 62% of nasal bone deviation cases determined by clinical examination. the patients' self-assessments were 100% sensitive whereas the image assessment had only a 38% sensitivity for detecting a deviated nose. it was determined that the use of photographs alone, without a telephone consultation or high resolution image, was considered unfeasible for diagnosis of nasal fractures. 28 the patients who refused to participate in the moumoulidis et al. 28 believe that facial trauma is a unique injury with its own physical and psychological characteristics that require a specific focus on this topic of interest for providers. during the covid-19 pandemic, patients and health care providers alike will continue to face more safety and logistical obstacles during this time of uncertainty and limited clinical resources. telemedicine in regards to facial injuries holds future potential for improved patient and provider safety, triage, speed of consultation, costs of care, follow-up, and extended geographic access to care. one must also realize the current limitations of telemedicine in regards to sensitivity and specificity in evaluating facial trauma as discussed in this article. with expected future disruptions from anticipated second waves of covid-19, telemedicine will likely be a useful complementary tool in the clinical management of facial trauma. maxillofacial trauma management during covid-19: multidisciplinary recommendations covid-19 pandemic: effects and evidence-based recommendations for otolaryngology and head and neck surgery practice coronavirus disease 2019 (covid-19): emerging and future challenges for dental and oral medicine covid-19 and rhinology: a look at the future practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-ncov) patients toward a consensus view in the management of acute facial injuries during the covid-19 pandemic epidemiology of facial fractures: incidence, prevalence and years lived with disability estimates from the global burden of disease 2017 study changing trends in adult facial trauma epidemiology telemedicine: a guide to assessing telecommunications in health care embracing telemedicine into your otolaryngology practice amid the covid-19 crisis: an invited commentary the regular practice of telemedicine: telemedicine in otolaryngology telemedicine in otolaryngology traveling an audiologist to provide otolaryngology care using store-and-forward telemedicine. telemed e-health preferred reporting items for systematic reviews and meta-analyses: the prisma statement the use of teleradiology for triaging of maxillofacial trauma accuracy of diagnosis of fractures by maxillofacial and accident and emergency doctors using plain radiography compared with a telemedicine system: a prospective study remote stereotactic visualization for image-guided surgery: technical innovation. j cranio-maxillo-fac surg off publ eur assoc cranio-maxillo-fac surg telementoring demonstration in craniofacial surgery with hololens, skype, and three-layer facial models ocular examination for trauma; clinical ultrasound aboard the international space station evaluation of an off-the-shelf mobile telemedicine model in emergency department wound assessment and management a retrospective study of the influence of telemedicine in the management of pediatric facial lacerations electronic follow-up of facial lacerations in the emergency department the role of telemedicine in the management of maxillofacial trauma in emergency departments -preliminary results plastic surgery telehealth consultation expedites emergency department treatment telemedicine in plastic surgery: e-consult the attending surgeon validation of videoconference with smartphones in telemedicine facial trauma care: analysis of concordance to on-site evaluation face-to-face versus video assessment of facial paralysis: implications for telemedicine a novel use of photo messaging in the assessment of nasal fractures which transfers can we avoid: multi-state analysis of factors associated with discharge home without procedure after ed to ed transfer for traumatic injury hundreds of u.s. coronavirus cases may have slipped through screenings keep calm and log on: telemedicine for covid-19 pandemic response where does telemedicine fit into otolaryngology? an assessment of telemedicine eligibility among otolaryngology diagnoses. otolaryngol-head neck surg off j am acad otolaryngol-head neck surg a guide to facial trauma triage and precautions in the covid-19 pandemic navigating telemedicine for facial trauma during the covid-19 pandemic the authors declare no conflicts of interest. https://orcid.org/0000-0001-9973-8379david b. hom https://orcid.org/0000-0002-1000-3171 key: cord-029848-dj5xqlz1 authors: mahajan, vidushi; singh, tanvi; azad, chandrika title: using telemedicine during the covid-19 pandemic date: 2020-05-14 journal: indian pediatr doi: 10.1007/s13312-020-1895-6 sha: doc_id: 29848 cord_uid: dj5xqlz1 telemedicine is the delivery of health care services using information or communication technology. in the current pandemic scenario, telemedicine can supplement health-care delivery in the absence of in-person visit. the government of india has recently launched the e-sanjeevani opd, a national teleconsultation service, which has been adopted by many state governments as mandatory for health-care providers. with indian medical association issuing an advisory against the use of telemedicine except in few situations, a lot of confusion exists in the mind of a pediatrician. despite the uncertain situation, we have to remember that other diseases shall not stall in the face of a pandemic. since telemedicine is an evolving subject, training of medical professionals, clear guidelines and good quality internet service systems will go a long way in increasing the acceptability of telemedicine in the indian population. we herein discuss issues related to using telemedicine during the sars-cov-2 pandemic. i n the face of the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) pandemic, the indian government has proactively taken multiple measures to slow down disease progression. this includes converting some hospitals to dedicated covid-19 hospitals, and shutting down many routine hospital services including outpatient departments and elective operation theatres, while emergency services have continued. however, the patients face a tough dilemma of risk of infection during hospital visits vis-a-vis denial of adequate care because of these measures [1] . to ensure continued health services, the government has given guidelines for practicing telemedicine to aid continuous delivery of healthcare services to the public. telemedicine is defined as the delivery of health care services, where distance is a critical factor, by all healthcare professionals using information or communication technology. it serves the purpose of exchange of valid information for diagnosis, treatment and prevention of disease and injury, research and evaluation, and lessens overcrowding in hospitals, especially in the time of a pandemic [2, 3] . telemedicine aims to ensure equitable services to everyone, is costeffective, provides safety to both patient and doctors during pandemics, and offers timely and faster care. since children represent a vulnerable population, detailed guidance on the delivery of primary and emergent care via telemedicine services is the need of the hour. telemedicine can be classified on the basis of mode of communication as (i) audio, video or text-based (video mode is preferred as it allows limited examination as well); (ii) timing of information transmitted as real time or asynchronous exchange; (iii) purpose of consult as first time or follow up (in non-emergent cases or emergency consultation); and (iv) according to individuals involved as patient to medical practitioner, caregiver to medical practitioner, medical practitioner to medical practitioner or health worker to medical practitioner [2] . the use of telemedicine ranges from educational purposes such as teleconferencing and tele-proctoring, health care delivery, screening of diseases, and disaster management [3] . telemedicine is widely used in areas of radiology, dermatology and pathology; but has had a limited role in other branches in the past. in 2018, the bombay high court had convicted a doctor couple who were guilty of criminal negligence and death of a lady after delivery because the doctor had not come and physically examined the patient. the attending doctor directed her staff telephonically for patient management. the supreme court at that time had advised doctors to limit the use of telemedicine and to use it only in emergencies [4] . this will now change with the latest guidelines [2] . despite all its advantages, practicing telemedicine poses several challenges to clinicians as it is an evolving tool (fig. i) . following are some of the issues that need to be addressed by pediatricians in the current setting of the telemedicine has an inherent drawback since the patient is not actually present and a thorough physical examination is not possible. the limited examination, which is possible only through inspection, might be hampered by low video quality or lack of video facilities altogether. the younger the child (especially below 2 years), the more difficult it is to make a diagnosis based on history alone because of overlapping and nonspecific symptoms in children. this can often lead to underestimation or misinterpretation of the disease. to overcome this we can ask the patients to give a detailed description about their complaints and not merely state the issues. we can employ the use of peripheral examination devices like electronic stethoscope, electronic blood pressure apparatus, pulse oximeter and ultrasonography. however, accuracy and effectiveness of these devices needs to be ascertained before recommendations can be made. one way to partially overcome this challenge is to encourage telemedicine between a health worker and pediatrician to facilitate a rudimentary examination [5] . the pediatrician may need to have a low threshold for ordering basic investigations because of the limited examination possible. the health care worker can certainly assist in triaging patients and identifying sick children requiring an urgent inpatient visit. if no hospital is available nearby, telemedicine might be the only option available e.g. in a case with trauma, pediatrician can advise appropriate first aid which may be lifesaving after which the patient can visit the nearest hospital for assessment of the extent of trauma and stabilization. with the issue of telemedicine practice guidelines under the indian medical council act, 1956, medical practitioners are now empowered and legally protected to provide telemedicine services according to guidelines stated [2] . clinicians may face difficulties in providing telemedicine services in medicolegal cases as detailed documentation is required. doctors should avoid giving advice in such cases and the patient must be referred for an urgent in-person visit to the nearest hospital. in cases where patient initiates the conversation, the consent is implied, but if a doctor initiates the conversation an informed consent should be taken and documented. for a minor seeking health care, child assent is also required. the patient and the parent can send an email, text or an audio/video message. wherever in doubt, consent must be documented/ recorded. the doctor is liable for any advice he gives. in case the physician takes advice from another doctor, the liability lies on the primary physician and it is his discretion whether or not to follow the other doctors' advice. he can give a list of probable or differential diagnosis and can advise the patient to visit the nearest hospital. unless the physician is sure of the diagnosis, no prescription should be given -rather, patient should be advised to visit the nearest health facility. age and weight are important parameters in children for dosage calculation. hence we must avoid giving prescriptions if these parameters are not known. for patients with chronic diseases, assessment of disease activity becomes difficult and certain medications e.g. narcotics, psychotropic drugs etc. are prohibited for telemedicine use by the authorities. the prescriptions when given should be in the specified format [2] and can be counter checked at any point. proper record-keeping is essential for first time and refill prescriptions (allowed for a maximum 6-month period without onsite visit). a screenshot record of whatsapp chats, emails texts and video recording can be kept. the pediatrician can also ask the caregiver to call back when he feels the symptoms are in evolving phase. documenting the call-back instructions given to parents is often as important as documenting the reported symptoms to cover liability risks. prescriptions for common symptoms can be easily copied by quacks in large numbers leading to irrational drug use and quackery. for this we should have stringent laws and any defaulter should face vigorous punishment. the practitioner can choose his telemedicine consultation timings as per convenience. it is his choice to accept or decline a consultation at any time. it is duty of the doctor to maintain patient confidentiality and not to share patient details without consent. patient images should be sent via secure, encrypted means of communication [6] . however, in case either party records conversation there can be a breakdown of the doctor-patient relationship. this relationship has multiple cultural influences. the patient's trust in his/her doctor is not acquired in a moment, but in long coexistence, especially in situations of risk [9] . the government guidelines are not very explicit on how to address any barriers or chinks in doctor-patient relationship. however, the practitioner is not liable if the patient information gets shared due to technological issues [2] . a similar fee structure as applied for inpatient visits is applicable here as well. telemedicine is much more economical both for the patient and physician as it reduces cost of travel and stay (during out-station consultations). the indian academy of pediatrics has recently introduced an app for its members, which can be used for telemedicine consultation and payment services. using telemedicine, it is possible to provide a more holistic care faster e.g., we can take advice from the expert in a shorter duration without referring the patient for expert opinion. services such as tele-radiology, telepathology will also aid us in faster diagnosis. common procedures (such as use of metered dose inhalers, technique of giving insulin injections) can be shared with the patient/caregiver via youtube links, pre-prepared videos or live demonstrations. needless to say, this would be possible on a case-case basis depending on the literacy and understanding of the patient/caretaker. we can also screen patients through telecommunication. in case we find a disease suspect we can refer the patient for urgent testing, isolation and management. however, certain issues like child abuse and/or sexual abuse remain outside the purview of telemedicine in india currently and a hospital visit would be required. lack of widespread access to telecommunication facilities to the wider public leads to inequitable access to health services via telemedicine. for example, if there is a transient error in voice transmission the patient might receive incomplete information which can be hazardous and may have medico-legal implications. any breakdown in technology should preferably be documented by the provider. the primary person of contact in the pediatric age group is usually not the patients themselves, but the parents or the caregivers. the already difficult doctor-patient communication is further compounded with telecommunication. moreover, patient literacy and socioeconomic factors might pose challenges in communication during telephone or video calling. prescriptions via this mode can also be incorrectly interpreted, either by the patients themselves or the chemists, which can lead to disastrous results. the solution is to have good quality internet connections, uninterrupted power supply, volume 57 __ july 15, 2020 mahajan, et al. telemedicine during covid-19 workshops on telecommunication, and designated centers such as post offices, dispensaries and primary health care centers where good internet services and trained facilitators like accredited social health activists (ashas) are available (fig. i) . the staff should be trained in performing video calls and explaining prescription to the patients. we should avoid providing telemedicine by telephonic conversations and should encourage video calls and provide prescriptions in the fixed format via email. we should have a better liaison between tertiary care hospitals and primary heath care centers, as has been done with the village resource centers developed by indian space research organisation in october, 2018 [8] . if the practitioner still faces communication glitches, he can record the issue and terminate the conversation [2] . we as physicians have become comfortable with the traditional method of providing treatment but in the current scenario of the covid-19 pandemic, a temporary change is required [9] . with more and more healthcare professionals getting affected, the doctorpatient ratio will further deteriorate. telemedicine might be the only promising solution available. however as the usage of telemedicine will increase in india, more issues regarding medicolegal aspects might emerge, which should be deliberated among the medical fraternity a priori. although caution is necessary on the part of a pediatrician, given the benefits of telemedicine we must welcome it. we may find it as an important adjunct to the traditional way of practicing medicine. contributors: vm: conceived the idea, is providing telemedicine services, wrote the 1st draft, and approved the final manuscript; ts: literature search, assisted in writing the first draft and approved the final manuscript; ca: edited the manuscript, and approved the final manuscript. funding: none; competing interest: none stated. covid-19 and health care's digital revolution telemedicine practice guidelines enabling registered medical practitioners to provide healthcare using telemedicine telemedicine: pediatric applications prescription sans diagnosis: a case of culpable neglect development of digital stethoscope for telemedicine networked medical data sharing on secure medium -a web publishing mode for dicom viewer with three layer authentication telemedicine and the doctor/patient relationship village resource centre -isro the invisible hand -medical care during the pandemic key: cord-254040-s3k51rkk authors: bombaci, alessandro; abbadessa, gianmarco; trojsi, francesca; leocani, letizia; bonavita, simona; lavorgna, luigi title: telemedicine for management of patients with amyotrophic lateral sclerosis through covid-19 tail date: 2020-10-06 journal: neurol sci doi: 10.1007/s10072-020-04783-x sha: doc_id: 254040 cord_uid: s3k51rkk over the last months, due to coronavirus disease (covid-19) pandemic, containment measures have led to important social restriction. healthcare systems have faced a complete rearrangement of resources and spaces, with the creation of wards devoted to covid-19 patients. in this context, patients affected by chronic neurological diseases, such as amyotrophic lateral sclerosis (als), are at risk to be lost at follow-up, leading to a higher risk of morbidity and mortality. telemedicine may allow meet the needs of these patients. in this commentary, we briefly discuss the digital tools to remotely monitor and manage als patients. focusing on detecting disease progression and preventing life-threatening conditions, we propose a toolset able to improve als management during this unprecedented situation. realization of wards entirely devoted to covid-19 patients. most of visits for chronic diseases have been canceled, postponed, or converted to teleconsultations (remote consultations between patients and clinicians) [2] [3] [4] . in the next months, this situation will probably persist. in this context, patients affected by chronic neurological diseases, such as amyotrophic lateral sclerosis (als), are at risk of being lost at follow-up with a consequently higher morbidity and mortality. als is a neuromuscular progressive disorder, characterized by limb and bulbar muscle wasting and weakness. thirty percent of patients present a bulbar onset, while 70% a spinal onset, although most of them develop bulbar impairment during the course of the disease [5] . nowadays, there is still no curative treatment for als, and palliative care and symptomatic treatment are therefore essential components in the management of these patients. death occurs in 3-5 years, generally due to respiratory paralysis [5] [6] [7] . neurological examination and als functional rating scale revised (alsfrsr) are the most important tools to monitor disease progression. early detection of severe symptoms, such as dysphagia and respiratory impairment, reduces the risk of developing ab ingestis pneumonia and respiratory insufficiency, improving the prognosis [8] . therefore, it is important to establish an efficient service of telemedicine to replace face-toface visits, monitor progression of the disease, and manage complications as soon as possible [2] , especially lifethreatening ones. herein, we briefly review the available instruments to remotely manage als patients with the aim of proposing a digital toolset (fig.1 ) to face the current imposed stay-home policy. alsfrsr is commonly used to evaluate als progression. some recent studies explored the possibility of an online selfadministered version of alsfrsr scales [9, 10] reporting a high inter-rater and intra-rater reproducibility, and a low variability. beyond alsfrsr that can be easily compiled also by phone calls, performing a neurological examination remotely is also fundamental in the management of als. recently, the american academy of neurology (aan) published recommendations for improving a telemedicine service and suggested tools to perform a general neurological examination remotely [11] . neurological examination through an audiovideo link showed good results in terms of reliability and validity with bedside examination [12, 13] , although with some limitations in the assessment of muscle tone, vibration sensation, and deep tendon reflexes. in order to overcome limits intrinsic to remote neurological examination, digital complementary tools have been proposed. some sensors were developed to objectively homemonitoring als patients. recent pivotal studies have investigated the feasibility of wearable devices equipped with an accelerometer for motor activity assessment and heart rate variability detection [14] . remotely monitoring invasive and non-invasive ventilation through videoconferencing or homebased self-monitoring has strong application in telemedicine and in these patients could effectively reduce morbidity and mortality [15] . even bulbar function could be monitored in remote, through the analysis of the recordings of patients reading aloud a short paragraph, as allison et al. reported [16] . they observed that the longitudinal evaluation of the percentage pause time expressed in seconds (a marker of speech fluency) is one of the most important markers of pre-clinical bulbar involvement in als. another issue to be addressed is the monitoring of the nutritional status, which is a relevant prognostic factor. countless nutrition-based mobile health (mhealth) applications are available for both android and ios. all are accessible and easy to use, but only few were assessed in clinical studies. in a recent randomized trial comparing remote nutritional counseling with or without mobile health technology in als patients, nu planit application was an acceptable and useful mobile app to check nutritional status [17] . it is a nutrition-based mhealth applications that facilitate frequent reminders and measurements. patients can record their food habits and home weight measurements. moreover, based on patients' gain or loss weight, the nutritionist could remotely access to the app and modify dietary recommendation. in als evaluation of cognitive profile is important because around 30-50% of patients develop cognitive impairment. a review highlighted the usefulness of some neuropsychological test administered by videoconference in new diagnosis and in follow-up [18] . unfortunately, only few cognitive tests commonly used in als were tested, with a good agreement between videoconference and in clinic neuropsychological test. receiving a diagnosis of a deadly illness such as als can deeply affect the emotional, physical, and mental aspects of a patients' life, and in these patients, also the psychological support is a key aspect of management. transferring the meeting with the psychologist on a digital platform could be useful but not often accepted by the patients. indeed, previous work on multidisciplinary digital management of als patients showed that psychological support was requested in few cases, probably due to personal refusal, embarrassment, or preference for a face-to-face contact [19] . all the issues debated point out the complexity of als patients' management and the need to create multidisciplinary teams able to face the new challenges due to this novel approach to patients' care [20] . as discussed in detail by aghdam and colleagues, telemedicine offers a significant improvement in the organization of multidisciplinary team meetings compared with traditional settings. indeed, it allows an improved access to and collaboration of medical experts. this results in an increased level of medical competence improving diagnosis, treatment, and patients' follow-up irrespective of location [21] . in an ongoing project, de marchi and colleagues theorized that satisfactory multidisciplinary care could be provided to als patients in their home using technology. in this stay-home forced situation, they employed some of the tools discussed above in order to prevent a greater decline of the physical and psychological functions of als patients [22] . despite the relevance of this approach is yet to be proven, they aimed to detect, as soon as possible, how it can be useful to avoid the postponed disease-related complications of this devastating disease, trying to support patients and their caregivers in the best way [22] . overall, in our opinion, monitoring everyday life and potential life-threatening aspects of the disease should be the main goal of telemedicine in als patients, particularly at the time of covid-19 pandemic [23, 24] . as mentioned, alsfrsr and the neurological examination are the most important instruments to monitor disease status. therefore, they should be part of the set core of remote examination (fig. 1) and applied to all patients on follow-up teleconsultation. while the digital assessment of motor functions through digital devices, such as accelerometer, is not reliable in a context in which patients are forced to remain home, on the contrary, speech analysis for bulbar function and monitoring of invasive and non-invasive ventilation could be crucial in reducing morbidity and mortality and should be part of the set core. a study of remote pulmonary function tests was conducted by the penn state health hershey als center with patients, caregivers, and respiratory therapists reporting high acceptability [25] . moreover, monitoring nutritional status through mhealth applications is useful and accessible, and we suggest the use of those apps for all als patients. a future perspective could be the development of an app in order to achieve a complete selfassessed evaluation of nutritional status, respiratory function, motor ability, and subjective perceived health status, as was already done for patients with pompe disease [26] . the psychological support is very important especially immediately after diagnosis for both patients and their relatives. remote psychological support could be essential in a period in which hospital access has been reduced. therefore, patients and caregivers with psychological needs should receive the opportunity for scheduled psychotherapy or on-demand calls by a psychologist. in a recent paper, vasta and colleagues described their experience of telemedicine with the management of als patients during the covid-19 pandemic. in agreement with previous studies, they revealed that patients reported to be globally satisfied with respect to the telemedicine service they received, but, despite the risk of contracting sars-cov2 infection, most of them would have preferred an impatient visit. overall, the satisfaction of patients and caregivers for the use of telemedicine is good, although face-to-face visits are still largely preferred. thus, telemedicine for als patients should have a complementary and not a substitutive role, and it should replace the in-person care depending on circumstances and patient preferences [27] . limitations in the use of those complementary tools include the high costs to acquire the instrumentation to be given to patients, the training of patients' and caregivers, and the necessity of validation of some of these instrumentation and tools administered by videoconference or self-administered. in conclusion, implementing telemedicine services for patients with als is necessary to allow direct clinical evaluation during covid-19 pandemic, in order to plan the appropriate medical and nursing care, avoiding hospitalizations or urgent interventions. ethical approval none. open access this article is licensed under a creative commons attribution 4.0 international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. who director-general's opening remarks at the media briefing on covid-19 -11 technology enabled care services preparing a neurology department for sars-cov-2 (covid-19): early experiences at columbia university irving medical center and the new york presbyterian hospital digital triage for people with multiple sclerosis in the age of covid-19 pandemic amyotrophic lateral sclerosis plasma pnfh levels differentiate sbma from als amyotrophic lateral sclerosis practice parameter update: the care of the patient with amyotrophic lateral sclerosis: drug, nutritional, and respiratory therapies (an evidence-based review): report of the quality standards subcommittee of the american academy of neurology development and assessment of the inter-rater and intra-rater reproducibility of a selfadministration version of the alsfrs-r design and results of a smartphone-based digital phenotyping study to quantify als progression telemedicine and remote care multidisciplinary amyotrophic lateral sclerosis telemedicine care: the store and forward method telemedicine in general neurology: interrater reliability of clinical neurological examination via audio-visual telemedicine objectively monitoring amyotrophic lateral sclerosis patient symptoms during clinical trials with sensors: observational study home telemonitoring of non-invasive ventilation decreases healthcare utilisation in a prospective controlled trial of patients with amyotrophic lateral sclerosis the diagnostic utility of patient-report and speechlanguage pathologists' ratings for detecting the early onset of bulbar symptoms due to nutritional counseling with or without mobile health technology: a randomized open-label standard-ofcare-controlled trial in als neuropsychological test administration by videoconference: a systematic review and meta-analysis a pilot trial of telemedicine-assisted, integrated care for patients with advanced amyotrophic lateral sclerosis and their caregivers new technologies and amyotrophic lateral sclerosis -which step forward rushed by the covid-19 pandemic? role of telemedicine in multidisciplinary team meetings telemedicine and technological devices for amyotrophic lateral sclerosis in the era of covid-19 the tim system: developing a novel telehealth service to improve access to specialist care in motor neurone disease using user-centered design using telehealth in motor neuron disease to increase access to specialist multidisciplinary care: a uk-based pilot and feasibility study evaluation of remote pulmonary function testing in motor neuron disease a mobile app for patients with pompe disease and its possible clinical applications telemedicine for patients with amyotrophic lateral sclerosis during covid-19 pandemic: an italian als referral center experience publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord-287350-xj2i6fgd authors: camhi, stephanie s.; herweck, alexandra; perone, hanna title: telehealth training is essential to care for underserved populations: a medical student perspective date: 2020-06-15 journal: med sci educ doi: 10.1007/s40670-020-01008-w sha: doc_id: 287350 cord_uid: xj2i6fgd telehealth is an area of medicine which has magnified the ability to treat patients remotely. presently the education of medical professionals pertaining to the value, use, and implementation of telehealth is not adequate to harness the potential of available technologies. patients engaging in telehealth experience time and cost savings, improved disease management through remote monitoring programs, and high-quality care regardless of geographic location. despite this, medical education has been slow to evolve. it is therefore imperative that medical curricula incorporate training for this rapidly advancing mode of healthcare delivery to enable students to best care for their future patient population. telehealth (telemedicine, e-health) refers to utilization of technology to deliver healthcare services outside of traditional healthcare facilities such as through remote monitoring, video-conferencing, or electronic consultations [1] . surveys from the american hospital association support that use of telehealth has grown dramatically in the past decade, with 76% of united states (us) hospitals offering some form of telehealth services [2] . while thirty-five states in the us currently have enacted parity laws requiring health insurers to reimburse telehealth services, medicare reimbursement is slow to provide adequate compensation to all involved parties [2] . the advent of the coronavirus disease 2019 (covid-19) global pandemic propelled telehealth to the forefront with virtual care visits predicted to surpass 1 billion in this calendar year [3, 4] . while the agility of the healthcare system to adapt to this unprecedented challenge is admirable, the retroactive application of telehealth approaches highlights how unprepared our health system is to embrace widespread telehealth implementation. in part, this may be related to the fact that medical schools are similarly slow to adopt the growing movement of telehealth despite its promotion by the american medical association (ama). telemedicine has significant potential to combat health disparities, improve access to healthcare across all specialties, including the care of stigmatized populations, and improve patient outcomes through remote monitoring programs; however, effective implementation by healthcare providers requires early exposure throughout both allopathic and osteopathic education to adequately harness this potential. as of 2016, less than half of allopathic medical programs in new york and texas reported implementing preclinical telemedicine education. in the same time frame, states with predominantly rural populations, namely north dakota, kansas, and oklahoma, had yet to implement preclinical telemedicine in any of their allopathic schools [5] . according to the association of american medical colleges (aamc), the number of medical schools offering clerkship electives in telemedicine has increased from 44 in 2013 to 68 in 2019 [6] . while this increase is promising, the elective nature of telehealth training remains concerning. the ama seems to share this sentiment and recently launched the "accelerating change in medical education consortium" which granted $12.5 million to 32 medical schools for telehealth curricular development [7] . it is worth noting that medical education already aims to deliver a surplus of crucial biomedical information on a rather accelerated timeline, which appears to push telemedicine to the hierarchical backburner. one study from australia highlighted that telehealth training is not a priority for medical students given that accrediting bodies do not expect competency in this domain from medical graduates [8] . however, with the advent of the covid-19 pandemic, and despite the fact that mandatory telemedicine education is currently lacking in most allopathic schools, the united states medical licensing examination (usmle) has suggested that a telemedicine-style clinical skills examination may be forthcoming. this presents additional challenges including the complexity of technical work required for initiation of telehealth education, which to this point has been lacking, as well as the concerns of standardization and validation of new assessments over electronic video platforms [9] . despite these challenges, a few preliminary studies suggest that curricular reform to introduce and instruct regarding telemedicine is likely to be promising. one study from the university of iowa implemented a 3-module introductory educational program for second-year students and improved students' telemedicine knowledge and confidence [10] . a study from the uniformed services university of the health sciences similarly demonstrated an increase in telehealth knowledge following student completion of their pilot program consisting of telemedicine training, faculty-supervised patient encounters, and an introduction to telehealth surgical equipment [11] . telehealth applications stand to benefit patients given that medical appointments cause hourly workers to lose valuable income through loss of time at work, personal transportation fees, and copayments or other associated visit costs. recent work by ray et al. found the total time invested in travel to and from, wait time associated with, and clinical interaction comprising a single appointment to be 121 minutes [12] . after this substantial time and monetary investment, the patient may not even be visiting a center that is specialized in treatment of their specific complaint, leading to receipt of suboptimal medical care. another study at vermont veterans hospital showed an average travel and cost savings of 145 miles and 142 minutes per visit with the use of telemedicine clinic appointments [13] . in addition to permitting time and cost savings, telemedicine is essential to bridge structural barriers and provide access to vital emergency and/or specialty care to individuals in under-resourced settings. utilization of telehealth for triage has shown to be acceptable to patients and to potentially reduce the number of emergency department (ed) visits [14] . telehealth approaches also show promise for providing crucial urgent care services to rural populations [15] . this reduction in structural barriers does not come at a cost to patient satisfaction. a study in oncology patients suggested equivalent satisfaction ratings regardless of the care delivery method including telephone versus in-person appointments [16] . furthermore, telemedicine has improved access to specialists in resource-poor communities. one study of an interactive video colposcopy initiative in rural arkansas allowed health department nurses to conduct colposcopies and cervical biopsies through real-time inclusion of an obstetric-gynecologic specialist [17] . similarly, dermatology and gastroenterology telehealth pilot programs have decreased time to initiation of patient care [18] . during the covid-19 pandemic, telemedicine has been harnessed to continue regular non-urgent outpatient care and to provide covid-related care such as symptomatic monitoring and post-discharge follow-up [3] . widespread use and availability of mobile technologies allow for telemedicine utilization throughout the country. as of 2018, 81% of americans own a smartphone, nearly 75% of adults own desktop or laptop computers, and approximately 50% own tablet computers [19] . more than ever, individuals from all racial, ethnic, and income backgrounds can afford these technologies and therefore already possess the necessary supplies to engage in telehealth services. in the last 15 years, remote patient monitoring (rpm) via noninvasive devices has gained popularity and increased in availability for collection of immediate medical information and thereby monitoring of chronic health conditions. the most common rpm devices used include smartphones (19%), wearable devices (18%), biosensor devices (11%), and computerized systems (10%), with most rpm programs including multiple methodologies of monitoring patients (42%) [20] . rpm programs have improved self-management, which has been shown to reduce clinic visits and hospitalizations, for patients with chronic disease and reduced the severity of symptoms related to chronic respiratory, metabolic, and cardiovascular conditions [20] . patients with type 2 diabetes mellitus in an rpm program lost weight and had positive a1c outcomes [21] . in a study utilizing rpm for blood pressure control, systolic blood pressure outcomes were similar in patients with rpm alone compared with those who received both rpm and regular office visits, suggesting that both approaches were as efficacious as usual office care [22] . telehealth is also an important avenue for providing care to populations who may otherwise be stigmatized. men who have sex with men (msm) face many structural and cultural barriers, and studies have shown worse health outcomes in this population, particularly in those with hiv or aids. a recent study of msm in oklahoma suggested that geographical isolation significantly limits access to quality sexual healthcare and resources including hiv pre-exposure prophylaxis (prep) [23] . a pilot study in the rural us showed that electronic prescribing of prep resulted in many individuals initiating treatment, and additionally was preferred by patients over standard in-person care [24] . in addition to prep availability, msm have also indicated acceptability of telemedicine efforts to increase sexually transmitted infection (sti) screening. in a pilot study of home sampling for sti screening, forty-nine of fifty enrolled msm couples completed testing, indicating high acceptance among the msm population for this model [25] . telehealth further stands to improve ease of access to female reproductive health services including oral contraception. as of february 2018, nine platforms were electronically prescribing oral contraception with a greater adherence to cdc prescribing guidelines compared with in-person office visits [26, 27] . tele-contraception efforts have not only increased access to oral contraception but also empowered women with adequate knowledge pertaining to their contraceptive options [28] . these are merely a handful of studies highlighting the immense power for telemedicine to improve healthcare accessibility in stigmatized populations and promote safe sexual health practices. delivery of the highest quality telehealth care relies on physicians from numerous specialties, and therefore, all osteopathic and allopathic students would benefit from early exposure and training. there is much conversation in the medical education community pertaining to curricular reform and training "physicians of the future." while these groups discuss shortening the preclinical experiences, integrating basic sciences into clinical studies, and transitioning to symptombased education, an emphasis on telehealth is generally lacking. greater urgency should be exhibited to incorporate telemedicine into the training of young physicians and thereby harness the full potential of our rapidly advancing medical technologies. introduction specifically at the medical student level will provide students with a framework for developing further telehealth knowledge and experience as they progress through training. early and repeated exposure across varying institutions (i.e., medical school, residency training, fellowship training) will provide a more thorough "tour" of available telehealth approaches and technologies. in addition, the initial clerkship year, or just prior, is an ideal time frame for introduction given that students will then feel as though telemedicine is engrained into their clinical workflow. medical students in germany identified the growing prevalence of telehealth applications as an important learning goal [29] . a mixed-methods review of telehealth applications in us allopathic schools similarly details that most medical students find telemedicine-based training to be valuable [5] . telehealth applications are a main reason that the covid-19 pandemic failed to bring our medical education to a startling halt. objective structured clinical examinations (osces) were adjusted to take place as telemedicine encounters over video conference for core clerkships including pediatrics and psychiatry. in addition, a medical student-driven initiative to offer telehealth education to clerkship students, consisting of an introductory lecture and participation in telehealth encounters, was mandated for all 200 third-year students at our institution. following the lecture, students were paired with a provider in their specialty area of interest to participate in telehealth encounters. these experiences provide just a small taste of what telehealth applications stand to contribute to our future toolkit as physicians, and similar activities should be built into the curriculum rather than mandated in the context of pandemic response. some of the barriers to widespread implementation of telemedicine include uncertainty pertaining to reimbursement and licensure requirements. recent governmental actions have lessened these concerns, leaving the lack of training of medical professionals as a key barrier to implementation [5] . without expedited implementation of training within undergraduate medical education, the likelihood of provider knowledge keeping up with rapid technological advances is slim. how will we become public health physicians of the future without this vital training? how will we bridge the inequities that structural barriers have enacted? how will we offer the best care, to all patients, regardless of gender, race, religion, stigmatization of their medical condition, or physical location? and perhaps most pressingly, how can we ensure that our pandemic response is not dampened by the learning curve associated with retroactive telemedicine implementation? the answer is that we, as current physicians-in-training, will not succeed in these endeavors if our medical education does not prepare us to do so. our inability, as care providers, to implement telemedicine is a disservice to the rural, structurally disadvantaged, impoverished, and stigmatized communities which we, as physicians, cannot morally afford to underserve. telehealth transformation: covid-19 and the rise of virtual care telemedicine in the era of covid-19 telemedicine training in undergraduate medical education: mixed-methods review required courses and elective courses. aamc ama encourages telemedicine training for medical students, residents it's important, but not important enough: ehealth as a curriculum priority in medical education in australia united states medical licensing examination | announcements model for medical student introductory telemedicine education an interdisciplinary, multi-institution telehealth course for third-year medical students opportunity costs of ambulatory medical care in the united states va telemedicine: an analysis of cost and time savings potential of mobile health technology to reduce health disparities in underserved communities advancing health equity and access using telemedicine: a geospatial assessment telemedicine versus clinic visit: a pilot study of patient satisfaction and recall of diet and exercise recommendations from survivorship care plans distributing medical expertise: the evolution and impact of telemedicine in arkansas teledermatology consultation can optimize treatment of cutaneous disease by nondermatologists in under-resourced clinics remote patient monitoring via non-invasive digital technologies: a systematic review association between weight loss and glycemic outcomes: a post hoc analysis of a remote patient monitoring program for diabetes management randomized clinical trial to assess the effectiveness of remote patient monitoring and physician care in reducing office blood pressure barriers to access and adoption of pre-exposure prophylaxis for the prevention of hiv among men who have sex with men (msm) in a relatively rural state acceptability and feasibility of a telehealth intervention for sexually transmitted infection testing among male couples: protocol for a pilot study breaking down barriers to birth control access: an assessment of online platforms prescribing birth control in the usa a study of telecontraception | nejm the closer, the better:" the role of telehealth in increasing contraceptive access among women in rural south carolina the future of practical skills in undergraduate medical educationan explorative delphi-study acknowledgments the authors are thankful to dr. daniel lichtstein for his thoughtful review and support of our work.code availability not applicable.authors' contributions all authors made substantial contributions to the conception of the work, drafted the work and revised it critically for important intellectual content, and approved the version to be published. conflict of interest the authors declare that they have no conflict of interest. publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord-257229-5ml5ceu0 authors: grandizio, louis c.; mettler, alexander w.; caselli, morgan e.; pavis, elizabeth j. title: telemedicine after upper extremity surgery: a prospective study of program implementation date: 2020-07-18 journal: j hand surg am doi: 10.1016/j.jhsa.2020.06.002 sha: doc_id: 257229 cord_uid: 5ml5ceu0 purpose: our purpose was to evaluate the implementation of a postoperative hand and upper extremity telemedicine program. we aimed to compare travel burden, visit time, and patient satisfaction between an initial postoperative telemedicine visit and a second conventional in-clinic visit. methods: telemedicine guidelines established by our hospital system were used as inclusion criteria for this prospective study, which included patients indicated for surgery in the outpatient clinic during a 3-month period. patients were excluded if they had wounds closed with nonabsorbable suture, remained admitted to the hospital, or required a custom orthosis at their first postoperative visit. baseline demographics and patient-reported outcome measures were collected prior to surgery. information pertaining to technology usage was collected for the telemedicine visit and travel information was obtained for the in-clinic visit. patient satisfaction was recorded for both visits. results: fifty-seven of 87 patients (66%) who met the inclusion criteria elected to participate in the study. a cell phone was utilized by 89% of patients and 88% of visits were performed from the patient’s home. there were 4 technological complications during the study period (7%). mean round-trip travel distance for the in-clinic visit was 60 miles with an average drive time of 85 minutes. visit times were significantly shorter with telemedicine (7 minutes vs 38 minutes). telemedicine was preferred by 90% of patients for subsequent encounters. all 4 clinical complications were recognized during the telemedicine visit. conclusions: a telemedicine program for postoperative care after hand and upper extremity surgery decreases travel burdens associated with conventional in-clinic appointments. telemedicine significantly decreases visit times without decreasing patient satisfaction for patients who elect to participate in remote video visits. the ability to recognize early postsurgical complications was not compromised by utilizing this technology, even during our early experience. clinical relevance: telemedicine after hand and upper extremity surgery results in high levels of patient satisfaction and decreases visit times and the travel burdens associated with conventional in-clinic appointments. a s mobile video-conferencing technologies have evolved, so have telemedicine programs. purported benefits of telemedicine include cost-savings, decreased travel burden, and patient convenience. 1e3 as with any new technology, there are concerns regarding the safety and efficacy of telemedicine visits compared with conventional, inclinic encounters. specific to hand and upper extremity surgery, recent investigations have focused on the utilization of this technology for the evaluation of emergent conditions in the emergency department setting. 2 there is a relative paucity of literature investigating the use of telemedicine after upper extremity surgery. the purpose of this investigation was to evaluate the implementation of a postoperative hand and upper extremity telemedicine program. we aimed to compare travel burden, visit time, patient satisfaction, and ease of use between an initial postoperative telemedicine visit and the second conventional inclinic visit. in addition, we aimed to evaluate our early experience while implementing a new postoperative telemedicine program. we hypothesized that patients participating in telemedicine would have decreased visit times and demonstrate high levels of satisfaction. institutional review board approval was obtained for this prospective study. our outpatient clinic is part of a rural, academic, level-i trauma center with a catchment area of approximately 25,000 square miles. the study period was prior to the covid-19 pandemic, and during that time, outpatient telemedicine visits were only approved within our division for postoperative care within the 90-day global billing period after surgery. during this 90-day period, normal postoperative care is bundled into the global surgery fee. we utilized the telemedicine guidelines established by our hospital system as inclusion criteria for this study. patients younger than 18 years were included with parental consent. parents were required to initiate the telemedicine call for pediatric patients. in order to be eligible for telemedicine visits, patients must meet all of the following criteria: in addition to exclusion for technological criteria, we also established clinical exclusion criteria. patients were excluded if they had wounds that were closed with nonabsorbable suture, remained admitted to the hospital or nursing facility during the time of the postoperative visit, or required casting/custom orthosis at their first postoperative visit. although we did not establish specific exclusion criteria based on case complexity, the previously discussed clinical exclusion criteria resulted in the inclusion of mostly lower-complexity cases. for example, cases involving limb salvage or tendon reconstruction often require the use of a postoperative orthosis fitted by a therapist, and these types of cases were excluded. patients who required a radiograph at their first postoperative visit were allowed to do so at a location close to home and were not excluded from this study. the study period corresponded with the implementation of a postoperative telemedicine program within the hand surgery division at our institution. all patients from the senior author's (l.c.g.) outpatient clinic who were indicated for surgery during a 3-month period from february 2019 to april 2019 were screened for eligibility for this investigation. the first patient enrolled in this investigation was the first telemedical visit performed in our division. when a patient was indicated for surgical intervention, technological and clinical inclusion criteria were reviewed, and those patients meeting the criteria were offered the option of scheduling their first postoperative visit (7e14 days after surgery) as a telemedicine visit. the second postoperative visit (4e6 weeks after surgery) was a conventional inclinic appointment in the outpatient clinic for all patients. patients electing for a telemedicine postoperative visit were given a 1-page faq (frequently asked questions) and trouble-shooting guide (appendix a; available on the journal's web site at www. jhandsurg.org). they were then contacted by the scheduling department via e-mail. this e-mail contained a link to the telemedicine video-call application, which utilized a web-browserebased video conferencing feature for android and windows users and a downloadable mobile app for ios (apple) users. the telemedicine platform utilized was designed by intouch health (santa barbara, ca), and customized for our institution. telemedicine visits were conducted during regular clinic hours, during administrative time and between surgical cases. we utilized the same scheduling templates for both telemedicine and in-clinic visits. patients were sent automated appointment reminders 24 hours prior and 1 hour prior to their appointment. patients could log into the telemedicine platform prior to the visit in order to familiarize themselves with the software. the type of device utilized by the patient was recorded. the senior author (l.c g.) performed all of the postoperative telemedicine visits on a tablet device. both the patient and the surgeon logged into the telemedicine platform at the scheduled visit time. prior to initiating the visit, the patient signed an electronic informed consent. information relating to hipaa (health insurance portability and accountability act) compliance and protected health information relative to the software can be found on the intouch web site (https://intouchhealth.com/privacypolicy/). to further safeguard protected health information, the patient was informed whether any other people were present in the room, which included medical students, residents, and therapists. all visits were conducted with the office door closed. for the physical examination, patients were asked to remove their dressing and the wound was inspected. all wounds were closed with absorbable suture. a remote physical examination was then performed on all patients. we asked the patient to perform passive and active range of motion. sensation was assessed by having the patient compare sensation to light touch on regions of the surgical extremity to the nonsurgical side. if radiographs were obtained prior to the visit, they were viewed within the electronic medical record system. for patients who lived near a facility within our health system that had the ability to obtain radiographs, these images were immediately available within our picture archiving and communication systems (pacs). radiographs obtained at outside facilities were uploaded into lifeimage (newton, ma) and could be viewed during the encounter. orders for any medications were placed electronically. physical and occupational therapy referrals, if indicated, were ordered electronically as well. we utilized our electronic medical record system to document the clinic note, which included documentation stating that this was a telemedicine visit. this was the same process utilized for conventional in-clinic visits. baseline demographics were recorded for each patient. at the time of the initial consultation prior to surgery, patients were asked to complete a numeric pain rating scale (nprs) and patient-reported outcomes measurement information system (promis) instruments, which included the promis self-efficacy for managing symptoms short-form 4a, promis pain interference short-form 4a, and the promis upper extremity short-form 7a. patients completed an nprs during the first postoperative telemedicine visit. both the patient and the surgeon were asked to rate the audio and video quality of the call on a 3-point scale with 1 indicating no audio or visual availability, 2 indicating reduced audio or visual feed quality, and 3 indicating a wellfunctioning, clear audio or visual feed. the length of the telemedicine call was also recorded. during the second in-clinic postoperative visit, patients were asked to complete an nprs and the promis upper extremity questionnaire. in addition, we recorded visit time, travel time, travel distance, and patient satisfaction information. mileage and travel times were recorded using google maps (https://www.google.com/maps), utilizing the patient's home address and the address of our outpatient clinic. travel times were determined at the time of the clinic visit in order to account for traffic fluctuations. when multiple routes were available, the shortest travel time was recorded. visit times were recorded using the appointment "check-in" and "check-out" times within our electronic medical records system. at the conclusion of the in-clinic visit, patients were asked to rate the telemedicine program with respect to ease of use on an 11-point likert scale, with 0 indicating very difficult and 10 indicating very easy. patients also completed an 11-point likert scale to rate their satisfaction with both the telemedicine and the in-clinic postoperative visits, with 0 indicating very unsatisfied and 10 indicating very satisfied. patients were asked whether they would choose a telemedicine or an in-clinic postoperative visit in the future. utilizing a similar written questionnaire distributed by abel et al 4 for a telemedicine program, patients were asked to select their reasons for choosing telemedicine. the time required to complete outcome measures and questionnaires was included in the visit times for both the telemedicine and the inclinic visit. descriptive statistics were used for baseline demographics. we used student t testing and chi-square testing to compare the means or proportions between the 2 visits. differences of p less than .05 were considered statistically significant. during the 3-month study period, the senior author (l.c.g.) preformed a total of 147 surgical procedures. twenty-four patients did not meet the inclusion criteria. an additional 36 patients had clinical exclusion criteria and were not eligible to participate. fifty-seven of the 87 patients who met inclusion criteria, and were eligible for the study, elected to participate (66%). all of the 57 included patients completed both postoperative visits. baseline demographics for all patients included in this investigation are presented in table 1 . demographic information for patients who met inclusion criteria but declined to participate in presented in table 2 . table 3 describes the technological quality and types of devices utilized. eighty-nine percent of patients utilized a cell phone and 88% of visits were preformed from the patient's home. there were 4 visits (7%) with technological complications during the study period. during 1 visit, the surgeon was unable to see the patient on video, but the audio was working. in this case, the patient sent images of the surgical site via the electronic medical record system and the visit was conducted with audio only for the surgeon (the patient had normal audio and video feeds). in 3 additional cases, the audio and video feed did not work for either the patient or the surgeon. these visits were rescheduled for later the same day and the telemedicine visit was completed without incident. overall, patients rated technological ease of use as 9.5 on an 11-point likert scale, with 10 being very easy. table 4 illustrates the differences between travel and visit times for the telemedicine visit and the inclinic visit. the mean travel distance for patients was 60 miles round-trip (range, 5e304 miles) and patients spent an average of 85 minutes driving. visit times were significantly shorter for telemedicine visits (7 minutes vs 38 minutes; p< .05). visit satisfaction was higher for telemedicine visits (9.9) than for in-clinic visits (9.5) and these results were statistically significant (p < .05). figure 1 includes the results to a survey asking patients why they chose to utilize telemedicine for their postoperative visit. all 57 patients responded and a total of 148 responses were recorded. the most common reasons for choosing telemedicine were that it was "more convenient overall" (32%) followed by "less driving" and "less wait time" (24%). there were 4 patients (7%) with recognized clinical complications during the study period: wound dehiscence after mass excision, supraclavicular sensory neurapraxia after an open reduction internal fixation (orif) of a clavicle fracture, digital stiffness after a combined carpal tunnel and trigger digit release, and a lateral antebrachial cutaneous neurapraxia after a distal biceps tendon repair. all 4 complications that were identified during the study period were recognized during the telemedicine visit. the patient with digital stiffness and the 2 patients with neurapraxic injuries had resolution of their symptoms with observation only. no additional clinic visits were required. the patient with a wound dehiscence after mass excision healed by secondary intention with local wound care. wound care instructions were provided during the telemedicine encounter and the wound was healed by the scheduled in-clinic visit. these data support our initial hypothesis that patients participating in telemedicine would have decreased visit times and demonstrate high levels of satisfaction. there are several advantages for patients electing to participate in telemedicine after hand and upper extremity procedures. telemedicine visits decreased total encounter times by 31 minutes in our series and patients avoided an average round-trip drive time of 85 minutes. similar to our findings, sathiyakumar et al 1 demonstrated that telemedicine can reduce travel time, visit times, and time away from work for patients undergoing nonsurgical treatment of orthopedic trauma injuries. whereas patient satisfaction with both telemedicine and in-clinic visits was high in our series, all but 1 patient (98%) preferred the telemedicine visits for future encounters. it is unlikely that the differences in patient satisfaction scores for telemedicine and conventional in-clinic visits were clinically significant. for general orthopedic patients, previous authors have demonstrated that 63% of patients randomized to an in-clinic consultation and 86% of patients randomized to a telemedicine visit preferred telemedicine for future encounters. 5 able et al 4 found that, for adolescent patients after knee arthroscopy, two-thirds preferred telemedicine visits. in implementing this program and analyzing our early experience, we were concerned about technological access issues, particularly for older patients. the average age of patients in our series was 51 and patients up to 78 years old elected to participate. at our rural center, patient convenience appears to be a factor in choosing to participate in telemedicine. thirty-two percent of patients stated that visits were "more convenient overall" and 9% cited "convenient appointment times." in addition, we found these visits were often more convenient for the surgeon because they could be conducted outside of standard clinic times, particularly during longer-case turnovers at our main hospital. limitations of this study include that it involved a single surgeon and a single institution in a rural location with a homogeneous patient population. the methodology utilized for this investigation is subject to selection bias with respect to patient satisfaction and preferences for telemedicine over conventional clinic visits because all these patients chose to participate in a telemedicine program. however, in clinical practice, only patients willing and able to participate in telemedicine will choose to perform these visits, so our results likely reflect the patient experience with this technology. we recorded travel distances from patient's home addresses. in some cases, it is possible that the patient may have traveled from work or another location to their in-clinic visit. in addition, the patients in our series underwent lower-complexity surgical procedures owing, in part, to the clinical exclusion criteria. there are inherent limitations associated with physical examination during telemedicine encounters, particularly with respect to the assessment of sensation and provocative maneuvers. although the remote examination appears to be sufficient for these lower complexity postoperative visits, future analysis of the accuracy of telemedicine examinations is necessary. future investigations are necessary to analyze the utility of this technology for higher-complexity procedures, particularly with respect to complication recognition. a telemedicine program for postoperative care after hand and upper extremity surgery decreases travel burdens associated with conventional in-clinic appointments. furthermore, telemedicine significantly decreases visit times without decreasing pa-tient satisfaction for patients who elect to participate in remote video visits. the ability to recognize early postsurgical complications was not compromised by utilizing this technology, even during our early experience. prospective randomized controlled trial using telemedicine for followups in an orthopedic trauma population: a pilot study the use of telemedicine decreases unnecessary hand trauma transfers clinical effectiveness and cost analysis of patient referral by videoconferencing in orthopaedics can telemedicine be used for adolescent postoperative knee arthroscopy follow-up? patient satisfaction with remote orthopaedic consultation by using telemedicine: a randomized controlled trial the authors would like to acknowledge amy reitz and janice heimbach, rn, for their assistance with patient scheduling and study coordination. key: cord-309074-pys4aa60 authors: huang, victoria w.; imam, sarah a.; nguyen, shaun a. title: telehealth in the times of sars-cov-2 infection for the otolaryngologist date: 2020-05-30 journal: world j otorhinolaryngol head neck surg doi: 10.1016/j.wjorl.2020.04.008 sha: doc_id: 309074 cord_uid: pys4aa60 objective: in response to the american academy of otolaryngology – head and neck surgery’s recommendations to limit patient care activities in the times of sars-cov-2, many elective surgeries have been canceled without patient clinics transitioning to virtual visits. with regulations for telemedicine loosened, new possibilities for the practice of otolaryngology have opened. to address the uncertain duration of this pandemic, a review was conducted of current literature on use of telemedicine services in the current sars-cov-2 pandemic and in previous national emergencies to reveal the role telemedicine can play for otolaryngology practices. data sources: pubmed articles with an independent search query were utilized. methods: literature review performed by one author searched for all published english-language literature on telehealth in the sars-cov-2 era. articles were considered for discussion if they provided relevant developments for telemedicine in the context of the sars-cov-2 pandemic. results: telemedicine can be up-scaled in the current sars-cov-2 pandemic where exposure containment is of the utmost priority. with patient interaction possible through virtual communication, telemedicine allows continued patient care while minimizing the risk of viral spread. in the realm of otolaryngology, telemedicine has been used in the past during disasters with other studies demonstrating high diagnostic concordance with inpatient visits. many institutions have recognized the potential for such care as they begin utilize both virtual visits and in-person care during this pandemic. conclusion: to limit the spread of sars-cov-2, we support the aao-hns recommendation for the adoption of novel ways to employ telemedicine in this era. many emergency departments and health care systems have the infrastructure necessary for synchronous video telemedicine visits that can be leveraged to provide quality care with patients. with the continued need to socially distance, telemedicine can protect both physicians and patients from unnecessary exposure to the virus. socially distance, telemedicine can protect both physicians and patients from unnecessary exposure to the virus. the practice of medicine is changing as the coronavirus infection, also known as severe acute respiratory syndrome coronavirus 2 (sars-cov-2), continues to spread. currently, without a vaccine, social distancing and isolation have become the most effective measures to decrease transmission 1,2 .otolaryngologists appear to be at higher risk than their colleagues of contracting sars-cov-2 according to the director of the intensive care unit at peking union medical college hospital 3 . this may be due to high viral load in the nasal cavities and nasopharynx 4 . additionally, the frequent use of irrigation and anesthetic sprays in otolaryngology may aerosolize these viral particles. this can dramatically increase exposure to sars-cov-2 as the virus can remain airborne viable for longer than three hours 5, 6 .these compounding risks have resulted in the cancellation of elective surgeries, rescheduling of nonurgent office visits, and even alterations to how standard physical exams and diagnostic tests are performed 7 . however, high-quality patient care must still be provided while minimizing the risk of exposure of patients and providers to the virus. in response to these evolving needs, the american academy of otolaryngology -head and neck surgery (aao-hns) telemedicine committee has put forth new recommendations to prioritize novel applications of telehealth to help limit coronavirus disease pandemic spread while maintaining quality care 8 . telehealth and telemedicine are defined as direct exchanges of medical information from one site to another through secure electronic communication to improve a patient's health 9 . many health systems in the u.s. already have telemedicine programs in place, allowing clinicians to see patients who are at home. these services have traditionally been used for chronic disease management with increasing research in mental health and counseling use especially during times of crisis 10, 11 . these virtual sessions can be either synchronous with real time video exchange or asynchronous (store-and-forward) with clinical data stored and forwarded to a remote clinician for further analysis. in the current sars-cov-2 pandemic, the medicare population continues to be at high risk and a transition to telemedicinecare for these patients may greatly reduce exposure and decrease risk of infection. there are three main types of virtual services practitioners can provide to medicare beneficiaries: medicare telehealth visits, virtual check-in, and e-visits 12 . medicare telehealth visits require audio and video telecommunication systems that allow real-time communication between the patient and the distant site. in the past, these visits required a prior relationship with the provider, but in this declared national emergency, the u.s.department of health and human services (hhs) stated that they will not conduct audits to confirm a relationship with the provider. another major barrier to wide-spread adoption was reimbursement 12 . to address this, the hhs has waived certain telehealth regulations to allow for its expanded use for medicare patients. retroactive to march 6, 2020, medicare will pay for office, hospital, and other visits through telehealth across the country at the same rate as regular, in-person visits. additionally, the hhs office for civil rights has also made flexibilities on hipaa guidelines, allowing clinicians and patients to communicate through any non-public facing remote communication product including apple facetime, facebook messenger video chat, google hangouts video, and skype, though hipaa-compliant video communication products such as skype for business, updox, vsee, zoom for healthcare, doxy.me, and google g suites hangouts meet are still recommended 13 . as infection rates continues to change, the duration of this pandemic remains uncertain and necessitates plans to utilize available structures. in this article, we review the current literature on use of telemedicine services in the current sars-cov-2 pandemic and its use in previous national emergencies to help realize the true value of telemedicine and change the way otolaryngologists can provide care for patients. with the aao-hns telemedicine committee advocating for novel applications of telemedicine in this era of sars-cov-2, a review of its previous applications revealed telemedicine has long played a role in medical response to disasters 14 . telemedicine can deploy large numbers of providers and facilitate triage to prevent the overwhelming of front-line providers. this makes it an ideal model to up-scale in a pandemic where exposure containment is of the utmost priority. pandemic responses in the united kingdom and australia have already called upon the increased use of telemedicine 11 . however, clinician willingness and acceptance of telehealth, reimbursement, and organization of the current health care systems continue to be major barriers to increased implementation outside of the emergency department 11, 15 . in the u.s., many hospital systems already have telemedicine departments embedded within their systems. recognizing that much of medicine is cognitive, many neurologic intensive care units across institutions like cleveland clinic, university of pittsburgh and jefferson health provide virtual icu visits through which neurointensivists monitor patients remotely while bedside critical care nurses examine patients with their guidance 16, 17 . the use of electronic consults(econsults),which allow primary care physicians to consult specialists through the electronic medical record, has been documented in the canadian health system 18, 19 .this was recently studied in the otolaryngology practice at ucsd and resulted in improved access to specialists for timely advice and reduced unnecessary face-to-face specialist referrals 20 . many major university hospital sites are now adopting more technology to improve their response to the sars-cov-2 pandemic. ucla and new york presbyterian hospitals have followed singapore's response by providing rapidly accessible information through a chatbox on their websites to answer any questions regarding sars-cov-2 11, 21, 22 . as testing in the u.s. becomes more available in this era of sars-cov-2, telemedicine continues to take the main role of "forward triage", evaluating patients with respiratory symptoms before they arrive in hospitals 23 with the aao-hns recommending all otolaryngologists to limit patient care activities to time-sensitive, urgent, and emergent medical conditions, elective surgeries have been canceled with many outpatient clinics rescheduling appointments and transitioning to virtual visits 7, 8 . at institutions like johns hopkins and ohio state, providers are asking patients to change appointments to virtual ones 29, 30 .telemedicine appointments can be conducted with both the clinician and patient at home, limiting travel and exposure while maintaining uninterrupted quality care with established patients. as a part of the covid-19 public health emergency response, medicare has stated that it will pay for office, hospital, and other visits through telehealth across the country at the same rate as regular, in-person visits 12 this presents a unique opportunity for clinicians to make use of telemedicine. the otolaryngology field has been slow to widely adopt telemedicine, though it has been gaining ground as the frequent archiving of audio and visual images from exams makes the field uniquely suited to adopt advances in telemedicine. in 2010,the hurricane katrina disaster left louisiana state university health science center with no neurotology service. a store-andforward model of telemedicine was implemented and a previously established telemedicine neurotology clinic in baton rouge forwarded clinical materials to a neurotologist in pittsburgh, which resulted in positive anecdotal patient responses 33 .to identify specific areas in otolaryngology that would be most suitable for telemedicine visits, a study on veterans in the new england area identified that 62% of visits did not require specialized procedures and could be conducted with the help of a health technician that could synchronously communicate with a remote otolaryngologist 34 . taking advantage of telemedicine and remote centers can also greatly reduce travel burden as the study found 42% of patients were driving over 3 hours for otolaryngology services. to address concerns of diagnostic accuracy through telemedicine visits, ohio state piloted studies assessing diagnostic concordance of an on-site and remote practitioner receiving synchronous information through video 35 .for the21 cases, there was a 95% diagnostic concordance for patients presenting with a variety of diagnoses such as vocal cord leukoplakia, acute otitis externa, and septal deviation. of note, only 62% of patients indicated they would travel to see an otolaryngologist, suggesting that about one third of patients may not have pursued otolaryngology care if there was not a nearby telemedicine clinic. physician and patient satisfaction of the video and audio quality were both over 95% and both agreed that care was more accessible with this technology. while all these applications of telemedicine resulted in high patient and provider satisfaction, they still required patients to travel to a telemedicine clinic and interact with a healthcare provider, making them less ideal in the era of sars-cov-2. some hospitals have employed telemedicine in ways that do not require any travel to a clinic to limit patient exposure to providers. following head and neck free tissue transfer, residents at ucsf performed60 flap checks through video. evaluations of skin color, skin turgor, capillary refill and doppler signal were similar between telemedicine and in-person groups 36 . however, if patients experience flu-like symptoms, they are urged to call the clinic or hospital and asked to call another number to assess if they will need further testing. anecdotal evidence from physicians noted better reimbursement when compared to telephone visits and higher physician satisfaction with patient interaction. however, as the aao-hns still allows for inperson care of "time-sensitive, urgent, and emergent medical conditions", hospitalized patients and post-operative visits after major surgery are still seen in-person with proper protection. seattle's slowing infection rates highlights how adherence to early social distancing and quarantine can reduce infection rates of sars-cov-2 40 . even as elective surgeries are cancelled and non-urgent outpatient visits are postponed, there is still a way to provide quality care for patients. with the need for social distancing, telemedicine has become the ideal tool to allow communication between a physician and a patient. to limit the spread of sars-cov-2, we support the aao-hns recommendation for the adoption of novel ways to employ telemedicine in this era. as many emergency departments and health care systems have the infrastructure necessary for synchronous video telemedicine visits, we propose the adoption of novel uses for existing telemedicine portals. for those without an existing structure, it is possible to outsource telemedicine services to programs such as teladoc health or american well 23 . we have reviewed the available methods of employing telemedicine and continue to encourage new applications and integration into otolaryngology practices. current use of telemedicine is targeted toward the screening and management of suspected sars-cov-2 patients. as the sars-cov-2 pandemic continues to unfold, recommendations on social isolation may evolve and require adjustments to traditional patient care workflow. we support the aao-hns recommendation to limit all in-person care to urgent cases, but propose the use of telemedicine to continue quality care with established patients. with the continued need to socially distance, telemedicine can protect both physicians and patients from unnecessary exposure to the virus. none. none. none. scientific and ethical basis for social-distancing interventions against covid-19 world health organization. guidance for health workers europe's doctors repeat errors made in wuhan sars-cov-2 viral load in upper respiratory specimens of infected patients aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review academy supports cms, offers specific nasal policy prioritizing novel approaches to telehealth for all practitioners successful telemedicine programs in otolaryngology the role of telehealth in reducing the mental health burden from covid-19 telehealth for global emergencies: implications for coronavirus disease 2019 (covid-19) medicare telemedicine health care provider fact sheet notification of enforcement discretion for telehealth remote communications during the covid-19 nationwide public health emergency the role of telehealth in the medical response to disasters video consultations for covid-19 telemedicine/virtual icu: where are we and where are we going tele-critical care: an update from the society of critical care medicine tele-icu committee the impact of electronic consultation on a canadian tertiary care pediatric specialty referral system: a prospective single-center observational study improving access to otolaryngology-head and neck surgery expert advice through econsultations electronic consults in otolaryngology: a pilot study to evaluate the use, content, and outcomes in an academic health system ucla health. coronavirus information new york-presbyterian. coronavirus (covid-19): what to know virtually perfect? telemedicine for covid-19 how to start a virtual care visit cleveland clinic express care online getting care during the covid-19 outbreak johns hopkins health. coronavirus (covid-19) information and updates people who are at higher risk for severe illness telemedicine is a smart, safe choice telemedicine-assisted neurotology in post-katrina southeast louisiana where does telemedicine fit into otolaryngology? an assessment of telemedicine eligibility among otolaryngology diagnoses developing a synchronous otolaryngology telemedicine clinic: prospective study to assess fidelity and diagnostic concordance comparison of video and in-person free flap assessment following head and neck free tissue transfer telemedicine in otolaryngology outpatient setting-single center head and neck surgery experience detection of sars-cov-2 among residents and staff members of an independent and assisted living community for older adults physical distancing is working and still needed to prevent covid-19 resurgence in king not applicable. not applicable. the datasets supporting the conclusion of this article are included within the article.authors' contributions san, vwh, sai drafted the manuscript;all authors read and approved the final manuscript. this study requires no ethics approval due to public data-based analysis.the authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. not applicable all authors declare no conflict of interest in this study. this article does not contain any studies with human participants or animals performed by any of the authors. key: cord-104485-3anla664 authors: patel, tushar a; johnston, craig a; cardenas, victor j; vaughan, elizabeth m title: utilizing telemedicine for group visit provider encounters: a feasibility and acceptability study date: 2020-08-02 journal: int j diabetes metab syndr doi: nan sha: doc_id: 104485 cord_uid: 3anla664 background: the value of telemedicine has been underscored during the coronavirus pandemic. utilizing telemedicine could markedly enhance group visit scalability and sustainability. however, there are limited data demonstrating telemedicine use for group visits. objective: to evaluate the feasibility and acceptability of provider encounters conducted via telemedicine in group visits. materials and methods: we conducted a 6-month diabetes group visit program and compared in-person (months 1–3) versus telemedicine (videoconferencing) (months 4–6) patient-provider encounters. participants completed the telehealth usability questionnaire (tuq) at 6-months (primary outcome). to ensure telemedicine did not negatively affect clinical outcomes, we compared in-person versus telemedicine differences in hba1c, blood pressure, body mass index (bmi), and attendance. results: the tuq revealed that participants (n=19) found telemedicine useful and easy to use (4.9/5.0, 4.4/5.0, respectively) and with excellent interface (4.3/5.0), interaction (4.6/5.0), reliability (4.2/5.0), and satisfaction (4.4/5.0). there were no significant differences in clinical outcomes between arms: hba1c (in-person: −0.60%, telemedicine: −0.52%, p=0.86), blood pressure (systolic: p=0.475, diastolic: p=0.683), weight (p=0.982), bmi (p=0.981), attendance (in-person: 75.44%, telemedicine: 70.12%, p=0.551). conclusion: provider telemedicine encounters in group visits are feasible and acceptable. this is a promising model to address provider limitations in group visits and increase access to care. larger studies are needed to further evaluate these findings. more than half of the world lacks access to essential health services [1, 2] . diabetes group visits, shared medical appointments that include education and medical evaluation, are costeffective programs that have demonstrated increased healthcare access and improved clinical outcomes [3, 4] . a four-year, multicenter randomized controlled trial (n=815) revealed that individuals receiving group visits significantly improved body mass index (bmi), fasting glucose, hba1c, blood pressure, and cholesterol levels compared to those in usual care (p<0.001) [5] . similarly, a systematic review of 26 diabetes group visit programs showed significant hba1c reductions (-0.46%, 95% confidence interval −0.80% to −0.31%) [6] . however, ongoing shortages of primary care providers (pcps) place group visits at risk [7] . low-and middle-income countries have continued to face severe deficiencies [8] . there are 80 pcps/100,000 us persons, which decreases to 68/100,000 in rural settings [9] . though there are more pcps/person in urban settings (84/100,000) [9] , healthcare distribution is disproportionally lower for resource-poor populations and retention remains problematic [10] . covid-19 has highlighted the value of telemedicine and the facilitation of health-related services via digital communication [11, 12] . yet, there are limited data exploring the use of telemedicine in group visits. a va team from hawaii conducted diabetes group visits with participants in guam via telemedicine and found that intervention participants improved hba1c levels compared to individuals in usual care (p=0.03) [13] . another telemedicine group visit investigation of young adults with type 1 diabetes revealed fewer non-study office visits and hospitalizations of individuals in the program compared to those in usual care [14] . however these studies did not include low-income, uninsured, or minority individuals. lowincome settings often have local staff including community health workers (chws), diabetes educators, and nurses available to conduct group visit education in-person [3] . these individuals offer great value to minority populations by enhancing healthcare systems' understanding of cultural elements to care [15] . however, these settings are severely limited by lack of pcp availability [9, 10] . utilizing telemedicine for provider encounters while a local team conducts group visits inperson is a promising strategy to address provider limitations. the objective of this study was to evaluate the feasibility and acceptability of group visit provider encounters conducted via telemedicine while chws led the educational sections in-person for a low-income, latino(a) population. specifically, we compared in-person months 1-3 to telemedicine (videoconferencing) months 4-6. outcomes included the telehealth usability questionnaire (tuq) [16] (primary) and in-person versus telemedicine clinical comparisons (hba1c, blood pressure, bmi, attendance) to ensure there were no negative affects during the latter period. we hypothesized that telemedicine encounters would be feasible and acceptable and that these months would not negatively affect clinical outcomes. we conducted a prospective, feasibility and acceptability study of provider-patient telemedicine encounters in diabetes group visits at a 501(c)(3) community clinic that serves low-income (≤250% federal poverty level), uninsured individuals in houston, texas. the diabetes group visit program structure was based on our prior study [17] . briefly, group visits met monthly for six months and consisted a clinical visit (vitals, labs, 1:1 physician encounter) and chw-led education (large group and small group break-out sessions). the institutional review board at baylor college of medicine approved the study (irb h-40322). written consent and signed group visit confidentiality forms were obtained from each participant. zoom was the software platform. it provided end-to-end 256bit encrypted, secured, and hipaa-compliant audio and video conferencing [18] . participants first met with a provider (physician) in-person months 1-3 and then via telemedicine months 4-6. the provider encounter included reviewing laboratory data and home glucose logs (if applicable), medication titration and refills for diabetes, hypertension, and hyperlipidemia. during the inperson encounters, the provider met with the participant one-on-one in the same room. during the telemedicine encounters, the provider met with participants from a remote site via video conferencing while study staff sat with the participant at the clinic for assistance e.g., holding up medication bottles, reading glucose logs, etc. a local physician was on-site at the clinic at all times should participants have needed to be seen in-person. inclusion criteria consisted included a documented diagnosis of type 2 diabetes (i.e., hba1c ≥6.5), ability to understand spanish, and self-identified as latino(a). individuals were excluded if their healthcare needs were too complex or not appropriate for a group setting (i.e., pregnancy). potential participants were identified primarily by the clinic database. study staff called the eligible participants, explained the study, and, if interested, invited them to an orientation where they obtained baseline data and written consents [17] . feasibility and acceptability were measured by the tuq (primary outcome). the tuq consists of 21 questions ranked on a fivepoint likert scale (definitely disagree, disagree, neutral, agree, and definitely agree) and divided into six sections: usefulness (3 questions), ease of use (3 questions), interface and interaction quality (4 questions), reliability (3 questions), and satisfaction and future use (4 questions). each of these variables has demonstrated good to excellent internal consistency (standardized cronbach coefficient alpha 0.81-0.93) and strong content validity and reliability [16] . in addition, three openended, free-text questions were added at the end of tuq to provide descriptive data of participant likes, dislikes, and items they would like to change about the telemedicine process. due to a limited literacy in low-income settings and minority populations [19] , surveys were read aloud by a native spanish speaker and assistance for writing was provided as needed. the tuq was translated from english to spanish using iso 17100:2015 compliant gts translation service [20] . we also evaluated eight focal areas of feasibility: acceptability (how participates reacted to telemedicine), adaptation (changing program (if applicable)), demand for intervention (attendance), expansion (potential success within a different population or setting), limitedefficacy testing (i.e., tuq, clinical outcomes), implementation (likelihood telemedicine could be conducted as proposed), integration (level of change needed to initiate telemedicine), and practicality (extent telemedicine could be delivered) [21] . further, to evaluate if participants had adverse effects associated with telemedicine, we compared the baseline to 6-month change of hba1c, blood pressure, and bmi. sigmaplot version 13.0 was used for statistical analysis. descriptive statistics, including mean and standard deviation was performed on the tuq scores, hba1c, weight, bmi, and blood pressures. a paired t-test was used for normally distributed data. wilcoxon signed rank test was used to evaluate distributions that failed normality test (shapiro-wilk). tuq missing data was omitted from the analysis. clinical missing data was handled by last observation carried forward. analysis was intention to treat. statistical significance was set at p<0.05 was considered statistically significant. this was a feasibility and acceptability study and not powered for statistical significance [21] . baseline characteristics of the participants are illustrated in table 1 . our sample consisted of slightly more females (52.6%), and the average age was 52 years (range 27-63 years). the most common work was domestic (52.6%) followed by manual labor (e.g., construction, landscaping) (36.9%) and food service (10.5%). the mean time since diagnosis of diabetes was less than 10 years (mean 8.69). baseline clinical data showed mean hba1c levels were uncontrolled (8.46%) and bmi averaged in the obese range (37.77 kg/m 2 ). other baseline clinical levels were near-normal: ldl cholesterol (101.18 mg/dl), triglycerides (186.89 mg/ dl), and blood pressure (133.50/77.68). the tuq resulted in systematic positive findings ( table 2) . participants reported high levels in regards to its usefulness (4.9/5.0), ease of use (4.4/5.0), interface (4.3/5.0), interaction (4.6/5.0), reliability (4.2/5.0), and their satisfaction (4.4/5.0). descriptive data revealed that participants valued clear visualization and real-time conversations without interruption the most. participants improved glycemic control during the six-month diabetes group visits (hba1c: 8.46 to 7.86%, p=0.12), which had a moderate effect size (49.7). within group comparisons revealed that hba1c improvements were comparable during the in-person months 1-3 versus the telemedicine months 4-6 (-0.60% (effect size 25.0) vs. −0.52% (effect size 24.0), respectively). similarly, in-person versus telemedicine blood pressure, bmi, and weight changes were not significantly different. blood pressure trends favored the telemedicine more than the in-person months: (systolic: 4.31 vs. −2.53 mmhg (p=0.475), diastolic: 2.63 vs. −1.32 mmhg (p=0.683), respectively). attendance was comparable during in-person and telemedicine encounters (75.4% vs. 70.2%, respectively, p=0.551) ( table 3 ). this study evaluated patient-provider telemedicine encounters during group visits and found that they were feasible and acceptable as evidenced by systematic positive findings on the tuq and no negative clinical impact during the virtual months. covid-19 has highlighted telemedicine's ability to facilitate healthcare [11, 12] . telemedicine could greatly improve diabetes group visit scalability and sustainability. however, there is a limited data demonstrating its use in these important programs [13, 14] and no reported investigations in low-income, minority populations prior to the current study. numerous studies have demonstrated that diabetes group visits are valuable in improving health outcomes and reducing disparities [3, 4, 6] . utilizing telemedicine for group visits has the potential to markedly increase access to care, which is becoming increasingly important with ongoing primary care deficiencies [7] . the heightening shortage of primary care providers that disproportionately affects underserved communities has made access to healthcare a pressing issue [8] [9] [10] . the covid-19 pandemic has underscored disparities amongst low-income minorities and the value of telemedicine [11, 12] . new and innovative ways are critical to reach communities. healthcare practitioners are a vital piece of group visits as they provide medications review, titration, and refills [22] [23] [24] . this telemedicine modality has the ability to enable providers to care for individuals across expansive geographical borders while locally trained individuals, such as chws, provide education on-site. maintaining local staff educators is especially beneficial in addressing cultural barriers and individualizing needs, particularly in low-income and minority populations [15] . there are several important points related to eight feasibility focal areas: acceptability, adaptation, demand, expansion, limited-efficacy testing, implementation, integration, practicality [21] . the program was acceptable as measured by patient satisfaction (tuq), particularly the intent to continue use (mean 4.4/5), and by clinical data. limited-efficacy testing was demonstrated by positive tuq and noninferior clinical outcomes. there was a consistent demand for the program as documented by the attendance. there was a slight, nonsignificant drop (75.4% to 70.2%, p=0.551) from months 1-3 to 4-6 but this was more likely due to the longevity of the class rather than a reflection of the telemedicine encounters. prior studies have also supported the demand of telemedicine in diabetes care; a 12-month randomized controlled trial comparing telemedicine diabetes self-management education revealed greater hba1c reductions in the intervention group (9.4 to 8.2% vs. 8.8 to 8.6%, respectively), which continued to improve for 24-months [25] . a key part of integration, and thereby expansion, is a needs and asset assessment [26] . for example, the healthcare site's technology structure and software platforms, which are widely variable particularly within low-income settings, need to be examined to determine what structures are in place and will need to be added. implementation and practicality success in the current study was supported by the software program and server (zoom) that has been used extensively worldwide and is encrypted for patient safety [18, 27] . the internet was occasionally unreliable, causing the video-conference to stall or disconnect entirely, which may be reflected in some of the lower tuq scores. conducting the study over a reliable internet or a physical connection via ethernet port can mitigate this issue. to evaluate expansion, further investigations are needed with larger sample sizes and in other settings. this study is limited by size and in one locale but it provides foundational data to expand to larger, more diverse areas. also, since all patients spoke spanish but not all study staff members were bilingual, this may have increased telemedicine encounter time and altered tuq outcomes. we observed that when native speakers interacted with the participants, encounters were smoother and the encounter times decreased. these findings provide preliminary data of a novel intervention of patient-provider telemedicine encounters in group visits that is promising to increase access to care and sustainability of these valuable programs. these findings are particularly important with the ongoing shortages of primary care providers worldwide and critical needs to increase access to care in vulnerable populations. larger multi-center studies are warranted to evaluate the expansion of these findings. patient-centred access to health care: conceptualising access at the interface of health systems and populations tracking universal health coverage a narrative review of diabetes group visits in low-income and underserved settings using group medical visits with those who have diabetes: examining the evidence rethink organization to improve education and outcomes (romeo): a multicenter randomized trial of lifestyle intervention by group care to manage type 2 diabetes. diabetes care effectiveness of group medical visits for improving diabetes care: a systematic review and meta-analysis the primary care physician shortage primary healthcare system performance in low-income and middle-income countries: a scoping review of the evidence from unequal distribution of the u.s. primary care workforce commitment to care for the community telemedicine in the face of the covid-19 pandemic telehealth for global emergencies: implications for coronavirus disease 2019 (covid-19) the utilization of video-conference shared medical appointments in rural diabetes care cost-effectiveness of shared telemedicine appointments in young adults with t1d: coyot1 trial. diabetes care cultural elements underlying the community health representative -client relationship on navajo nation development of the telehealth usability questionnaire (tuq) a telehealth-supported, integrated care with chws, and medication-access (time) program for diabetes improves hba1c: a randomized clinical trial addressing health literacy and numeracy to improve diabetes education and care how we design feasibility studies medication adherence: who cares? the unmet challenge of medication nonadherence poor medication adherence in type 2 diabetes: recognizing the scope of the problem and its key contributors telehealth improves diabetes self-management in an underserved community: diabetes telecare. diabetes care assets-oriented community assessment the authors wish to thank the host clinic, san jose (houston, tx) and the community health workers who were essential to the study findings. the authors are grateful for the many contributions of dr. david hyman who recently passed away june 22, 2020 and offer their sincere condolences to his family. he is missed greatly.the authors declare that there is no conflict of interest. the national institutes of health, national institute of diabetes, digestive, and kidney diseases (federal award identification number dk11034) supported this work (pi, vaughan). key: cord-330545-jrmott3i authors: abuzeineh, mohammad; muzaale, abimereki d.; crews, deidra c.; avery, robin k.; brotman, daniel j.; brennan, daniel c.; segev, dorry l.; al ammary, fawaz title: telemedicine in the care of kidney transplant recipients with covid-19: case reports date: 2020-07-16 journal: transplant proc doi: 10.1016/j.transproceed.2020.07.009 sha: doc_id: 330545 cord_uid: jrmott3i abstract kidney transplant recipients who develop symptoms consistent with covid-19 are bringing unique challenges to health care professionals. telemedicine has surged dramatically since the pandemic in efforts to maintain patient care and reduce the risk of covid-19 exposure to patients, healthcare workers, and the public. herein we present reports of three kidney transplant recipients with covid-19 that were managed using telemedicine via synchronous video visits integrated with an electronic medical records system, from home to inpatient settings. we demonstrate how telemedicine helped assess, diagnose, triage, and treat patients with covid-19 while avoiding an emergency room or outpatient clinic visit. while there is limited information about the duration of viral shedding for immunosuppressed patients, our findings underscore the importance of using telemedicine in the follow-up care for kidney transplant recipients with covid-19 who have recovered from symptoms but might have persistently positive nat tests. our experience emphasizes the opportunities of telemedicine in the management of kidney transplant recipients with covid-19 and in the maintenance of uninterrupted follow-up care for such immunosuppressed patients with prolonged viral shedding. telemedicine may help increase access to care for kidney transplant recipients during and beyond the pandemic as it offers a prompt, safe, and convenient platform in the delivery of care for these patients. yet in order to advance the practice of telemedicine in the field of kidney transplantation, barriers to increasing the widespread implementation of telemedicine should be removed, and research studies to assess the effectiveness of telemedicine in the care kidney transplant recipients are needed. that were managed using telemedicine via synchronous video visits integrated with an electronic medical records system, from home to inpatient settings. we demonstrate how telemedicine helped assess, diagnose, triage, and treat patients with covid-19 while avoiding an emergency room or outpatient clinic visit. while there is limited information about the duration of viral shedding for immunosuppressed patients, our findings underscore the importance of using telemedicine in the follow-up care for kidney transplant recipients with covid-19 who have recovered from symptoms but might have persistently positive nat tests. our experience emphasizes the opportunities of telemedicine in the management of kidney transplant recipients with covid-19 and in the maintenance of uninterrupted follow-up care for such immunosuppressed patients with prolonged viral shedding. telemedicine may help increase access to care for kidney transplant recipients during and beyond the pandemic as it offers a prompt, safe, and convenient platform in the delivery of care for these patients. yet in order to advance the practice of telemedicine in the field of kidney transplantation, barriers to increasing the widespread implementation of telemedicine should be removed, and research studies to assess the effectiveness of telemedicine in the care kidney transplant recipients are needed. • telemedicine helped diagnose, triage, and manage transplant patients with covid-19 • practical workflow process for covid-19 test and surveillance • telemedicine aid from home to inpatient settings, while avoiding er or clinic visit • telemedicine provides prompt, safe, and convenient approach to covid-19 patients kidney transplant recipients who develop symptoms consistent with covid-19 are bringing unique challenges to health care professionals. 1,2 while the potential for both community and nosocomial spread of covid-19 when such patients seek care is a major concern, proper diagnosis and management of these patients must be accommodated. [3] [4] [5] [6] [7] telemedicine has emerged dramatically during the covid-19 pandemic and allowed clinicians to offer the standard of care to their patients with covid-19, but with heightened public health consciousness. telemedicine offers an immediate virtual patient-provider visit without increasing the risk of covid-19 exposure to patients, healthcare workers, and the public. telemedicine also helps to preserve the supply of personal protective equipment (ppe) by limiting the number of times providers need to don ppe to clinically evaluate patients. 8 regulatory and financial burdens to the spread of telemedicine have been lifted temporarily in light of the covid-19 pandemic. [9] [10] [11] in a national survey of us transplant centers, 98.4% limited in-person outpatient visits for solid organ transplant recipients and 96.8% implemented telemedicine in response to the pandemic. 12 these adopted telemedicine initiatives leverage existing, underutilized telecommunications technology and nationally mandated electronic medical records. 13 herein we present three kidney transplant recipients with covid-19 that were managed using telemedicine via synchronous video visits integrated with an electronic medical records system, from home to inpatient settings. a 53-year-old male with a prior history of end-stage renal disease (esrd) secondary to hypertensive nephrosclerosis who underwent a living related kidney transplant in january 2012. he had induction therapy with rabbit antithymocyte globulin (ratg) and was maintained on an immunosuppression regimen of prednisone 2.5 mg once daily and tacrolimus dosed to achieve target trough level of 4-6 ng/ml. he was off mycophenolate mofetil (mmf) due to a history of bk viremia and skin cancer. he had stable allograft function with a baseline creatinine of 1.3 mg/dl. he called the transplant team complaining of dry cough, low-grade fever, chills, nausea and vomiting, watery diarrhea, and loss of the sense of smell. covid-19 testing was performed in a designated drive-through area at our center on the same day (naso/oropharyngeal swab, nucleic acid test [nat] was used to detect covid-19 rna by polymerase chain reaction [pcr]). he was asked to self-quarantine while awaiting his test results, according to centers for disease control and prevention (cdc) guidelines. 14 on the following day, the covid-19 test resulted as positive, and an immediate telemedicine video visit was conducted by a transplant nephrologist. during this virtual visit, the patient was found to have worsening shortness of breath and increased work of breathing. his home vital signs were notable for blood pressure (bp) of 130/82 mmhg, heart rate of 88 beats per minute, oxygen saturation (o2 sat) of 94% on room air using a patient home kit. given stable vital signs but increased work of breathing, the decision was made to arrange for direct hospital admission to a dedicated covid-19 inpatient unit, avoiding the emergency room (er) route to reduce risk of exposure to patients, health care workers, and the public. a multidisciplinary team approach was initiated, including transplant infectious disease and nephrology, hospital medicine, and admission office. the infection control office provided special instructions to the patient facilitating safe transfer for hospital admission. his laboratory findings during hospitalization are summarized in table 1 . he was started on ceftriaxone 1 gm iv daily and azithromycin 500 mg p.o daily (to treat potential bacterial superinfection) and hydroxychloroquine 400 mg p.o twice daily for one day, then 400 mg daily on days 2, 3, 4 and 5. his electrocardiogram (ecg) showed qtc interval of 0.43 seconds. on day 3 of admission, he developed hypoxia and required 3 liters of oxygen via nasal cannula; other vitals remained within normal limits. chest ct scan findings were consistent with features for covid-19 infection. azithromycin was replaced with doxycycline for concern of azithromycin induced diarrhea. his oxygen requirements gradually improved and eventually he was weaned off supplemental oxygen. on day 6 of admission, his symptoms resolved, and he was discharged home in stable condition with instructions to self-quarantine. during his hospital stay, he was followed by the transplant nephrology consult team via telemedicine video visits to reduce exposure risk and preserve ppe. similarly, after discharge he was followed via telemedicine video visits. his covid-19 related hospital course and treatment are summarized in table 2 . a 56-year-old female with a prior history of esrd secondary to focal segmental glomerulosclerosis who underwent a living unrelated kidney transplant in june 2019. she had induction therapy with ratg and maintained on an immunosuppression regimen of prednisone 5 mg once daily, tacrolimus dosed to achieve target trough level of 5-8 ng/ml and mmf 500 mg twice daily. she had stable allograft function with a baseline creatinine of 0.9 mg/dl. she called the transplant team complaining of dry cough, rhinorrhea, and chest tightness. the patient was asked to stop mmf. covid-19 testing was done as mentioned in patient 1. on the following day, her covid-19 test returned as positive, and an immediate telemedicine video visit was conducted by a transplant nephrologist. during this virtual visit, she was found to have mild symptoms and home vital signs were noted to be normal. therefore, she was asked to continue self-quarantine and closely monitor her symptoms. on day five of the presentation, she reported not feeling well with fever of 100.7 o f and diarrhea. it was decided to proceed with a direct inpatient admission with a similar multidisciplinary approach mentioned in patient 1. on admission, her bp was 109/63 mmhg, temperature was elevated at 101 o f, heart rate was 94 beats per minute and her o2 sat was 99% on room air. her laboratory findings during hospitalization are summarized in table 1 . she was started on cefepime 1 gm iv every 8 hours (to treat potential urinary tract infection), and hydroxychloroquine 400 mg p.o twice daily for one day, then 400 mg daily on days 2, 3, 4, and 5. her ecg showed qtc interval was 0.407 seconds. on the 4 th day of admission, she developed hypoxia and required 4 liters of oxygen via nasal cannula; other vitals remained stable. a chest x-ray showed leftsided lower lobe patchy opacity. she was treated with iv tocilizumab 4 mg/kg per dose for two doses on days 4 and 5 of admission. her oxygen requirements gradually improved and eventually she was weaned off supplemental oxygen. on the 7 th day of admission, her symptoms resolved, and she was discharged home in stable condition with instructions to self-quarantine. during her hospitalization, she was followed by the transplant nephrology consult team via telemedicine video visits, as mentioned in patient 1. similarly, after discharge, she was followed via telemedicine video visits. her covid-19 related hospital course and treatment are summarized in table 2 . the patient had a family gathering with her extended family members and more than 20 family members were present. several family members had mild symptoms with loss of smell and taste, and her husband had a low-grade fever. she called the transplant team complaining of mild headache, rhinorrhea, and fatigue. covid-19 testing was done, as mentioned in patient 1. on the following day, her covid-19 test resulted as positive and an immediate telemedicine video visit was conducted by a transplant nephrologist. during this virtual visit, she was found to have mild headache and no other symptoms. she reported home vital signs which were noted to be normal. thus, she was asked to continue to self-quarantine and closely monitor her symptoms. her symptoms were improving gradually without specific treatment. she was followed as an outpatient by a transplant nephrologist via telemedicine video visits and a transplant coordinator via telephone calls. her covid-19 related outpatient course is summarized in table 2 . in these cases of kidney transplant recipients who presented with covid-19 symptoms, telemedicine provided a safe, and convenient approach to managing these patients in both home and inpatient settings. we found that telemedicine provided an immediate virtual face-to-face, patient-provider visit for clinical assessment, planning for covid-19 testing, and safe management to reduce the risk of exposure. this approach allows for the rapid identification of those in need of hospitalization through an er admission or an arranged direct admission, versus those who are able to remain home with selfquarantine and careful surveillance as summarized in figure 1 and table 3 . also, it facilitates uninterrupted follow-up care for patients during inpatient admission and outpatient monitoring. it is worth noting that the three patients expressed good experience and satisfaction. our management of these patients is consistent with the emerging approach at other us transplant centers. based on a recent national survey, nearly all in-person outpatient visits were suspended in response to the coivd-19 crisis. meanwhile, for those who would have been seen in an outpatient visit, telemedicine has emerged as the preferred option available to them. 12 this adoption of telemedicine on a national scale has been supported by the centers for medicare & medicaid services (cms). under the cms 1135 coronavirus waivers, medicare will pay for office, hospital, and other visits furnished via telemedicine across the country. 9 likewise, many states have issued licensure waiver with respect to telemedicine for out-of-state medical licensees. 10 unlike immunocompetent patients, immunosuppressed patients may shed covid-19 for longer periods of time, potentially increasing transmissibility. [15] [16] [17] this underscores the importance of telemedicine visits in reducing exposures from patients who have recovered from symptoms but might have persistently positive nat tests. in our case reports, two patients who had follow-up covid-19 tests remained positive at 18 and 21 days from onset of diagnosis. one converted to be negative at 24 and 28 days, whereas the other one was persistently positive by nat testing at 24, 28, 35, and 42 days although she had a negative test at 38 days, and eventually converted to be negative at 45 and 48 days. while there is limited information about the duration of viral shedding for immunosuppressed patients and it is not yet known whether protracted persistent nat positivity reflects continued capacity for viral transmission, our case reports suggest longer periods of self-quarantine are appropriate for kidney transplant patients with 19 for patients with scheduled visits/tests that cannot be performed through telemedicine and that will occur within 6 weeks of symptom onset, patients may undergo covid-19 repeat test-based strategy as outpatients (table 3) . a key strength of telemedicine was the promptness and safety in the handling of these three patients with covid-19. patients called in with symptoms of covid-19, a nat test rapidly confirmed that they were positive for coivd-19, a telemedicine video visit was implemented, and a management plan was executed, all within 24 hours. another important strength of telemedicine is the maintenance of continuity of care for transplant patients. creating a systematic telemedicine schedule with the transplant clinician provides an expanded opportunity for patient questions, transmission of information, reassurance, and creating a sense that they are being cared for in a comprehensive way. this application of telemedicine should be generalizable to other solid organ transplant recipients. by extension, telemedicine may help increase access to live kidney donor transplant evaluation, especially for those who have financial challenges to come for an in-person visit or those who live a significant distance from a transplant center. 20-22 that said, we recognize the potential limitations of telemedicine. access to a smart device or computer may not be available for every patient to connect via telemedicine video visits, although audio telephone visits are another option if video technology is not available. 23 other barriers to telemedicine include out of state medical license requirements, reimbursement policies variations, and infrastructure support and personnel staffing need. 24 as such, cost-effectiveness and future reimbursements for telemedicine beyond the covid-19 crisis remain not well defined. in these three reports of kidney transplant recipients, telemedicine helped assess, diagnose, triage, and treat patients with covid-19 while avoiding an er or outpatient clinic visit. our experience emphasizes the opportunities of telemedicine in the safe management of kidney transplant patients with covid-19 from home to inpatient settings and in the maintenance of uninterrupted follow-up care for such immunosuppressed patients with prolonged viral shedding. telemedicine may help increase access to care for kidney transplant recipients during and beyond the pandemic. yet in order to increase the widespread implementation of telemedicine, existing regulatory and financial barriers should be removed permanently. research studies to advance the practice of telemedicine and assess its effectiveness in the care kidney transplant recipients are needed. author contributions: dr. al ammary had full access to all the data in the case reports and takes responsibility for the integrity of the data. study concept and design: al ammary, abuzeineh. drafting of the manuscript: al ammary, abuzeineh, muzaale, avery, crews, segev. critical revision of the manuscript for important intellectual content: al ammary, abuzeineh, muzaale, avery, brennan, brotman, segev. study supervision: al ammary. the authors declare no conflicts of interest. financial disclosure statement: the authors declare no funding was received for this study. the datasets generated and/or analyzed during the current study are not publicly available due to patient privacy but are available from the corresponding author on reasonable request. funding: this work did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. during hospitalization, patient developed shortness of breath and hypoxia. 1 patient 2: dry cough, chest tightness, and rhinorrhea, and subsequently developed high-grade fever and diarrhea. during hospitalization, patient developed shortness of breath and hypoxia. 1 patient 3: mild headache, rhinorrhea and fatigue; symptoms were improving gradually without specific treatment. 2 naso-oropharyngeal swab, nucleic acid test (nat) was use to detect covid-19 rna by polymerase chain reaction (pcr): (+) covid-19 rna detected, (−) covid-19 rna not detected. 3 hydroxychloroquine 400 mg twice daily for 1 st day, then 400 mg once daily for days 2, 3, 4, and 5. 4 tocilizumab 4 mg/kg per dose once daily for a total of two doses. ⁵patient was also followed by a transplant coordinator via telephone calls twice weekly. covid-19 and solid organ transplant coronavirus disease 2019: implications of emerging infections for transplantation. american journal of transplantation : official journal of the american society of transplantation and the american society of transplant surgeons us department of health and human services, cdc novel coronavirus (sars-cov-2) infection in a renal transplant recipient: case report. american journal of transplantation : official journal of the american society of transplantation and the american society of transplant surgeons successful recovery of covid-19 pneumonia in a renal transplant recipient with long-term immunosuppression case report of covid-19 in a kidney transplant recipient: does immunosuppression alter the clinical presentation? american journal of transplantation : official journal of the american society of transplantation and the american society of transplant surgeons american journal of transplantation : official journal of the american society of transplantation and the american society of transplant surgeons shortage of personal protective equipment endangering health workers worldwide medicare telemedicine health care provider fact sheet. expansion of telehealth with 1135 certification/surveycertemergprep/1135-waivers. accessed on apr 15, 2020. 10. states waiving telehealth licensure requirements accessed on telehealth coverage policies in the time of covid-19. the center for connected health policy early impact of covid-19 on transplant center practices and policies in the united states adoption of electronic health record systems among u.s. non-federal acute care hospitals if you are sick virological assessment of hospitalized patients with covid-2019 had mild acute kidney injury (aki) and acute hyponatremia on admission mmol/l and serum osmolarity was 258 mosm/kg suggestive of volume depletion. hence, his home lisinopril was stopped, and he received ringers lactate intravenous (iv) fluid replacement carefully. figure 1: practical workflow process for covid-19 test and surveillance. ¹severe shortness of breath, hypoxia, hypotension, acute chest pain to call 911 for a transfer to hospital emergency room telemedicine via a synchronous video visit for clinical assessment and management to self-quarantine per cdc guidelines and to keep home log of vital signs twice daily in the first two weeks. patients are instructed to seek immediate medical attention if symptoms worsening to be followed-up by a transplant coordinator via telephone calls twice weekly and transplant nephrologist via telemedicine video visits close to two-week post covid-19 diagnosis and thereafter as clinically determined. ⁵hospitalization through an er admission or an arranged direct admission to covid-19 inpatient unit. ⁶to repeat covid-19 nat at two-week post covid-19 diagnosis for twice weekly until nucleic acid test (nat) to detect covid-19 rna by polymerase chain reaction (pcr) key: cord-337338-7uj2r0gy authors: ohlstein, jason f.; garner, jordan; takashima, masayoshi title: telemedicine in otolaryngology in the covid‐19 era: initial lessons learned date: 2020-08-02 journal: laryngoscope doi: 10.1002/lary.29030 sha: doc_id: 337338 cord_uid: 7uj2r0gy objectives: the covid‐19 pandemic has led to unprecedented global changes in the delivery of healthcare over a short period of time. with the implementation of “shelter in place” orders, otolaryngology clinic visits at our institution were transitioned to telemedicine. this change enabled the rapid characterization of the patients who accepted and declined telemedicine. methods: review of 525 otolaryngology patients at a tertiary care referral center with scheduled visits requiring rescheduling to a future date or a telemedicine visit. visit, demographic information, and reason for deferring telemedicine were collected for analysis. results: 72% of patients declined a telemedicine visit with the most common reason being the lack of a physical exam (97%). there was an even distribution of demographics between those who accepted and declined visits. there was an association between declining telemedicine with older age (p = 0.0004) and otology visits (p = 0.0003), while facial plastics patients were more likely to accept (p < 0.0001). patients scheduled earlier during the pandemic were more likely to accept a visit with a median of 28 days from onset of “shelter in place” orders vs 35 for those who declined (p < 0.0001). conclusions: we describe our initial experience with a transition to telemedicine, where the majority of patients would decline a virtual visit due to the lack of a physical exam. while the future remains uncertain, telemedicine will continue to play a vital role in healthcare delivery; we believe that understanding our patient base gives critical insights that will help guide and improve virtual care to meet patient's needs. the coronavirus disease 2019 (covid-19) global pandemic has led to a drastic change in our current and future management of patients and delivery of care, particularly in the otolaryngology field. several early studies have shown that otolaryngologists are at a heightened risk of contracting covid-19 due to our intimate role in the evaluation and examination of the upper aero-digestive tract, an area found to have high levels of covid-19 colonization 1,2 . given this increased exposure risk along with mandated "shelter in place" and "stay at home" orders there has been an abrupt shift to a virtual care setting. prior to the covid-19 pandemic, virtual care and telemedicine was considered a niche part of medicine, historically being relegated to the advancements in treating patients in rural america mainly by general practitioners [3] [4] [5] . telemedicine at its most basic application is a medical consultation and remote diagnosis and treatment of a patient 6 . these visits have typically sought to manage chronic conditions such as: blood pressure, blood sugar, and overall health with easy to assess virtual findings. this type of visit has been challenging and slow to develop in the surgical specialties, such as otolaryngology, where there is a heavy reliance on physical exam and often in-office technology for diagnosis and planning [6] [7] [8] . this life changing moment in our history has led to a complete deviation for normal practices along with a push for innovation through technology. with the near complete transition from in-person to virtual care, it has also given the rare opportunity to study patients and their willingness to accept a virtual visit. we evaluated the characteristics of those electing for virtual visits and those declining at a large multi-specialty otolaryngology group based in an academic tertiary referral center in the texas medical center. the covid-19 pandemic has changed the way healthcare will be practiced forever. moving forward and looking ahead, telemedicine use will continue to increase along with technological advances and overall societal changes 9 . we believe that this novel data will help define these currently unknown population characteristics and will provide valuable information as we craft and hone the future delivery of virtual care. between march 9 th and may 1 st 2020, 525 consecutive patients were contacted to reschedule pending in office visits. patients were given the option to reschedule their clinic visit for a virtual telehealth visit. those who declined rescheduling to a virtual visit were asked for their reason. patients presenting for all subspecialties, otology, head and neck oncology, laryngology, rhinology, and facial plastics, at the houston methodist otolaryngology department were included in the study. patients with needs for in office evaluation (malignancies, airway concerns) and post-operative follow ups were excluded from the study. all virtual visits were conducted through the epic telehealth system. additional demographic data for patients was collected which included: age, sex, insurance type, visit type (new vs follow up), subspecialty of visit, zip code, and date of visit. total study population demographics were then created and subset analysis was performed for patients who elected for a virtual visit compared to those who declined. zip codes were used to link to median household income through the 2018 american community survey (acs) 5-year estimates. distance to care was calculated as the linear distance between reported patient zip code and institution zip code. date of visit was calculated by counting the number of days from initiation of "shelter in place" orders to date of scheduled clinic visit, median visit dates were created for those who accepted and declined telemedicine visits. this study met institutional review board (irb) exemption status, and all patient information and data was collected and protected following guidelines set forth by both our institution's irb and hippa regulations. data and statistical analysis was performed using sas 9.4 (sas institute, cary, nc) and prism 8 (graphpad software, san diego, ca). averages, medians, and percentiles were calculated for all data. normality was assessed and the unpaired t-test was used to determine the statistical significance between continuous variables, the mann-whitney u test was used for nonparametric data sets, and two-tailed fisher's exact was used for all categorical variables. p values less than 0.05 were considered significant. analysis of the total study population revealed an average age of 58 with a slight female predominance (59%) along with the majority of patients presenting for established visits (69%). patients typically held a private insurance plan (70%) over medicare (27%), median income on average was $83,409.15, and average distance to care was 28.87 miles. when comparing subspecialty visits to our practice, otology was the most common (31%) followed by, laryngology (31%), rhinology (22%), facial plastics (8%), and head and neck (7%). 126 patients (28%) accepted a virtual visit, while 329 (72%) declined (table 1 and figure 1a -e). when comparing those who accepted a telemedicine visit to those who declined, those who declined were statistically older with a median age of 63 vs 57 (average age of 59 vs 54) in those who accepted (p=0.0004). there was a relatively even distribution of sex, visit type, and insurance type between the two groups. there was no statistical difference between median household income and distance to care between the two groups. when comparing subspecialty visits, otology patients were significantly less likely to accept a virtual visit (p=0.0003) and facial plastics patients were significantly more likely to accept a visit (p<0.0001). the median scheduled visit date for those who accepted a telemedicine visit was 28 days from initiation of "shelter in place" orders compared to 35 days for those who declined a visit (p<0.0001). (table 2 , figure 2a-d) . finally, of the 379 patients who declined a virtual visit, 369 said this was due to lack of physical exam. (figure 3 ) while telemedicine has slowly been gaining popularity with general practitioners and in the acute care setting, the use of telemedicine has remained low among surgical specialties 3-6, 10 . adoption has been especially low in the otolaryngology field largely due to the fact that the majority of our patients are referred from primary care for sub-specialty evaluations. these evaluations frequently include: microscopic otoscopy, nasal and laryngeal endoscopy, stroboscopy, and cosmetic evaluations; as well as, evaluations provided by ancillary services including audiology and speech pathology 6, 8 . the use of telemedicine in otolaryngology has been previously described as a life line for patients during hurricane katrina, delivering compassionate care to palliative patients, and largely on a trial basis for rural or post-operative patients [10] [11] [12] . however, these experiences were in the context of barriers to care such as natural disasters and large distances to care and not necessarily addressing routine visits under normal circumstances 13, 14 . while the covid-19 pandemic is similar to previous natural disasters with a disruption of standard operations, it differs from past natural disasters, such as hurricane katrina, in that it represents a situation where the normal infrastructure for the delivery of care is still in place. initially, and still to this day, the exact natural history of covid-19 remains uncertain, as opposed to other disasters where there is clearer timeline for recovery. this uncertainty and unique psychology could possibly be represented in our data where patients were initially more apt to accept a telemedicine visit during the early stages of "shelter-in-place" mandates 15,16 . when evaluating for differences between those who accepted compared to those who declined a virtual visit we found that both populations had a fairly similar composition of gender, visit type, insurer, and income. previous studies have highlighted distance to care and socioeconomic status as driving factors behind telehealth adoption; however, there were no differences between household incomes nor between distance to care in our study population. those who declined virtual visits were older, 63 vs 57 (p =0.0004), and patients with otology appointments more often declined virtual visits when compared to the other specialties (p =0.0003). reasons for this difference could be related to otology patients typically presenting with concurrently scheduled audiograms or the limitation of virtual otoscopic evaluations. another possibility is otology patients commonly being older, on further subgroup analysis, patients with otology visits were found to be significantly older when compared to other subspecialty visits with an average age of 64 compared to 53 for rhinology, 58 for head and neck, 60 for laryngology, and 56 for facial plastics (p=0.0006). those with scheduled facial plastic visits were more likely to accept a telemedicine visit when compared to their counterparts (p<0.0001). we speculate that this could be due to facial analysis and cosmetic consultations being more easily conducted through a virtual video platform than other specialty or endoscopic exams; however, the number of facial plastic patients in our study population was markedly lower than the other subspecialties. over the past several years with advances in technology, the ubiquity of cameras, greater high-speed internet access, and the adoption of electronic medical records, telemedicine has evolved from a telephone based platform to a virtual exam room where face to face contact is possible 17 . as this new healthcare delivery modality gains further use, it is important to identify patterns of usage and acceptance amongst patients. previous studies highlighted the limitations of early iterations of telemedicine which solely used the phone and its impersonality 6 . early studies additionally highlighted cost, and technical difficulties as the main impediments to telemedicine, with the perceived lack of physical exam as a secondary factor. in recent years these technological advancements have led to greater adoption and use amongst patients and practitioners; however, these advances have come with increased complaints of logistic and technical difficulties, especially in older populations 6, 7, 9, 17, 18 . in our study population, the majority of patients declined a telemedicine visit due to the lack of a physical exam (97%) with only 1% citing technical difficulties as their reason for declining. further analysis, revealed that the average age of those declining visits due to technical difficulties was 80 years of age. we did demonstrate a statistical association between older age and deferring a virtual visit, which is in line with previous studies suggesting an association between age, technical difficulties, and hesitation in the adoption of virtual medicine 10 . while these data suggest the need for further outreach and focus on increased accessibility for older patients, they do suggest that familiarity with mobile technology and video teleconferencing has grown as well. the overwhelming response of patients declining a virtual visit due to lack of a physical exam, highlights the unique relationship that otolaryngologists have with our patients and our value as a specialty to adeptly evaluate areas that others cannot. despite our unique toolset, mccool et al. recently described a series where over 60% of patients were eligible for and would be served well by a virtual visit 7 . this poses the question of how can we better examine patients through a virtual visit? additionally, how do patients view their visits with us? patients perceive their otolaryngology visits as typically heavily exam oriented and might wonder if their specialist co-pay is money well spent on a limited face to face virtual encounter. on this front, as technology has advanced allowing for more widely available commercial endoscopes, there are initial investigations into the use of remote smart-phone enabled otoscopes 19 . while this is just one possible intervention, there is still much more needing to be done to communicate and demonstrate the effectiveness and value of virtual medicine in our field. another consideration is the economics and eligibility of patients for telemedicine visits. during the initial covid-19 outbreak, payers relaxed many of the requirements and restrictions for reimbursement for virtual visits and telehealth visits. this has eased the transition from clinic visits to virtual and has made it financially viable for physicians. in our study only one patient declined a visit due to insurance issues. while our institution and patients benefited from early payer acceptance of virtual visits and visit codes, this experience seems to be quite variable and there are some instances of payers increasing eligibility restrictions again. however, we suspect as telemedicine continues to be an important part of care delivery across all fields, further lobbying, legislation, and insurer policy will provide for clear rules for reimbursement and it will continue to be an option for both provider and patient. limitations of this study include that it is limited to a single center's experience and unique study demographics and our resulting final study population which did not have an equal distribution of patients between all subspecialties. there is inherent geographic bias with covid-19 and differences in local "shelter in place" restrictions and hospital policies that might not be applicable to other institutions or areas of the country. finally, this study only captured the first two months of our experience with covid-19. while our study did recognize a temporal bias that patients were more likely to accept telemedicine visits during the initial phases of "shelter in place" mandates and during the initial impact of covid-19, the psychology of change and reluctance to accept a new form of care delivery should not be understated. as the availability and economics of telemedicine continues improve, patient trust and perceptions of utility should continue to improve and this initial aversion to telemedicine will likely decline. the covid-19 pandemic has resulted in unprecedented changes to the medical field. unlike past natural disasters with a known or expected course for recovery, our future and return to normalcy remains uncertain, especially in otolaryngology where we have been identified as a high-risk specialty. history has shown that in times of conflict there is often great advances in technology and innovation. the same can be said now with the drastic shift to an underused and underdeveloped telemedicine system. with decreased cost, better reimbursements, greater availability and familiarity with technology among the general population, telemedicine has become a more viable option for care delivery. herein we report our initial experience with an abrupt transition to telemedicine, where we found that the majority of our otolaryngology patients would decline a virtual visit. while previous studies have highlighted differences in socioeconomic status and distance to care as potential drivers for willingness to accept telemedicine, we found that age was the only demographic factor associated with declining a visit. the lack of a physical exam was the main driving force behind patients declining virtual care, suggesting that we have grown past the early technologic and cost barriers to telemedicine. much like any other new technology early acceptance can initially be slow. as the economics of telemedicine continue to improve, our focus moving forward will need to not only be for innovation in remote examinations, but also to effectively communicate and demonstrate the value of telemedicine to our routine patients in hopes to encourage greater adoption in our field. we hope this study provides the basis for future interventions targeted at developing better patient outreach, virtual examinations, and patient education. table 1 (41%) males compared to 308 (59%) females. c) distribution of new 161 (31%) compared to established visits 364 (69%) who were contacted for rescheduling. d) distribution of insurance types with the majority of patients holding private insurance (343, 70%), followed by medicare (135 37%), and finally self-pay (15 3%). e) distribution of subspecialties visits which were contacted for rescheduling with the majority in laryngology (162, 31%), followed by otology (161, 31%), rhinology (121, 23%), facial plastics (43, 8%), and finally head and neck oncology (38,7%) figure 2 ) comparison between those electing and declining telemedicine visits. a-c) there was a similar distribution between sex, visit type, and insurance type between those who accepted telemedicine visits and those who declined with no significant differences demonstrated. d) there was a trend towards more patients declining rhinology, head and neck oncology, laryngology and otology visits; while, patients were more likely to accept virtual facial plastics visits. distribution of reported reasons for declining telemedicine visits. 369 or 97% of patients reported their primary concern and reason for declining a virtual visit was the lack of a physical exam. this was followed by technical issues (5), feeling better (4), and insurance denial (1). covid-19 in otolaryngologist practice: a review of current knowledge. european archives of oto-rhino-laryngology : official journal of the european federation of oto-rhino-laryngological societies (eufos) : affiliated with the german society for oto-rhino-laryngology -head and neck surgery sars-cov-2 viral load in upper respiratory specimens of infected patients the telehealth satisfaction scale: reliability, validity, and satisfaction with telehealth in a rural memory clinic population telemedicine and rural health care applications tele-education in a telemedicine environment: implications for rural health care and academic medical centers telemedicine in otolaryngology where does telemedicine fit into otolaryngology? an assessment of telemedicine eligibility among otolaryngology diagnoses. otolaryngology--head and neck surgery : official journal of american academy of successful telemedicine programs in otolaryngology an evolutionary examination of telemedicine: a health and computer-mediated communication perspective telemedicine in otolaryngology outpatient setting-single center head and neck surgery experience forging a new frontier: providing palliative care to people with cancer in rural and remote areas bringing palliative care to underserved rural communities telemedicine-assisted neurotology in post-katrina southeast louisiana nuss dwet al. factors affecting access to head and neck cancer care after a natural disaster: a post-hurricane katrina survey post-katrina: study in crisis-related program adaptability. otolaryngology--head and neck surgery : official journal of american academy of covid-19: e8-learning from katrina the role of telehealth in the medical response to disasters cost savings associated with an outpatient otolaryngology telemedicine clinic utility of a smartphone-enabled otoscope in the instruction of otoscopy and middle ear anatomy this article is protected by copyright. all rights reserved. key: cord-271573-qsr3ka5p authors: schafer, austin; market, sarah; elmaraghy, charles a. title: telemedicine in pediatric otolaryngology: ready for prime time? date: 2020-09-24 journal: int j pediatr otorhinolaryngol doi: 10.1016/j.ijporl.2020.110399 sha: doc_id: 271573 cord_uid: qsr3ka5p the purpose of this paper is to explore the current literature on telemedicine in otolaryngology, focusing on the potential for telemedicine in the field and the major modalities available. ultimately, the goal is to summarize telemedicine implementation in otolaryngology during the covid-19 pandemic and potential long term applications. this paper analyzes a variety of studies that have evaluated the efficacy of different telemedicine approaches in otolaryngology, with commentary on what these results mean for the potential of telemedicine during the covid-19 pandemic. otolaryngology is well-suited for telemedicine, and this technology is viewed favorably by both patients and physicians. however, its application cannot be generalized to such a wide-ranging specialty. furthermore, store and forward technology, which has been traditionally used to provide care to remote and underserved populations, and synchronous technology both have the potential to limit unnecessary in-person visits—ultimately keeping both patients and providers safe as social distancing continues. the practice of telemedicine can be defined as the use of any technology that provides remoteaccess medical care, most frequently to isolated or underserved populations. historically, specialties such as radiology, dermatology, cardiology, and psychiatry have adopted the most widespread telemedicine initiatives. 1 however, in the midst of the covid-19 pandemic, the applications of telemedicine are rapidly expanding to include the entire medical field. 2 otolaryngology may be one of the most important specialties to address when it comes to the implementation of telemedicine in the era of covid-19, as otolaryngologists are at a particularly high risk of viral transmission via aerosol generating procedures. 3 j o u r n a l p r e -p r o o f despite many studies demonstrating its potential, telemedicine has not been widely adopted in the specialty of otolaryngology. 4 this may be attributed to concerns over the diagnostic accuracy of remote evaluations, training requirements, and an uncertainty over which of the many telemedicine approaches yield the best results. 5, 6, 7 fortunately, multiple studies agree that otolaryngology is a specialty well-suited for telemedicine. 8 the challenge, however, is determining which telemedicine approaches are the most appropriate, and how to effectively implement these protocols during the covid-19 pandemic and beyond. otolaryngology is a robust specialty that involves the treatment of a variety of ear, nose, throat, and in some practices, head and neck conditions. due to this variation, diagnostic exams are not standardized between patients, and the technology needed to accurately assess a patient's condition may vary from case to case. 6 ultimately, it is the pertinent anatomy that will determine how a patient is evaluated. thus, in an effort to develop efficient protocols, it is important to determine which otolaryngology cases are amendable to telemedicine. in a study published in 2018, mccool and colleagues 4 attempted to discern which otolaryngology patients may benefit the most from telemedicine. to do this, they estimated the rates of telemedicine eligibility among specific diagnoses through a retrospective cohort study. a total of 1,385 otolaryngology encounters over a 2-year period were classified as either "eligible" or "ineligible" for telemedicine, on the basis of whether or not a specialized procedure was j o u r n a l p r e -p r o o f performed during the visit. overall, 62% of encounters were considered eligible for telemedicine. more importantly, however, is that eligibility varied with anatomic subsite. while 92% of inner ear diagnoses were considered eligible for telemedicine, only 39% of laryngeal diagnoses were similarly eligible. although this study has limitations being a retrospective analysis, it supports visualization of pertinent anatomical structures is relevant .moreover, it demonstrates that otology can be eligible for telemedicine, validate by other studies. 1 this is significant for pediatric practices, as otitis media is one of the most common causes of healthcare visits in this population. 9 another study published in 2020 by miller and colleagues 6 evaluated the reliability and accuracy of remote nasopharyngolaryngoscopy (npl) examinations in pediatric patients. the group conducted a prospective, blinded study in which the npl was performed by an in-office otolaryngologist using an iphone attachment to record the examination. a second, remote otolaryngologist later evaluated the recording. both physicians completed the same diagnostic survey, evaluating a variety of anatomic subsites and ultimately providing a final diagnosis for the 45 patients who underwent npl. inter-rater agreement was calculated using the κ statistic for each subsite and for the final diagnosis. a percentage agreement was also calculated. overall, there was 80% agreement on the final diagnosis (κ = 0.71). however, the agreement varied considerably depending on the anatomic subsite, with the nasopharynx and oropharynx having the highest inter-rater agreements (κ = 0.75). interestingly, mccool and colleagues 4 determined that diagnoses of the oral cavity (75%), nasal passage (75%), sinuses (58%), and pharynx (58%) were the most telemedicine-eligible diagnoses after the ear (middle and inner) and skin. furthermore, the anatomic subsite with the lowest inter-rater agreement in the study by j o u r n a l p r e -p r o o f miller and colleagues 6 was the larynx and its components, such as the epiglottis (κ = 0.43), the arytenoids (κ = 0.34), and the aryepiglottic folds (κ = 0.20). although these sites maintained modest percentage agreements, they were still relatively lower than the values for the nasopharynx and oropharynx. once again, there is concordance with mccool and colleagues, 4 as diagnoses of the larynx were deemed the least eligible for telemedicine in their study. although these are very different studies, it is clear that there are certain ent diagnoses for which telemedicine is better suited. it may more appropriate to remotely evaluate the inner ear middle ear, nasopharynx, and oropharynx, than to remotely evaluate the larynx. understanding these differences and stratifying patients accordingly could improve the efficiency and costeffectiveness of telemedicine in otolaryngology during the covid-19 pandemic. in response to the covid-19 outbreak, the american academy of otolaryngology-head and neck surgery released guidelines to provide only "time sensitive" or "emergent" surgical care. with many surgical consultations now taking place via telemedicine, it is important to ensure that these visits appropriately triage patients and maintain diagnostic accuracy. 10 if telemedicine can be successfully employed as a reliable method of surgical consultation and preoperative planning, otolaryngologists can productively make use of clinical time that may have been previously spent in the operating room. in a 2008 study, smith and colleagues 5 attempted to determine concordance between pediatric otolaryngology diagnoses and surgical management plans made via a live videoconference and a subsequent, in-office consultation. regional pediatricians conducted the physical exams under j o u r n a l p r e -p r o o f the remote guidance of an ent specialist. among the 68 patients with both consultations, there was diagnostic agreement in all but 1 case (99%). moreover, surgical management plans were concordant in 63 of the 67 cases (93%). it is important to note that of the 5 patients who underwent procedures that differed from the original videoconference plans, 4 had only minor alterations-such as the addition of tympanostomy tubes to an adenotonsillectomy. the remaining patient had a perforated tympanic membrane for which a myringoplasty was performed after conservative management failed. one limitation of this study is this a single surgeon study. nonetheless, the results demonstrate that live videoconference should be considered as a reliable alternative to in-office surgical consultation. in 2010, kokesh and colleagues 11 published a study aimed at determining the feasibility of using telemedicine to accurately plan ear surgery. the group reviewed charts for 45 elective major ear surgeries (tympanoplasty, tympanoplasty with canalplasty, mastoidectomy, stapedectomy, or stapedotomy and myringoplasty) referred via telemedicine over a 13-month period and documented the recommended surgeries and estimated operative times. these cases were then matched with 45 patients seen in-office who ultimately had identical surgeries recommended. importantly, telemedicine evaluations accurately predicted the eventual surgical procedure 89% of the time, compared to 84% for the in-office evaluations. furthermore, the average difference between the actual operative time and estimated operative time between telemedicine evaluations (32 minutes) and in-office evaluations (35 minutes) was not statistically significant. although it is retrospective with a limited sample size, this study demonstrates that telemedicine can be used for accurate preoperative planning, especially in otology-although pediatric providers should note that tympanostomy tube placement was not included in this study. overall, it is clear that there is a role for telemedicine in surgical consultations and preoperative planning in otolaryngology. while more data is certainly needed, both of these studies support telemedicine as an accurate alternative to the traditional in-office consultation. as covid-19 protocols continue, the ability to utilize telemedicine as a means of reliably diagnosing and triaging surgical patients will go a long way in maintaining efficiency, and most importantly safety-among both patients and providers alike. the store and forward approach the store and forward approach, one of the original telemedicine modalities used in otolaryngology, involves a referring physician or trained health worker collecting patient history and imaging, and subsequently forwarding this data to a consulting physician for review. 1 this system is asynchronous, meaning that it does not require the providers to align their schedules for a patient consultation. moreover, the consulting physician can review cases at his or her own discretion, when time is available. 12 limitations to this approach must be noted, however, such as physical exam limitations and a loss of the traditional, face-to-face patient-physician interaction. 13 furthermore, although the store and forward approach provides more flexibility for review, the consulting physician should be aware that a patient's condition is subject to change, especially as the time from referral to consultation increases. 11 due to its format, the store and forward approach has been especially successful in providing consultations, relying on community health workers as well as audiologists to provide the initial visits. the authors explain that a single otolaryngologist was responsible for responding to the influx of telemedicine consultations on a given day, and that this responsibility rotated daily. at the time of publication, telemedicine cases had a 75% same-day response rate, and a 90% 24hour response rate. moreover, 73% of telemedicine consultations prevented patients from having to travel-a significant benefit for a remote population. this group has published an assortment of studies detailing the successful use of store and forward telemedicine in their practice. 11, 12, 14 more recently, gupta and colleagues 7 published a study in 2020 that examined the feasibility of equipping trained health workers with a store and forward telemedicine device to triage underserved otology patients in india. entraview, the telemedicine device utilized in this study, is a camera-enabled phone integrated with an otoscope. the health workers underwent extensive training with this device, as well as 3 months of otology curriculum. community clinics were then organized, and the five health workers screened 3,000 patients with subjective ear complaints over a 6-month period. while 1,619 (54%) patients were referred to an ent specialist based on their screening results, only 13% had followed-up at the time of publication. while this may be a promising model for widespread screening coverage in developing countries, the results demonstrate that asynchronous technology may lead to gaps in the continuum of care in some cases. while much of the literature focuses on store and forward telemedicine in the context of providing care to remote or underserved populations, its benefits should be considered by all ent practices during the covid-19 era, as advances in technology have improved its cost effectiveness and convenience. 9 one of these advances, smartphone otoscopy, may be particularly well suited for use during the current pandemic. 15 a smartphone-enabled otoscope can be configured by attaching a modified otoscope head to the camera of an existing smartphone. in many cases, these attachments are commercially available online. 16 this technology is ideal for use in the pediatric population as it theoretically enables parents to capture images and subsequently send them to an otolaryngologist for remote review and diagnosis. 9 until recently, studies validating the use of smartphone otoscopy have utilized only trained healthcare professionals to capture images-not parents. however, new studies have examined the ability of parents to effectively use this technology. 9, 16 in a 2018 study, shah and colleagues 9 examined the diagnostic reliability of videos of the tympanic membrane captured by parents using an iphone otoscope (cellscope). in the clinic, parents were given the device and instructions, and watched the standard training video within the application. without additional assistance, they attempted to capture recordings of the tm with the device. a second-year otolaryngology resident then captured videos of the same ears, and both recordings were later reviewed by an attending pediatric otolaryngologist who attempted to discern diagnoses from the videos. pneumatic otoscopy was also performed by a different pediatric otolaryngologist for comparison. eighty ears (40 patients) were included in the study. while there was high agreement (κ = 0.74) between pneumatic otoscopy and remote diagnosis when the recordings were obtained by an otolaryngologist, there was low agreement (κ = 0.42) when the remote recordings were obtained by a parent. in other words, many of the videos obtained by the parents were not of diagnostic quality, as opposed to the videos captured by the physician. the effectiveness of the device when operated by a specialist is something that has been previously described in multiple studies. 17, 18 however, this study indicates that the cellscope is only reliably effective in the hands of a capable user-which might not be a parent just yet. it is important to note that despite these shortcomings, 92% of participating parents reported that they would feel comfortable using the device at home. thus, if the learning gap is bridged, cellscope certainly has the potential to be successfully utilized by parents. in 2019, erkkola-antinnen and colleagues 16 published a similar study in which they evaluated the ability of parents to reliably perform smartphone otoscopy for the eventual diagnosis of acute otitis media (aom). eligibility for this study was contingent on at least 1 diagnosis of aom in the 90 days leading up to the study. at the initial visit, study participants were allocated to either an immediate teaching group, or a delayed teaching group. during this same visit, parents of children allocated to the immediate teaching group were given an introductory presentation on the basic anatomy of the middle and inner ear, as well as a tutorial on how to use the smartphone otoscope (cellscope). conversely, parents of children allocated to the delayed teaching group did not receive this training until at least a week later. all parents from both groups were asked to perform a bilateral smartphone otoscopy on at least 5 days during the first study week. after that, parents were asked to perform bilateral smartphone otoscopy at various frequencies depending on their child's condition. over the 6-month study period, 1,442 videos were obtained from 40 participants. during the first study week, 62% of the videos from the immediate teaching group were of sufficient technical quality, compared to only 22% from the delayed teaching group. after the teaching intervention, however, 64% of the videos from the delayed group were sufficient, demonstrating the importance of instruction for proper smartphone otoscopy technique. after all participants underwent training, 67% of the videos were of sufficient technical quality. of these videos, 53% enabled a diagnosis to be made. while a specific diagnosis was often difficult to come by, it is important to note that aom could at least be detected or excluded in most (87%) of the videos obtained from symptomatic children. furthermore, 85% of parents agreed that performing smartphone otoscopy was easy, while 95% agreed that they learned to recognize the appearance of a healthy middle ear. both of these studies indicate that smartphone otoscopy can be performed by parents; however, the diagnostic reliability of the captured media must improve for this technology to be widely implemented. furthermore, a teaching intervention is critical for parents to successfully utilize smartphone otoscopy, which takes time and resources. despite these shortcomings, most parents view the technology favorably and find it easy to use. furthermore, the fact that parents were able to capture videos that could reliably detect or exclude aom in symptomatic children is a huge success. during the covid-19 pandemic, using smartphone otoscopy in this manner could prevent unnecessary emergency room or primary care visits, limiting exposure to both patients and providers. the live, or synchronous approach, refers to telemedicine that is conducted in real-time between a patient and a provider. this modality is advantageous in that it maintains the structure of an in-j o u r n a l p r e -p r o o f office encounter, providing the traditional patient-physician interaction. moreover, synchronous telemedicine offers a better platform for taking patient histories and performing physical exams. 13 however, it can be extremely difficult to coordinate these appointments, making this modality potentially more expensive and logistically challenging than the store and forward approach. 1 while the use of synchronous telemedicine remains limited in otolaryngology, technological advances have made it worthy of further exploration, especially as healthcare delivery evolves due to covid-19. in a 2018 study, seim and colleagues 13 evaluated the fidelity and diagnostic concordance of synchronous technology for use in a telemedicine ent clinic. twenty-one patients at an existing community ent clinic in rural ohio were evaluated by an on-site physician, who used the quintree system to stream the encounter to a consulting physician for remote participation and evaluation. both physicians were experienced otolaryngologists. after the physical exam was complete, the remote physician muted the encounter while the on-onsite physician recorded a diagnosis and counseled the patient. after this, the remote physician had the opportunity to ask the patient any follow-up questions before documenting a diagnosis. post-encounter surveys were completed by both patients and physicians. overall, the physicians were satisfied with the technology, with satisfaction rates of 98% and 100% for image and audio quality, respectively. other than anterior rhinoscopy (59%), all of the other exams (otoscopy, oral cavity, laryngoscopy) were satisfactory in at least 88% of cases. patients were equally satisfied, with 95% indicating that they felt comfortable during the encounter, and 90% indicating that they would use the technology again. furthermore, diagnostic concordance was seen in all but 1 case (95%), with the single exception due to a lack of diagnostic specificity. however, it is important to note that kappa coefficients could not calculated because the diagnoses were recorded in an open-ended format. although this was a pilot study with a limited sample size, it nonetheless supports synchronous telemedicine as a viable approach to patient care in otolaryngology. the results are consistent with the previously mentioned study by smith and colleagues 5 in 2008, which evaluated the diagnostic concordance between real time telemedicine and in-office consultations. furthermore, a 2019 publication by philips and colleagues 19 has since validated synchronous telemedicine as a cost-effective option for ent clinics. as far as implementing this technology during the covid-19 pandemic and beyond, following the protocol evaluated by smith and colleagues 5 may be a reasonable approach. by having pediatricians or general practitioners perform specialized physical exams under the remote guidance of ent physicians, patients would remain distanced from large medical centers in urban settings, where a majority of ent physicians practice. 1 however, more studies are needed to evaluate the efficacy of such protocols, especially in regard to new technology. unlike other specialties, otolaryngology has been slow to adopt telemedicine into practice. as specialized physical exams are needed to make many ent diagnoses, there has been concern over the diagnostic reliability of telemedicine technology. moreover, much of the focus has been on utilizing telemedicine to provide ent care to remote or underserved populations, as there has not been a need for telemedicine in the general population-until now, that is. social distancing protocols due to covid-19 have brought telemedicine to the forefront of patient care. while previous literature has demonstrated that otolaryngology is amendable to telemedicine, there is j o u r n a l p r e -p r o o f no doubt that its potential is greater now than it has ever been, especially considering its support from both patients and physicians. however, for successful implementation, it is important to understand where exactly this potential lies, and what modalities are available for use. ent care is incredibly wide-ranging; thus, it is not appropriate to generalize the evaluation of telemedicine to the entire field of otolaryngology. specifically, there is evidence that telemedicine can be successfully used for surgical consultation and planning. furthermore, otology visits seem to be more suitable for telemedicine than visits pertaining to other anatomical sites, such as the larynx. this is especially important for pediatric practices, with such a high prevalence of otitis media in this population. while more data is needed on store and forward technology in the hands of parents, such as smartphone otoscopy, it is certainly worthy of further exploration as a means of preventing unnecessary healthcare visits. likewise, synchronous technology has the potential to reduce avoidable in-person contact, keeping both patients and providers safe during the covid-19 pandemic and beyond. successful telemedicine programs in otolaryngology covid-19 transforms health care through telemedicine: evidence from the field a commentary on safety precautions for otologic surgery during the covid-19 pandemic otolaryngol head neck surg where does telemedicine fit into otolaryngology? an assessment of telemedicine eligibility among otolaryngology diagnoses concordance between real-time telemedicine assessments and face-to-face consultations in paediatric otolaryngology reliability and accuracy of remote fiberoptic nasopharyngolaryngoscopy in the pediatric population community triage of otology patients using a store-and-forward telemedicine device: a feasibility study covid-19 and rhinology: a look at the future iphone otoscopes: currently available, but reliable for tele-otoscopy in the hands of parents? framework for prioritizing head and neck surgery during the covid-19 pandemic preoperative planning for ear surgery using storeand-forward telemedicine the alaska experience using store-and-forward telemedicine for ent care in alaska developing a synchronous otolaryngology telemedicine clinic: prospective study to assess fidelity and diagnostic concordance traveling an audiologist to provide otolaryngology care using store-and-forward telemedicine smartphone-enabled wireless otoscope-assisted online telemedicine during the covid-19 outbreak smartphone otoscopy performed by parents comparison of traditional otoscope to iphone otoscope in the pediatric ed assessment of a smartphone otoscope device for the diagnosis and management of otitis media cost savings associated with an outpatient otolaryngology telemedicine clinic key: cord-330017-t14o7rua authors: galiero, raffaele; pafundi, pia clara; nevola, riccardo; rinaldi, luca; acierno, carlo; caturano, alfredo; salvatore, teresa; adinolfi, luigi elio; costagliola, ciro; sasso, ferdinando carlo title: the importance of telemedicine during covid-19 pandemic: a focus on diabetic retinopathy date: 2020-10-14 journal: j diabetes res doi: 10.1155/2020/9036847 sha: doc_id: 330017 cord_uid: t14o7rua recently, telemedicine has become remarkably important, due to increased deployment and development of digital technologies. national and international guidelines should consider its inclusion in their updates. during the covid-19 pandemic, mandatory social distancing and the lack of effective treatments has made telemedicine the safest interactive system between patients, both infected and uninfected, and clinicians. a few potential evidence-based scenarios for the application of telemedicine have been hypothesized. in particular, its use in diabetes and complication monitoring has been remarkably increasing, due to the high risk of poor prognosis. new evidence and technological improvements in telemedicine application in diabetic retinopathy (dr) have demonstrated efficacy and usefulness in screening. moreover, despite an initial increase for devices and training costs, teleophthalmology demonstrated a good cost-to-efficacy ratio; however, no national screening program has yet focused on dr prevention and diagnosis. lack of data during the covid-19 pandemic strongly limits the possibility of tracing the real management of the disease, which is only conceivable from past evidence in normal conditions. the pandemic further stressed the importance of remote monitoring. however, the deployment of device and digital application used to increase screening of individuals and monitor progression of retinal disease needs to be easily accessible to general practitioners. telemedicine is usually defined as a combination of both technologies and devices able to remotely gain information about a patients' health status, so to aid in deciding if there is a need or urgency to intervene [1] . hence, it may represent both a screening and diagnostic tool, which demonstrated remarkable importance in recent literature, mostly due to the higher deployment and development of digital technologies (e.g., smartphones and digital connections). appropriate tools allow clinicians at reaching and periodically monitoring individuals who have difficulties attending specialist visits, especially patients affected by chronic diseases, who require continuous follow-up. as well as this, on the off chance of a firsthand appointment, therapy could be periodically assessed by sending the data recorded on the digital tool to a specialist. two of the major clinical areas covered by telemedicine are cardiovascular diseases and diabetes, alongside all its chronic complications. particularly, retinopathy, the most widespread diabetes complication, usually needs a fundus oculus examination by an eye-care specialist; however, in rural environments or those who live far from dedicated referral centers, patients either cannot easily attend these examinations or exert a poor adherence to the visit. the latter is mainly due to the disparity between the low number of ophthalmologists and the large population of diabetic patients, as well as to the uncomfortable traditional fundus oculi, which provide pupil dilation after instillation of eye drops. mydriasis has the disadvantage that patients must wait both for performing the exam and to come back to the daily routine. conversely, telemedicine can counterbalance this burden, as suggested by current guidelines. in fact, after appropriate training, all clinicians and dedicated clinical personnel can easily take photos of the fundus oculi with nonmydriatic fundus cameras ( figure 1 ) [2] . retinal digital photos, though not representing the gold standard, may be equally used to screen the diabetic population and differentiate among the different stages of diabetic retinopathy (dr), thus referring to the ophthalmologist only ungradable images or suspicious cases. herein, we analyze the state of the art of telemedicine during the pandemic, particularly focusing on the management of diabetes and its complications. in fact, during the covid-19 pandemic, due to the mandatory social distancing imposed to prevent the outspread of infection, the use of telemedicine in diabetes monitoring has been remarkably increasing. as aforementioned, telemedicine has initially arisen to provide medical assistance either in rural areas or where access to care is hard, mainly aimed at improving chronic disease management [3] , mostly in urgencies [4] . over the years, the onset of either epidemics or pandemics has led to the employment of increasingly novel digital technology strategies, which have also triggered the use of telemedicine during the diverse stages of the infection much more frequently, such as in the cases of the sars epidemic in 2003 and, later, mers-cov in 2013 [5] . due to its novelty, as well as the large spectrum of potential applications, a clear differentiation of settings in which to use telemedicine during emergency periods has also been challenging. a few potential evidence-based scenarios have been hypothesized in 2015 [6] . for example, e-health can be applied to all asymptomatic subjects in an epidemic area. this "home-based" management is most useful in the suspect of infection-related symptoms and allows to address subjects to dedicated referral centers. moreover, positive asymptomatic subjects can be followed up by periodic phone and web consulting. beyond these, over the last years, digital geolocalization tools further contributed to an improvement of these services. in addition, telemedicine is also useful to take care of individuals either in domiciliary or nosocomial isolation. in this latter case, telemedicine ensures an adequate safety to both clinicians and caregivers limiting the direct contact with the infected patients only to strictly nondeferrable urgencies [7] . lastly, up to now, telemedicine can also support the outpatients' management of periodical visits, which are halted due to the mandatory lockdown imposed by local governments. among chronic diseases, cardiovascular diseases particularly require constant monitoring, thus increasing the risk of infection both for patients and clinicians [8] . in this setting, remote monitoring has been expanding also beyond emergency situations, to observe a rapid enhancement of ehealth technologies during either epidemics or pandemics. as an example, electrophysiologists have been converting most clinical visits to remote monitoring (phone, video calls for visits, review of data from digital wearables, etc.) [9, 10] , as well as cardiac implantable electronic device checks, whenever feasible [11] , as suggested as class i recommendation [12] . where possible, nonurgent procedures should be postponed or, in the case of need, coordinated on the same day of visit to minimize multiple exposures, whilst postprocedural follow-up should be performed remotely. in this sense, the pandemic caused by sars-cov-2 coronavirus has been giving a remarkable impulse of the management of other chronic diseases. figure 1 : telemedicine approaches for the screening or the diagnosis of diabetic retinopathy. thanks to both positive evidence from previous epidemics/pandemics and technological advancements, during this critical period, the use of telemedicine has increased, especially in industrialized countries, mostly the united states [13] , the united kingdom, and china [14, 15] . much more novel digital technologies have supplemented common phone interviews. both national and international guidelines should consider the introduction of e-health technology in their updates, strictly differentiating recommendations for common use and emergency situations. as a matter of fact, the lack of either vaccines or effective treatments, due to social boundary and lockdown as main preventive measures, renders telemedicine the safer interaction system between patients and clinicians [16] . the large proportions of this pandemic have also encouraged a reduction of the gap related to the poor compliance to the use of digital tools. based on past evidence and previous models, during the covid-19 pandemic, social distancing has triggered three potential e-health applications [6, 17, 18] . on the one hand, patients at higher risk of infection, especially those with either chronic, autoimmune, or immunosuppressant diseases can prevent the exposure to risk factors by virtually communicating with their general practitioner and/or specialist. referral to clinical facilities is thus limited to extreme needs. in addition, novel strategies of telephonic triage have been proposed, which allows for better screening of suspect sars-cov-2 cases, reducing referral to firsthand aid of a huge amount of people worried about potential infection by sars-cov-2. definite positive cases, either asymptomatic or mildly symptomatic, do not obtain the priority to hospitalization; nonetheless, they are carefully followed up by dedicated channels with both covid-19 centers, general practitioners, and local health authorities. further, e-health communication has helped mildly infected clinicians not to discontinue their routine practice [19, 20] , providing them with the opportunity to pursue their activities remotely. the feasibility of this innovative medical approach is still the object of debate [21] . moreover, the cost-to-benefit ratio of these tools should be maximized for a better global utilization of telemedicine in the next future beyond the current emergency setting, with a higher focus on chronic disease management [22, 23] . management during covid-19 up to now, several studies worldwide have evaluated the efficacy of telemedicine in different clinical settings, especially focusing on a very specific medical branch, ophthalmology. in fact, teleophthalmology has been assessed in numerous clinical subsettings. as an example, several studies have considered telemedicine usefulness in glaucoma diagnosis, with findings mostly comparable. the largest study, conducted in the uk on over 24,000 subjects, showed an agreement of 87% between optometrist and ophthalmologist examinations (cohe's kappa = 0:69) [24] . similar findings were obtained in kenya, where teleglaucoma disclosed a sensitivity of 41.3% and a specificity of 89.6% as compared to the standard fundus oculus exam by the eye-care specialist [25] . a similar study was led in canada on innovative smartphone applications, even though, despite the similar findings, images were ungradable in 24% of cases [25] . however, smartphone ophthalmoscopy showed substantial agreement with slit-lamp examination for the estimation of the vertical cup-to-disc ratios in glaucoma screening [26] . evidence on e-health technologies on cataract and agerelated macular degeneration screening is still poor and on small populations, even the modest literature on these topics has shown an overall good quality of acquired images in 93-100% of cases [27] . as briefly mentioned before, among chronic diseases, diabetes, alongside its diverse complications, renders patients at high risk of poor prognosis [28, 29] . over the years, telemedicine has been proven as a useful tool to allow for periodic management of glycemic levels [30] . telemedicine has been further implemented to gain an effective screening of complications without requiring mandatory on-site visits. lack of time, distance from specialized centers, disabilities, and long waiting lists are among the most common causes of a limited access of patients to specialty visits. in the case of pandemics, social distancing further contributes [31] [32] [33] [34] [35] . of interest, the development of digital devices for glycemia monitoring (e.g., glycemic holters and micropump) both in type 1 and type 2 diabetic patients has allowed the deployment of an easier self-monitoring of glycemia. in fact, data are rapidly collected and transferred either to the specialist or the general practitioner (e.g., by email or digital systems), who could consider eventual therapy modifications, as well as deeper diagnostic/therapeutic urgent investigations [36] [37] [38] . many studies have also demonstrated an increased rate of hba 1c target achievement among users of glycemic monitoring devices rather than controls, with a subsequent reduction also in the risk of complications [39] [40] [41] [42] . telehealth may also help in the screening of diabetes complications. in particular, for years, diabetic retinopathy has been the object of screening and monitoring programs. fundus cameras and other portable devices make it possible to take retinal photos, which can be sent to specialized referral centers for reading, by both clinicians and technicians. available data worldwide have demonstrated the efficacy and usefulness of telemedicine in this context. thanks to these tools, screening has been extended to a much larger portion of diabetic subjects, and the comparison between telemedicine and standard fundus oculus exam has revealed a good efficacy from the use of nonmydriatic cameras both in terms of sensitivity and specificity [43] . in india, a recent screening investigation by fundus on phone (remidio fop), a smartphone-based imaging device, 3 journal of diabetes research [44, 45] . as well as this, after a 6and 18-month follow-up, telemedicine has been reported to significantly increase the individuals screened for dr [46] . a further study, on about 100 diabetic patients, reported a sensitivity of 97.1% and a specificity of 95% of fundus oculus photos in detecting mild nonproliferative dr (npdr) than the standard mydriatic exam. in moderate npdr assessment, though demonstrating with a similar specificity (96.9%), sensitivity was lower (53.3%) [47] . conversely, another study on a similar sample size showed both a high sensitivity (85%) and specificity (90%) in the diagnosis of moderate npdr with 2-field 50-degree nonstereo digital fundus photographs than slit-lamp ophthalmoscopy performed by an ophthalmologist [48] . a larger scale teleretinal screening was deployed on a sample of over 20,000 people from the us diabetic population [49] . in our experience of the no blind study, a multicenter cross-sectional study, almost 1,500 diabetic subjects were screened for dr by a digital smart ophthalmoscope. fundus oculus photos performed by trained diabetologists were diagnostic for diabetic retinopathy in 15.5% of the study population, with both a high sensitivity and specificity (94.3% and 100%, respectively), as compared with standard fundus oculus examination in mydriasis [50] . in the last years, at the same time, many smartphone applications have been developed to acquire nonmydriatic images of any area of the eye [51] . some recent studies, consistent with our estimates [50] , have predicted a potential increase of screened patients of 50-60% [52] [53] [54] , also thanks to a remarkable improvement of image quality [53, 55, 56] . similarly, two screening programs conducted both in africa and canada were aimed at improving both health and life quality of people affected by diverse retinal diseases, as well as at reducing complication frequency [57, 58] . moreover, teleophthalmology disclosed a good cost-toefficacy ratio, both in terms of human and monetary resources, and travelling costs for patients and public health systems [59] . it has been recently demonstrated, in a metaanalysis focused on cost efficacy assessment of ophthalmologic screening programs by telemedicine in several countries (e.g., the united states, canada, singapore, india, brazil, and south africa), that, though with an initial increase of costs related to devices and training, over time, there is an economic saving [31] . likewise, in our multicenter experience, remarkable monetary savings from the use of retinal cameras rather than traditional exam (estimated mean cost per patient equal to €3.02 vs. €7.75) were observed, as well as time savings both for patients and clinicians (about 2/3 minutes vs. 20/30 minutes) [50] . even though several studies support diabetic retinopathy screening by digital technology (table 1) , up to now, no national screening program has aimed at dr prevention and diagnosis. evidence about diabetes remote monitoring during the covid-19 pandemic is still poor. recent diffusion of the pandemic and lack of data strongly limit the possibility of tracing the real management of the disease. we may only hypothesize, from previous data on subjects already using these devices, that data transmission allows for distant monitoring. a similar approach can be considered for diabetic retinopathy; hence, it is reasonable that general practitioners adopt either retinal cameras or other devices to promote an effective control also during pandemics. current emergency status due to the pandemic could represent a further stimulus to the diffusion of large telemedicine screening programs in routine clinical practice. new evidence and technological improvement of devices have made telemedicine a useful solution for diabetic retinopathy screening. these advancements could be useful to widen the number of individuals screened and monitor progression of retinal disease, both in conditions of pandemics/urgencies and in routine clinical practice. the campania region was among the first and few italian regions to legislate in favor of telemedicine. writing the decree signed by the general director of the regional health service (protocol 2020_ 0175167 on 27/03/2020), telemedicine was approved and regulated as a tool for diabetes treatment. the document describes the methods and the paths to follow, the actors, and the users. therefore, diabetologists are invited to register and report all the procedures and methods carried out. in this way, once the covid-19 pandemic is over, it will be possible to analyze approaches and results in order to transform telemedicine as a commonly used tool. this is the challenge that diabetologists are pursuing, especially in the field of diabetic retinopathy. however, the deployment of such devices and digital applications needs to be rendered easier and accessible without specific long training. additionally, the cost-tobenefit gap should be minimized. thus, it would be hopeful to extend the use of telehealth systems to general practitioners, as well as to increase the proportion of users among patients themselves. as already observed in other microangiopathic complications of diabetes [60] , for the concerns raised by dr, an integrated assessment of both firstand second-class medical care would be desirable. the majority of patients could keep remotely connected with their specialist, overcoming common barriers, especially in definite areas, and still contain the spread of the virus by social distancing. the authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. communication technologies through an etymological lens: looking for a classification, reflections about health, medicine and care diabetic retinopathy: a position statement by the american diabetes association the empirical foundations of telemedicine interventions for chronic disease management telemedicine in the intensive care unit: its role in emergencies and disaster management application of a telemedicine platform, isolation communication management system, for the care of dangerous infectious disease: a case series telemedecine : applications potentielles en situations epidemiques the role of telehealth in the medical response to disasters guidance for cardiac electrophysiology during the covid-19 pandemic from the heart rhythm society covid-19 task force; electrophysiology section of the american college of cardiology; and the electrocardiography and arrhythmias committee of the council on clinical cardiology cardiovascular considerations for patients, health care workers, and health systems during the covid-19 pandemic wearable devices for ambulatory cardiac monitoring: jacc state-of-the-art review optimizing implantable cardioverter-defibrillator remote monitoring: a practical guide hrs expert consensus statement on remote interrogation and monitoring for cardiovascular implantable electronic devices interpreting covid-19 and virtual care trends: cohort study telemedicine 2020 and the next decade the role of telemedicine during the covid-19 epidemic in china-experience from shandong province global telemedicine implementation and integration within health systems to fight the covid-19 pandemic: a call to action the effective use of telemedicine to save lives and maintain structure in a healthcare system: current response to covid-19 how about actively using telemedicine during the covid-19 pandemic? covid-19 transforms health care through telemedicine: evidence from the field incorporating telemedicine as part of covid-19 outbreak response systems telehealth for global emergencies: implications for coronavirus disease 2019 (covid-19) virtually perfect? telemedicine for covid-19 rapidly converting to "virtual practices": outpatient care in the era of covid-19 service innovation in glaucoma management: using a web-based electronic patient record to facilitate virtual specialist supervision of a shared care glaucoma programme the muranga teleophthalmology study: comparison of virtual (teleglaucoma) with in-person clinical assessment to diagnose glaucoma comparison of smartphone ophthalmoscopy with slit-lamp biomicroscopy for grading vertical cup-to-disc ratio comparing smartphone camera adapters in imaging post-operative cataract patients covid-19 and diabetes: knowledge in progress real-time teleophthalmology versus face-to-face consultation: a systematic review cost-effectiveness of diabetic retinopathy screening programs using telemedicine: a systematic review ebola outbreak in w e s t a f r i c a busting the myths about ebola is crucial to stop the transmission of the disease in guinea community perspectives about ebola in bong, lofa and montserrado counties of liberia: results of a qualitative study western area surge combats ebola pro-actively evidence of a strong association between frequency of self-monitoring of blood glucose and hemoglobin a1c levels in t1d exchange clinic registry participants once daily self-monitoring of blood glucose (smbg) improves glycemic control in oral hypoglycemic agents (oha)-treated diabetes: smbg-oha follow-up study a structured self-monitoring of blood glucose approach in type 2 diabetes encourages more frequent, intensive, and effective physician interventions: results from the step study welldoc mobile diabetes management randomized controlled trial: change in clinical and behavioral outcomes and patient and physician satisfaction cluster-randomized trial of a mobile phone personalized behavioral intervention for blood glucose control use of a novel, remotely connected diabetes management system is associated with increased treatment satisfaction, reduced diabetes distress, and improved glycemic control in individuals with insulin-treated diabetes: first results from the personal diabetes management study improving self-monitoring of blood glucose among adults with type 1 diabetes: results of the mobile™ study sensitivity and specificity of automated analysis of single-field non-mydriatic fundus photographs by bosch dr algorithm-comparison with mydriatic fundus photography (etdrs) for screening in undiagnosed diabetic retinopathy use of telemedicine technologies in diabetes prevention and control in resource-constrained settings: lessons learned from emerging economies validation of smartphone based retinal photography for diabetic retinopathy screening long-term comparative effectiveness of telemedicine in providing diabetic retinopathy screening examinations: a randomized clinical trial effectiveness and safety of screening for diabetic retinopathy with two nonmydriatic digital images compared with the seven standard stereoscopic photographic fields a telemedical approach to the screening of diabetic retinopathy: digital fundus photography implementation and evaluation of a largescale teleretinal diabetic retinopathy screening program in the los angeles county department of health services telemedicine for screening diabetic retinopathy: the no blind italian multicenter study smartphone assisted slit lamp free anterior segment imaging: a novel technique in teleophthalmology a systematic review of healthcare applications for smartphones comparison of smartphone ophthalmoscopy with slit-lamp biomicroscopy for grading diabetic retinopathy telemedicine and diabetic retinopathy: moving beyond retinal screening diabetic retinopathy screening using tele-ophthalmology in a primary care setting smartphones, tele-ophthalmology, and vision 7 journal of diabetes research teleophthalmology and vision 2020 in south africa improving access to eye care: teleophthalmology in alberta, canada a comparative cost analysis of digital fundus imaging and direct fundus examination for assessment of diabetic retinopathy management of cardiovascular risk factors in advanced type 2 diabetic nephropathy: a comparative analysis in nephrology, diabetology and primary care settings key: cord-301083-nnh95i0k authors: jumreornvong, oranicha; yang, emmy; race, jasmine; appel, jacob title: telemedicine and medical education in the age of covid-19 date: 2020-09-10 journal: acad med doi: 10.1097/acm.0000000000003711 sha: doc_id: 301083 cord_uid: nnh95i0k the covid-19 pandemic has offered medical schools an opportunity to incorporate telemedicine training into the curricula in a timely and practical manner. telemedicine has grown exponentially in the united states, and the shift toward remote care to align with social distancing guidelines is fueling this growth. training medical students to deliver high-quality, secure, and personalized health care through telemedicine will prepare the next generation of physicians to conscientiously use these technologies and meet a growing need for telehealth services. telemedicine-specific educational goals can be incorporated into curricula and integrated with existing clinical experiences to provide students with core telemedicine and clinical skills to prepare them for current and future pandemics. medical educators could explore 5 major telemedicine domains: (1) access to care, (2) cost, (3) cost-effectiveness, (4) patient experience, and (5) clinician experience. schools could use the following learning vehicles to help medical students explore these domains: (1) asynchronous lectures covering telehealth history; (2) discussions on applications, ethics, safety, etiquette, and patient considerations; (3) faculty-supervised standardized patient telehealth encounters; and (4) hands-on diagnostic or therapeutic procedures using telehealth equipment. incorporating telemedicine into the medical school curriculum exposes students to the application of telemedicine across specialties as well as its limitations. medical education has been affected by the rapid outbreak of the coronavirus . 1 in line with social distancing guidelines and recommendations from the association of american medical colleges, in march of this year, medical schools transitioned the preclerkship curriculum to online, and many paused clinical rotations. 2,3 lectures and small-group learning activities continued virtually. clinical skills sessions either moved online or were deferred. many examinations are now administered online. in other times of crisis, such as after the september 11, 2001 , terrorist attacks, medical students were able to continue their education and help in the crisis response. 4 however, given virus transmission risk and personal protective equipment (ppe) shortages, educators have been cautious in allowing students to be involved in patient care during the pandemic. fourth-year medical students were given the option to graduate early. medical students also volunteered to support frontline workers remotely by triaging patients, assessing patients using telehealth platforms, transferring patient calls, conducting covid-19 research, and providing both peer and patient mental health support. additionally, they have assisted onsite with ppe donation and pharmacy logistics. 5 thus, lectures and exams are not the only aspects of the medical student experience that can be done remotely. these students also witnessed and took part in remote versions of vital medical tasks such as scribing, telemedicine encounters, medication reconciliation, and social work coordination. with research models predicting that intermittent social distancing may be recommended through 2022, this pandemic has allowed medical schools the opportunity to incorporate telemedicine into their curricula. 6 here, we examine the state of telemedicine in the united states and propose a longitudinal telemedicine curriculum in undergraduate medical education so that future doctors may be prepared to smoothly transition to telemedicine during future pandemics. telemedicine is defined as "the provision of health care services over a spatial distance through the use of telecommunication technology with the aim of benefitting a patient or population." 7 telemedicine can improve both the care experience and patients' health, and reduce per capita costs of health care. 8 in 2019, the telemedicine market was worth over $41.4 billion. 9 the world health organization also highlighted telemedicine as an essential service in response to the covid-19 emergency. 10 the health care landscape in the age of covid-19 presents ideal conditions to accelerate this growth. a global physical workforce shortage, geographic maldistribution of primary and specialist care, and high national health care expenditure incentivize the deployment of telemedicine in rural, urban, military, and veterans affairs settings. 11, 12 in a 2019 survey, about 85% of consumers were interested in receiving virtual health care, but only 17% had access to it. 13 in response to covid-19, electronic health record providers such as cerner and epic have evolved to support more telemedicine capabilities. for example, the mobile epic medical records system now includes infection tracing, communication with isolated patients, and remote monitoring. it also allows for the coordination of patient transfers between facilities, ppe tracking, handheld charting, and guidance for the covid-19 pandemic has offered medical schools an opportunity to incorporate telemedicine training into the curricula in a timely and practical manner. telemedicine has grown exponentially in the united states, and the shift toward remote care to align with social distancing guidelines is fueling this growth. training medical students to deliver high-quality, secure, and personalized health care through telemedicine will prepare the next generation of physicians to conscientiously use these technologies and meet a growing need for telehealth services. telemedicine-specific educational goals can be incorporated into curricula and integrated with existing clinical experiences to provide students with core telemedicine and clinical skills to prepare them for current and future pandemics. medical educators could explore 5 major telemedicine domains: (1) access to care, (2) cost, (3) cost-effectiveness, (4) patient experience, and (5) clinician experience. schools could use the following learning vehicles to help medical students explore these domains: (1) asynchronous lectures covering telehealth history; (2) discussions on applications, ethics, safety, etiquette, and patient considerations; (3) faculty-supervised standardized patient telehealth encounters; and (4) hands-on diagnostic or therapeutic procedures using telehealth equipment. incorporating telemedicine into the medical school curriculum exposes students to the application of telemedicine across specialties as well as its limitations. telemedicine and medical education in the age of covid-19 nurses on remote patient support. 14 these technologies have enabled continuity of care during the pandemic and can continue to bolster care beyond the immediate crisis. providers' concerns about telemedicine include compromised quality of care as compared with in-person visits, reduced privacy and security of patients' health information, and the potential lack of personal connection between providers and patients during telemedicine visits. 15, 16 in addition, there is evidence that direct-to-consumer telehealth may increase medical malpractice. 17, 18 health care providers may also resist innovations in telemedicine because they perceive technology to be in competition with their services. 19 however, training physicians during medical school to deliver high-quality, secure, and personable health care through telemedicine can alleviate concerns and promote population-wide adoption of the technology. through a curriculum that incorporates telemedicine training, medical students could learn how to maintain a strong patient-doctor relationship, protect patient privacy, promote equity in access and treatment, and seek the best possible outcomes while using telemedicine platforms. store-and-forward telemedicine education-involving the acquisition of clinical information transferred to multiple clinical sites and appropriate specialists, such as radiology, dermatology, pathology, and ophthalmology-has also been shown to be effective. 20 medical trainees who completed this curriculum reported that it helped them develop core competencies in patient care, medical knowledge, practice-based learning and improvement, and systems-based practices. concerns about telemedicine at a system-wide level include legal and liability uncertainties, licensure requirements, and nascent reimbursement mechanisms. 21 a longitudinal telemedicine curriculum could equip future providers with a more comprehensive understanding of the legal and regulatory resources in the states in which they practice. 22 the american medical association has encouraged telemedicine training for medical education, and the liaison committee on medical education's survey shows that over a quarter of md degree-granting medical schools have implemented telemedicine training components into the preclinical phase of their curriculum and nearly half have implemented it into the clerkship phase. 7,23 therefore, we hope to advocate for more institutions to rapidly incorporate telemedicine education into their curricula and recommend how the process could occur. the basic goals of using telemedicine platforms in medical education include: facilitating basic knowledge acquisition, improving decision making, enhancement of perceptual variation in anatomy lessons or 3-dimensional simulations, improving skill coordination, practicing for rare or critical events, learning team training, and improving psychomotor skills. 24 these goals can be incorporated into curricula and integrated with existing clinical experiences to provide students with core telemedicine and clinical skills to prepare them for current and future pandemics. through meaningful and sustained remote patient care in a wide variety of clinical settings, supervised by a diverse, interprofessional faculty body, students will learn how to incorporate telemedicine in a patient-centered, compassionate way while practicing history taking, guiding patients through self-examination, and acquiring clinical reasoning skills remotely. historically, the clerkship curriculum is where most medical schools incorporated their telemedicine education. 7 however, preclinical education is also an opportunity for telemedicine training and exposure during didactic lectures or small-group discussions. videoconferencing technologies, such as project echo (extension for community healthcare outcomes), can aid in the incorporation of case-based discussions, short didactic presentations, and real-time evaluations to educate future providers in underserved areas or global settings on remote care. 25 although medical students may not directly be involved in patient care at such an early stage of their training, it is important to expose them to different technologies and teach them how to incorporate telemedicine into their own careers. medical educators could explore 5 major telemedicine domains: (1) access to care, (2) cost, (3) cost-effectiveness, (4) patient experience, and (5) clinician experience. 26 they could use the following learning vehicles to help medical students explore these domains: (1) asynchronous lectures covering telehealth history; (2) discussions on applications, ethics, safety, etiquette, and patient considerations; (3) faculty-supervised standardized patient telehealth encounters; and (4) hands-on diagnostic or therapeutic procedures using telehealth equipment such as live video, the store-and-forward method, remote patient monitoring (rpm), and mobile health. 26, 27 telemedicine's applications are abundant and we will focus on how medical schools can consider formalizing the medical student exposure in 4 key areas: (1) telesurgery, (2) telerehabilitation, (3) tele-intensive care units (tele-icus), and (4) chronic disease management and rpm. during telesurgery, surgeons use wireless networking and robotic technologies to operate on patients who are distantly located. 28 it facilitates surgical education in medically underserved locations, especially in rural areas where health care capacity may be lower. 29 virtual interactive presence allows for real-time, long-distance surgical collaboration during complex microsurgical procedures using shared 3-dimensional displays via high-definition binoculars. 30 this technology could enable remotely located experts to mentor medical students or residents at the surgical site with applications in surgical training programs, remote proctoring for proficiency, and expert support for rural and global health settings. haptic sensation feedback technology also enables the transmission of tactile information to teleoperators, which allows the operators to feel tissue consistency and tension within the sutures, preventing damage to fragile tissues or tearing of sutures during the operation. 31,32 therefore, telesurgery can improve surgical patient care, eliminate the need for long-distance travel and costs, and increase surgical collaboration and education among academic medical centers around the world. with telesurgery, medical students on virtual surgical rotations and those interested in surgical specialties would gain observational experience of core procedures and become familiar with technologies they may use in the future to instruct other trainees globally. telerehabilitation allows for the transfer of inpatients to their homes after an acute phase of disease and reduces hospitalization costs for both patients and health care providers. 33 after recovering from covid-19, patients are at high risk of developing postintensive care unit syndrome-which could include cognitive, psychiatric, or physical disability after treatment. 34 telerehabilitation may promote social distancing and more effective integration of exercise routines into daily life. individualized exercise routines at home on a treadmill, telemonitoring by a physiotherapist via videoconferencing using a tablet computer, and selfmanagement via a customized website have been shown to be effective. 35 rehabilitation specialists and medical students can use technology to observe patients as they execute movements and monitor their improvement. covid-19 has also been reported to increase stroke incidence in younger patients. 36 telerehabilitation has proven to be effective in helping poststroke patients recover motor and sensory function of affected limbs and may be adapted to help a surge of younger poststroke patients. 37 individuals with underlying comorbidities, such as cardiovascular and pulmonary diseases, are at higher risk of developing severe covid-19 disease. 38 medical students may want to become skilled in cardiac telerehabilitation because it is as effective in decreasing morbidity and mortality as facility-based cardiac rehabilitation programs. 39 medical students can employ motivational interviewing skills, a core competency of clinical skills curriculum, to promote step counts, measure walking activity, and increase adherence to a schedule of regular physical activity. supervising members of the rehabilitation team could provide feedback on students' communication skills and efficacy of counseling after receiving quantitative data from step counters. students can serve as active partners with rehabilitation teams and form longitudinal relationships with rehabilitation patients while acquiring core competencies at the same time. a tele-icu uses technology to assist in providing care for critically ill patients with offsite clinical resources. 40 two types of tele-icus have been described in the literature. 41 the decentralized tele-icu is one or more medical facility that can be accessed from remote sites such as the office, home, or mobile clinic. in the centralized system, a single icu provides intensive care via telemedicine and remote monitoring to several satellite icus. physicians working in these systems might be able to more effectively treat icu patients, providing better clinical outcomes for patients at lower costs compared with hospitals without an icu. patients and health care workers have reported that the streamlining of workflows for rapid diagnosis and isolation, clinical management, and infection prevention are important during the covid-19 pandemic. 42 there may also be a shortage in icu resources such as dialysis machines and respiratory support equipment, so it is important that future providers learn how to adapt tele-icu care to their hospital's resource status. 43 research also indicates that a structured tele-education critical care program using case-based learning and icu management principles can facilitate knowledge translation and quality improvement in the critical care setting. 44 medical students rotating through a remote critical care elective would still be expected to learn the systems-based approach to the critically ill patient, report on patient statuses during daily rounds, and identify a plan for each systems-based issue. a shortcoming of such an elective, particularly for students interested in specializing in critical care, would be a lack of hands-on experience with standard icu interventions such as central catheter and line placements, intubation, and extubation, among others. such a deficiency could be countered by remote video monitoring capabilities that allow providers to be virtually present in patient rooms at all times, such that learners could continue to observe the procedures. remote monitoring of arterial lines, mechanical ventilators, dialysis machines, and infusion pumps would also allow for more accurate reporting of clinical status and assessment for next steps in management. emerging technologies such as inpatient telemedicine and online file sharing applications can enable clinical programs to continue to function while protecting medical staff and patients from the spread of covid-19. 45 rpm programs have been rapidly deployed to safely monitor the physical and mental well-being of patients who are at high risk of contracting or have contracted covid-19. 46 rpm has previously been shown to vastly reduce the rates of visits to the emergency department and re-hospitalizations in individuals managing multiple complex conditions. 47 emotional trauma instigated by largescale human disasters, such as covid-19, may require use of tele-psychiatry to mitigate costs and increase access to global psychological counseling. 48 rpm can also be used for continuous glucose monitoring, home monitoring of cardiovascular implantable devices, and remote consultations and diagnosis. 49 the food and drug administration also authorized a covid-19 test using saliva for home collection under the guidance of telehealth professionals. 50 such technologies invite students to learn and actively contribute in troubleshooting and refining interventions to be user friendly through community-based participatory research. 51 forward triage-sorting patients before they arrive in the emergency department-has been a central strategy for health care surge control during covid-19. 52 telemedicine allows efficient screening of patients while protecting patients, clinicians, and the community from exposure. it has also been deployed in the primary care setting and is valuable for patients in need of chronic or preventative care who are reluctant to visit the clinic because they're afraid of viral transmission. medical students could be directly involved in testing, screening, and triage using history taking and clinical reasoning skills to report findings to their preceptors. the current pandemic has rapidly accelerated the move toward telemedicine and has provided an opportunity for medical schools to prepare students to participate in and develop the competencies for this transition. over half of u.s. medical schools included telemedicine in required or elective courses during the 2016-2017 academic year. 53 we believe that a swifter transition toward telemedicine in medical education will help future doctors prepare for the present age of covid-19 and future pandemics. with the recent relaxation of restrictions on video visits, more practitioners are able to perform virtual visits across state lines and on non-health insurance portability and accountability act compliant platforms. 54 covid-19 has challenged providers to deliver health care remotely and has demonstrated which kinds of care are more readily offered virtually. incorporating telemedicine into medical school curricula will not only expose medical students to relevant telemedicine technologies but also increase their understanding of the complex ethical, regulatory, and legal issues related to such cases. importantly, patients should give their consent to student involvement in their telemedicine care. threats to patient privacy in a telemedicine education program, where information is shared on different devices and accessed by multiple students and providers, may make patients reluctant to participate. it is essential that a robust privacy and security plan is well implemented and disclosed to patients. medical students should also be exposed to telehealth visit disclosures in which providers discuss the risks and benefits of phone or video visits. as informed consent is a core competency for providersin-training, these disclosures must be conveyed to learners, and in turn, to their patients. in addition, research indicates an inequity in geographical distributions of telemedicine training, especially in rural areas where hospitals may benefit most from telemedicine. 55 the covid-19 pandemic has also exposed inequities in access to educational technologies. 56 thus, hospitals and/or state governments should consider supporting these initiatives to establish the technological infrastructure needed for providers and patients. to address the potential lack of educator training in teaching telemedicine, communities of collaboration, professional credentialing standards, and automated guidance systems based on learner feedback are warranted. 57 telemedicine curricula should include the limitations of telemedicine platforms, especially in emergency or urgent care. patients using on-demand telemedicine may encounter reduced care continuity since the same provider may not be available at different unscheduled visits. insufficient or disjointed efforts in establishing high-quality telehealth training may lead to inconsistent quality of care and risks to patient safety. 58 it could also place additional burdens on medical students who are already overwhelmed with existing coursework. rapid implementation of telemedicine based on profit-driven motives may lead future providers to ignore critical research on quality and cost of care and focus on efficient, rather than evidence-based, technology implementation. in addition, the lack of implicit cues, such as body language, during telehealth consultations increases the risk of misunderstandings between patients and providers. 59 new sensitivities are also required when discussing new diagnoses and end-of-life care across lines of technology. some clinicians have stepped in to provide guidelines for video and telephone visits. 60 learners should be briefed on these limitations and be provided with tools, such as the teach-back method, to ensure mutual understanding between clinicians and patients. in the teachback method, providers invite patients to explain their understanding of the information or action plans discussed. 61 teach-back may be useful not only for patient communication but also among telehealth providers to prevent medical documentation errors. by integrating telemedicine training into existing curricular structures such as clinical rotations, lectures, ethics programming, rural care exposures, electives, and research opportunities, medical schools can expose students to telemedicine without significant additional burden. existing online resources for students and providers include the american telemedicine association, center for telemedicine and ehealth law, health resource and services website, and the american academy of pediatrics' section on telehealth care and council on clinical information technologies. 22,62-65 as telemedicine training is incorporated into more medical schools, systemic evaluation of these training methods may also allow for more effective implementation of programs. more research on the efficacy of existing telemedicine curricula and practice implementation should be explored. covid-19 has highlighted possibilities for technological advancement within medicine and medical education. with greater knowledge about which aspects of medicine work best with telehealth, it is important to train future providers to use these technologies and provide these modes of care. telemedicine curricula should train future providers to deal with the ethical, legal, and regulatory implications of telemedicine this training is especially important in light of the imminent care needs during the covid-19 pandemic. physicians must not only be trained to use telemedicine but also learn how to do so professionally, safely, and in an evidence-based manner. news-insights/press-releases/ important-guidance-medical-studentsclinical-rotations-during-coronavirus-covid-19-outbreak medical student education in the time of covid-19 mount sinai takes on mental health impact of covid-19 crisis among health workers projecting the transmission dynamics of sars-cov-2 through the postpandemic period telemedicine training in undergraduate medical education: mixed-methods review the triple aim: care, health, and cost telemedicine market size, share, and trends analysis report analysis of third global survey on ehealth based on the reported data by countries utilization of telemedicine in the u.s. military in a deployed setting the use of deployable telehealth centers by military beneficiaries to access behavioral healthcare: an exploratory evaluation in american samoa survey: 83% of consumers are interested in receiving virtual care, but only 17% have access to it privacy and security concerns in telehealth telemedicine's potential ethical pitfalls reported cases of medical malpractice in direct-to-consumer telemedicine access and quality of care in direct-to-consumer telemedicine institute of medicine board on health care services. the role of telehealth in an evolving health care environment: workshop summary teledermatology as an educational tool for teaching dermatology to residents and medical students legal perspectives on telemedicine part 1: legal and regulatory issues amaencourages-telemedicine-training-medicalstudents-residents using technology to meet the challenges of medical education project echo: telehealth to expand capacity to deliver best practice medical care creating a framework to support measure development for telehealth an interdisciplinary, multi-institution telehealth course for third-year medical students telesurgery: past, present, and future. cureus telesurgery-an efficient interdisciplinary approach used to improve the health care system virtual interactive presence for real-time, long-distance surgical collaboration during complex microsurgical procedures the future of telesurgery: a universal system with haptic sensation the use of accelerometer-based navigation for coronal tka alignment: a prospective, single surgeon comparative study telerehabilitation: review of the state-of-the-art and areas of application adapting to the coronavirus disease long-term integrated telerehabilitation of copd patients: a multicentre randomised controlled trial (itrain) largevessel stroke as a presenting feature of covid-19 in the young telerehabilitation for stroke survivors: systematic review and metaanalysis characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72,314 cases from the chinese center for disease control and prevention cardiac patients' walking activity determined by a step counter in cardiac telerehabilitation: data from the intervention arm of a randomized controlled trial intensive care unit telemedicine a business case for tele-intensive care units asian critical care clinical trials group. intensive care management of coronavirus disease 2019 (covid-19): challenges and recommendations fair allocation of scarce medical resources in the time of covid-19 impact of weekly case-based tele-education on quality of care in a limited resource medical intensive care unit orthopaedic surgical selection and inpatient paradigms during the coronavirus (covid-19) pandemic uses remote patient monitoring to rapidly respond to covid-19 telehealth intervention programs for seniors: an observational study of a communityembedded health monitoring initiative impact of human disasters and covid-19 pandemic on mental health: potential of digital psychiatry remote patient monitoring and telemedicine in neonatal and pediatric settings: scoping literature review fda authorizes first covid-19 test for home collection using saliva building a primary care/research partnership: lessons learned from a telehealth intervention for diabetes and depression virtually perfect? telemedicine for covid-19 from bedside to webside: future doctors learn how to practice remotely medicare telemedicine health care provider fact sheet telemedicine and telehealth: the potential to improve rural access to care time to fix american education with race-for-space resolve telehealth innovations in health education and training acknowledgments: the authors would like to acknowledge the students and student leaders at the icahn school of medicine at mount sinai who contributed their time to the covid-19 response in new york, new york. they are the inspiration for this article. key: cord-265934-wjdxqj8h authors: singh, amrita k.; kasle, david a.; jiang, roy; sukys, jordan; savoca, emily l.; z. lerner, michael; kohli, nikita title: a review of telemedicine applications in otorhinolaryngology: considerations during the coronavirus disease of 2019 pandemic date: 2020-10-01 journal: laryngoscope doi: 10.1002/lary.29131 sha: doc_id: 265934 cord_uid: wjdxqj8h objective/hypothesis: review the published literature of telemedicine's use within otorhinolaryngology (orl), highlight its successful implementation, and document areas with need of future research. study design: state of the art review. methods: three independent, comprehensive searches for articles published on the subject of telemedicine in orl were conducted of literature available from january 2000 to april 2020. search terms were designed to identify studies which examined telemedicine use within orl. consensus among authors was used to include all relevant articles. results: while several, small reports document clinical outcomes, patient satisfaction, and the cost of telemedicine, much of the literature on telemedicine in orl is comprised of preliminary, proof‐of‐concept reports. further research will be necessary to establish its strengths and limitations. conclusions: particularly during the coronavirus disease of 2019 pandemic, telemedicine can, and should, be used within orl practice. this review can assist in guiding providers in implementing telemedicine that has been demonstrated to be successful, and direct future research. laryngoscope, 2020 telemedicine has enabled providers to care for patients in increasingly efficient, effective, and costsaving manners. 1, 2 many specialties have taken advantage of these technologies, primarily in triaging new patients and for follow-up of postoperative patients. [3] [4] [5] [6] [7] [8] [9] [10] while the utilization of telemedicine has gradually increased over the past decades in the united states, 11 the 2019 novel coronavirus (coronavirus disease of 2019 ) pandemic has thrust both its necessity and implementation into the forefront of medical practice. similar to other medical fields, otorhinolaryngology (orl) is experiencing challenges in attempting to maximize continued quality patient care, while minimizing risk to patients and providers. 12, 13 orl presents unique barriers to telemedicine implementation due to pervasive necessity of in-person examination techniques and procedures. 14 the objective of this review is to document the manners in which telemedicine has already been implemented across the various subspecialties of orl as a guide for current practitioners, highlight limitations of telemedicine, and elucidate areas in need of further study. three independent searches of scopus, pubmed, google scholar, and google for articles published on the subject of telemedicine in orl were conducted from january 2000 to april 2020 ( fig. 1 ). search terms were designed to identify studies which examined telemedicine use within orl (appendix s1). a total of 219 unique articles were found. articles were sorted according to the following categories: head and neck oncology, otology/neurotology, laryngology, rhinology, facial plastic and reconstructive surgery, and pediatrics, and selected based on relevance. case reports, and articles with a focus outside orl were excluded. a qualitative literature review was summarized (table i) . implications for practice and potential opportunities for additional investigation were discussed and established among all authors. findings. compared to the other orl subspecialties, head and neck surgical oncology has demonstrated relatively wide adoption of telemedicine (table ii) . a study conducted by dorrian et al. concluded that initial assessment by telemedicine lowered equipment costs for providers, travel costs for patients, and unnecessary transfers to specialist centers, without compromising diagnostic accuracy or patient satisfaction. 17 within the veterans affairs (va) system, beswick et al. demonstrated the safe use of a telemedicine protocol for preoperative visits in patients with high-grade head and neck malignancies. 18 kohlert et al. found that head and neck surgical oncology cases accounted for 48.6% of all orl consults to a regional electronic consulting service. 19 head and neck cancer care plans are often developed in a multi-disciplinary tumor board that includes otolaryngologists, pathologists, radiologists, medical and radiation oncologists. several studies note that a combination of real-time videoconferencing, and safely shared laboratory, imaging, and pathology data facilitate tumor board workflow, streamlining cooperation between colleagues. [20] [21] [22] lastly, telemedicine has proven effective in easing provider demands in the postoperative setting. rimmer et al. reported that, in appropriately selected patients, telemedicine postoperative visits were safe, time-saving, and satisfactory to patients. 21 recent studies on remote free flap monitoring provide clear examples of how telemedicine can not only expedite care, but also improve patient outcomes. 23 similarly, hwang and mun found that sharing of digital photographs of flaps between providers facilitated better communication within the care team, earlier detection of flap compromise, and ultimately increased overall flap survival. 24 recommendations for practice. we strongly recommend that telemedicine be utilized to expedite workup of new tumors, especially when there is concern for highgrade/aggressive pathology. this can be accomplished through streamlining referral systems, obtaining imaging based on electronic consultation, and hosting multidisciplinary discussions on audio/visual platforms. furthermore, we recommend that telemedicine be strongly considered in postoperative head and neck surgery visits when feasible. successful use of remote free flap monitoring suggests there is also a role for inpatient head and neck telemedicine implementation (table i) . there is a further need for controlled studies comparing telemedicine to in-person assessment of head and neck cancer patients in terms of cost, safety, surveillance adherence, and oncologic outcomes. findings. the field of otology/neurotology demonstrated early adaptation of telemedicine, driven by a high patient volume and lack of specialist centers, particularly in rural settings. advances in recorded otoscopy have bolstered promise in remote evaluation, but given the degree of specialized training and equipment required, concerns exist regarding the accuracy and safety of these technologies (table iii) . in a landmark study, kokesh et al. described a "store-and-forward model (saf)," wherein audiologists and advanced practice providers obtain patient histories and otologic examinations and forward these to otolaryngologists. [25] [26] [27] compared to in-person visits, saf evaluations demonstrated decreased wait times and reduced patient travel costs. recent technological advances have allowed for the recording and storage of otoscopic examinations, allowing for saf neurotology consults, with high level of accordance with in-person diagnoses. 16, [28] [29] [30] [31] [32] [33] with a focus on otitis media, biagio et al. used video-otoscopy recordings in children recorded by facilitators with limited training. 16 the quality of the video-otoscopy recordings was noted to be acceptable or better in 87% of cases. in a study by erkkola-anttinen et al., parents of pediatric patients were trained to use otoscopes attached to smartphones for diagnosis of acute otitis media, though videos of sufficient technical quality were only obtained in 67% of cases. 34 the primary concerns regarding video-otoscopy are poor image quality and examination reliability. subtle findings such as mild retraction pocket, atelectasis, pinhole perforation, or small cholesteatoma may not be apparent on low-quality images. 34 other limitations include access to at-home equipment, such as otoscopes, specula, and imagecapturing devices, as well as high-speed internet needed to transmit high-resolution images. [34] [35] [36] telehealth has been applied to tinnitus rehabilitation, cochlear implant fitting, programming, and maintenance, as well as hearing aid assessment and programming. 37, 38 a va study of tinnitus management utilizing a skills education program delivered via telephone showed far greater improvement in symptom management than the wait-list group. 39 luryi et al. examined the role of telemedicine in cochlear implant programming of va patients, and concluded that cochlear implant threshold, comfort, and impedance levels were readily obtained via telehealth and did not differ significantly to in-person sessions. 15 when assessing the feasibility of remote evaluation of cochlear implant candidacy, fletcher et al. reported comparable testing results across remote and in-person conditions in a within-subject control study. 40 despite the demonstrated applicability of telemedicine to neurotology, there is documented needs for improvement. several studies note that a reliable standardized grading scale or diagnostic guide could be of significance in remote evaluation of otitis media to ensure more uniform, standardized assessments. 31, 41 recommendations for practice. we recommend that telemedicine be used for the diagnosis, workup, and management of otologic pathologies in select circumstances (table i) . the feasibility of remote evaluation and programming of both hearing aids and cochlear implants have been demonstrated and may be particularly useful in rural areas with limited access to care. auditory rehabilitation following cochlear implantation is another promising application for remote health, yet does not come without risks (table i) . further research assessing the use of telemedicine in diagnosing and triaging inner ear pathologies, otologic/neurotologic tumors, and other common pathologies is warranted. findings. to assess the feasibility of remote vocal rehabilitation, mashima et al. compared treatment outcomes between patients seen in person or by video teleconference. 42 the authors reported no differences in outcomes between the groups, supporting noninferior use of telemedicine in vocal rehabilitation. doarn et al. developed an online portal to provide home practice support for children between weekly voice therapy sessions. 43 in addition to facilitating increased communication with clinicians, the study documented an increase in patient adherence to therapy recommendations. while telemedicine has been successfully applied to vocal rehabilitation, it faces challenges in diagnosis of laryngeal pathologies the examination of which requires technical skill and experience (table iv) . given the significant challenges of transmission risk and limited ppe in the covid-19 pandemic, alteration of typical methods of voice and swallowing triage, evaluation, and management must be considered. to address this, ku et al. published clinical practice guidelines for the management of dysphagia in the covid-19 pandemic, suggesting use of telemedicine for triage and remote evaluation. 44 for remote voice and swallowing disorder diagnosis, one strategy is the use of non-image-based tools like voice recordings, as described by wormald et al. 45 using an automated speech analysis system, the authors demonstrated 92% sensitivity and 75% specificity for detecting vocal fold paralysis. with regards to other laryngeal pathology, computed tomography (ct) scans and ultrasonography have the benefit of being noninvasive and amenable to store-and-forward telemedicine although such may miss early, small glottic cancers and subtle laryngeal lesions. 46 proxy practitioner capable of performing the procedure would be necessary, such as a speech and language pathologist or primary care provider. as in otology, any remote diagnostic modalities must prioritize high-quality imaging to meet standards of care. 51 recommendations for practice. we strongly recommend that telemedicine be applied to voice therapy, as it has been shown to meet standards of care with increased provider and patient satisfaction. machine learning-driven detection of vocal pathologies has also shown to be effective, and further studies examining this diagnostic modality are warranted. there has been early investigation into fiberoptic laryngoscopy with remote analysis by otolaryngologists, but this practice has not been well-established and faces barriers to implementation. imaging is an option to supplement and, at times, replace in-person laryngoscopy, but further research is needed to demonstrate its reliability. findings. similar to laryngoscopy, nasal endoscopy is considered high risk for exposure to covid-19. 52 furthermore, anesthetic sprays have aerosolizing potential, which increases risk of transmission not just to the direct provider but to adjacent personnel. due to the clinical needs and risks of nasal endoscopy, investigating alternatives to this procedure is of significant interest (table v) . ct sinus imaging can be used as an alternative to endoscopy. 53 a number of studies have revealed high diagnostic concordance between nasal endoscopy and ct in the evaluation of sinus disorders. 53, 54 an obvious benefit is that any diagnostic imaging is especially amenable to remote evaluation. another alternative is remote intranasal imaging, with setups similar to those described for video-otoscopy or laryngoscopy. a small number of studies have described systems for remotely performed nasal endoscopy with digital recording and saf transmission, including use of smartphone-compatible systems, though this has similar limitations to neurotolgy and laryngology with regards to implementing remote procedures. 55, 56 epistaxis is another common rhinologic referral and may be amenable to remote evaluation. 52, 57 telemedicine can help identify triggers, risk factors, and manage mild bleeding in low-acuity patients. red flags in the patient history or failure to control bleeding with conservative measures should prompt in-person evaluation. 52 specifically regarding follow-up care in rhinology, khanwalkar et al. used mobile technology to track postoperative outcomes following septoplasty and functional endoscopic sinus surgery. 58 mobile technology has also been successfully used in the management of allergic rhinitis. 59 recommendations for practice. telemedicine has demonstrated applicability in rhinology, and we recommend that it be used for follow-up in the management of allergic rhinitis (ar). further study is needed in remote management of nonallergic rhinosinusitis. while there is a need to limit intranasal endoscopy in the time of covid-19, sole use of ct imaging for diagnosis is a deviation from standards of care and may have medicolegal implications. further research is needed to establish the efficacy of ct as a substitute to nasal endoscopy. development of guidelines for triage and remote evaluation of potentially emergent conditions such as epistaxis and invasive processes is also needed. findings. telemedicine is readily applicable to many aspects of facial plastic and reconstructive surgery (table vi) . evaluation of facial soft tissue relationships and defects is already heavily based on digital photographic documentation and analysis. 60, 61 as such, assessment of facial trauma may be particularly amenable to remote assessment. fonseca et al. reported high concordance between in-person evaluations of facial trauma patients and evaluations carried out through smartphone videoconferencing with review of ct imaging. 62 a remote approach for triage can avoid unnecessary transfers for patients that do not require urgent intervention, and possibly reduce length of hospitalization. frequent video or image-based communication between patient and provider may improve patient satisfaction by facilitating closer postoperative followup and wound care. after telemedicine was utilized by a va plastic surgery department for assessment of nonurgent pathologies like skin lesions and wound care, 83% of patients reported that they would prefer telemedicine over traditional evaluation for similar future visits. 63 high levels of patient satisfaction were also achieved with smartphone-based follow-up of facial cosmetic surgery and reviewing images remotely. 64, 65 these reports of improved patient experience likely stem from improved perception of communication. limitations for telemedicine implementation in facial plastic surgery include the ability to obtain and transmit appropriately oriented, high-quality images for facial analysis, as well as the barriers to patient-surgeon relationship which, while affected in all sub-specialties, are particularly important in this arena. 61 recommendations for practice. we recommend that telemedicine be used in certain niches within facial plastic and reconstructive surgery such as facial trauma and wound management. while facial analysis can be achieved remotely, questions remain on how to readily obtain high-resolution photos with properly lighting and orientation. areas of needed study include viability of remote facial soft tissue image capture and feasibility of remote surgical planning for cosmetic surgery. findings. many disorders in pediatric orl overlap with adults, and the application of telemedicine to pediatric orl complaints, such as otitis media, has been described in the previous sections. telemedicine has a wide applicability in pediatric orl for obtaining patient history and assessing need for common surgeries such as obstructive sleep apnea, recurrent tonsillitis, and recurrent otitis media (table vii) . 66, 67 telemedicine has also been used for postoperative follow-up of common pediatric orl procedures, such as tonsillectomy and adenoidectomy. 68 for general pediatric care in the outpatient setting, telemedicine may improve communication with parents. 69 telemedicine has also been used to evaluated and manage pediatric acute tympanostomy tube otorrhea. shaffer and dohar reported that 83% of patients were diagnosed and treated without emergency room or office assessment, with no adverse outcomes recorded. 70 recommendations for practice. we recommend that telemedicine be used when feasible to enhance communication and access between parents and providers in pediatric orl, and to streamline referrals and work-up prior to in-patient consultation. further study is required to identify and describe most impactful applications. common pediatric emergencies like aerodigestive foreign bodies and postoperative complications like posttonsillectomy hemorrhage, however, will continue to require urgent in-person evaluation. in the era of covid-19, minimizing virus transmission has become a critical part of patient care, propelling telemedicine into the forefront of the healthcare conversation. to help meet the urgent need for telehealth implementation, federal agencies have increased coverage and suspended barriers to telehealth utilization. 71-73 a general limitation of telemedicine is that patients in rural or insurance portability and accountability act requirements broadening the technological applications that may be used to implement telehealth communications with patients during the covid-19 pandemic. 72 furthermore, the office of inspector general of the hhs has waived telehealth co-payments for medicare patients. 73 while many states have temporarily relaxed licensure requirements to allow physicians to provide telemedicine across state and medicare began reimbursing audio-only visits at the same rate as video and inperson visits reimbursement reform may be necessary to ensure that a full range of telehealth services is covered by insuring providers. 75,76 furthermore, remotely assisting personnel must seek payment directly from the billing physician, requiring a contractual arrangement with the physician. 77 fortunately, telemedicine is not new to orl, and has precedents in each of the main subspecialties ( table i) . applications of telemedicine within orl, as in other fields, fall into three distinct categories: synchronous care with and without assistant providers, as well as asynchronous care or saf. synchronous care without assistance includes interactions between the otolaryngologist and the patient without an assistant. these evaluations have been proven useful for head and neck oncology triaging and postoperative visits, vocal rehabilitation, endoscopic sinus surgery postoperative evaluation, allergic rhinitis management, facial trauma evaluation, and facial plastic postoperative evaluation. [17] [18] [19] 25, 45, 58, 60, 62, 64 the second category involves synchronous care with the presence of an assistant. such assistants may be able to perform or facilitate remote diagnostic procedures such as inpatient flap checks, otoscopic evaluation, voice rehabilitation, and swallowing evaluation, as well as pre-and postoperative evaluation of pediatric patients. 23, 35, 36, 44, 45, [66] [67] [68] 70 personnel must have adequate experience and training, without which the patient may be significantly at risk of pain, injury, or misdiagnosis. 15, 52 robust telehealth networks must be created, wherein otolaryngologists can easily work with a patient's primary care provider to offer remote services and consultation. 60 the third category is asynchronous care or saf telemedicine, in which primary data are collected, transmitted to the consultant, and evaluated at a later time point. pathologies appropriate for asynchronous care are inherently nonurgent. utilization of saf techniques have already proven useful in head and neck oncology consultations, remote otologic and audiologic evaluation, cochlear implant and hearing aid management, laryngeal ultrasonography, nasolaryngoscopy, as well as ct sinus review. 16, 19, [26] [27] [28] [29] 31, 32, 34, 35, 38, 39, 41, [49] [50] [51] [52] [53] [54] [55] [56] [57] conclusion telemedicine has been successfully utilized to varying degrees in the past. further studies must include rigorous design controls, and standardization of populations and outcome measures to reduce heterogeneity and improve applicability. 78 the covid-19 pandemic has propelled its necessity and utilization into the mainstays of current orl practice. now is the time to establish standards of practice that are safe, effective, and affordable for providers and patients. aks and dak conceptualized and designed the study, performed literature reviews, drafted and critically revised the manuscript. rj, js, els, and ml critically reviewed, performed and interpreted data/literature reviews, and revised the manuscript. nk conceptualized and designed the study, critically reviewed the manuscript draft and revisions. the relative cost of outpatient telemedicine services telehealth interventions for reducing waiting lists and waiting times for specialist outpatient services: a scoping review telemedicine and telepresence for trauma and emergency care management feasibility of orthopaedic teleconsulting in a geriatric rehabilitation service teledermatology for diagnosis and management of skin conditions: a systematic review telemedicine and plastic surgery: a review of its applications, limitations and legal pitfalls telemedicine use among burn centers in the united states: a survey in-home telerehabilitation compared with face-to-face rehabilitation after total knee arthroplasty: a noninferiority randomized controlled trial a systematic review of the use of telemedicine in plastic and reconstructive surgery and dermatology a review of the use of telemedicine in dermatologic surgery trends in telemedicine use in a large commercially insured population best practice recommendations for pediatric otorhinolaryngology during the covid-19 pandemic telemedicine in the time of coronavirus sars-cov-2 viral load in upper respiratory specimens of infected patients cochlear implant mapping through telemedicine-a feasibility study video-otoscopy recordings for diagnosis of childhood ear disease using telehealth at primary health care level head and neck cancer assessment by flexible endoscopy and telemedicine consultation via telemedicine and access to operative care for patients with head and neck cancer in a veterans health administration population improving access to otorhinolaryngology-head and neck surgery expert advice through econsultations the innovative bundling of teleradiology, telepathology, and teleoncology services telemedicine in otorhinolaryngology outpatient setting-single center head and neck surgery experience virtual slide telepathology enables an innovative telehealth rapid breast care clinic comparison of video and in-person free flap assessment following head and neck free tissue transfer an evolution of communication in postoperative free flap monitoring: using a smartphone and mobile messenger application preoperative planning for ear surgery using store-and-forward telemedicine traveling an audiologist to provide otorhinolaryngology care using store-and-forward telemedicine the impact of telehealth on wait time for ent specialty care telemedicine-assisted neurotology in post-katrina southeast louisiana where does telemedicine fit into otolaryngology? an assessment of telemedicine eligibility among otolaryngology diagnoses a cross-sectional evaluation of the validity of a smartphone otoscopy device in screening for ear disease in nepal remote evaluation of video-otoscopy recordings in an unselected pediatric population with an otitis media scale community triage of otology patients using a store-and-forward telemedicine device: a feasibility study digital images for postsurgical follow-up of tympanostomy tubes in remote alaska smartphone otoscopy performed by parents smartphone-enabled otoscopy in neurotology/otology iphone otoscopes: currently available, but reliable for tele-otoscopy in the hands of parents? the role of telemedicine in auditory rehabilitation: a systematic review need for mental health providers in progressive tinnitus management: a gap in clinical care audiology telemedicine evaluations: potential expanded applications digital otoscopy versus microscopy: how correct and confident are ear experts in their diagnoses? telehealth: voice therapy using telecommunications technology design and implementation of an interactive website for pediatric voice therapy-the concept of in-between care: a telehealth model management of dysphagia in the patient with head and neck cancer during covid-19 pandemic: practical strategy performance of an automated, remote system to detect vocal fold paralysis laryngeal cancer: is computed tomography a valuable imaging technique? a retrospective analysis the value of ct scans in improving laryngoscopy in patients with laryngeal cancer ultrasound imaging of the larynx and vocal folds: recent applications and developments usefulness of ultrasonography in assessment of laryngeal carcinoma laryngeal ultrasound as effective as ct scans for the diagnosis of various laryngeal lesions telemedicine in laryngology: remote evaluation of voice disorders-setup and initial experience covid-19 and rhinology: a look at the future diagnostic accuracy of nasal endoscopy as compared to computed tomography in chronic rhinosinusitis comparative study of diagnostic nasal endoscopy and ct paranasal sinuses in diagnosing chronic rhinosinusitis endoscope-i: an innovation in mobile endoscopic technology transforming the delivery of patient care in otolaryngology development of a microportable imaging system for otoscopy and nasoendoscopy evaluations developing a synchronous otolaryngology telemedicine clinic: prospective study to assess fidelity and diagnostic concordance utilization of a novel interactive mobile health platform to evaluate functional outcomes and pain following septoplasty and functional endoscopic sinus surgery change management in allergic rhinitis and asthma multimorbidity using mobile technology the alaska experience using storeand-forward telemedicine for ent care in alaska factors influencing patient satisfaction in plastic surgery: a nationwide analysis validation of videoconference with smartphones in telemedicine facial trauma care: analysis of concordance to on-site evaluation telehealth in plastic surgery: a veterans affairs hospital perspective patient satisfaction with an early smartphone-based cosmetic surgery postoperative follow-up using telemedicine in otolaryngology realtime telemedicine for paediatric ent pre-admission screening concordance between realtime telemedicine assessments and face-to-face consultations in paediatric otolaryngology the effects of tonsillectomy education using smartphone text message for mothers and children undergoing tonsillectomy: a randomized controlled trial section on telehealth c. telemedicine: pediatric applications evidence-based telehealth clinical pathway for pediatric tympanostomy tube otorrhea coronavirus preparedness and response supplemental appropriations act, 2020. h.r.6074-116th congress notification of enforcement discretion for telehealth remote communications during the covid-19 nationwide public health emergency office of inspector general. oig policy statement regarding physicians and other practitioners that reduce or waive amounts owed by federal health care program beneficiaries for telehealth services during the 2019 novel coronavirus (covid-19) outbreak assessment of disparities in digital access among medicare beneficiaries and implications for telemedicine federation of state medical boards. u.s. states and territories modifying requirements for telehealth in response to covid-19 medicare telemedicine healthcare provider fact sheet standards and guidelines in telemedicine and telehealth key: cord-322394-b18fv3r3 authors: eichberg, daniel g; basil, gregory w; di, long; shah, ashish h; luther, evan m; lu, victor m; perez-dickens, maggy; komotar, ricardo j; levi, allan d; ivan, michael e title: telemedicine in neurosurgery: lessons learned from a systematic review of the literature for the covid-19 era and beyond date: 2020-07-20 journal: neurosurgery doi: 10.1093/neuros/nyaa306 sha: doc_id: 322394 cord_uid: b18fv3r3 background: evolving requirements for patient and physician safety and rapid regulatory changes have stimulated interest in neurosurgical telemedicine in the covid-19 era. objective: to conduct a systematic literature review investigating treatment of neurosurgical patients via telemedicine, and to evaluate barriers and challenges. additionally, we review recent regulatory changes that affect telemedicine in neurosurgery, and our institution's initial experience. methods: a systematic review was performed including all studies investigating success regarding treatment of neurosurgical patients via telemedicine. we reviewed our department's outpatient clinic billing records after telemedicine was implemented from 3/23/2020 to 4/6/2020 and reviewed modifier 95 inclusion to determine the number of face-to-face and telemedicine visits, as well as breakdown of weekly telemedicine clinic visits by subspecialty. results: a total of 52 studies (25 prospective and 27 retrospective) with 45 801 patients were analyzed. a total of 13 studies were conducted in the united states and 39 in foreign countries. patient management was successful via telemedicine in 99.6% of cases. telemedicine visits failed in 162 cases, 81.5% of which were due to technology failure, and 18.5% of which were due to patients requiring further face-to-face evaluation or treatment. a total of 16 studies compared telemedicine encounters to alternative patient encounter mediums; telemedicine was equivalent or superior in 15 studies. from 3/23/2020 to 4/6/2020, our department had 122 telemedicine visits (65.9%) and 63 face-to-face visits (34.1%). about 94.3% of telemedicine visits were billed using face-to-face procedural codes. conclusion: neurosurgical telemedicine encounters appear promising in resource-scarce times, such as during global pandemics. t elemedicine is defined as the use of electronic means for exchange of health information for delivering health care remotely. although utilized since at least 1995 in neurosurgery, 1 telemedicine has not had widespread implementation in neurosurgery. lack of reimbursement, inferiority of remote neurological exam, patient confidentiality concerns, the importance of in-person presence to establish the physician-patient bond, lack of technology, and acuity of disease processes treated are all reasons why the field of neurosurgery has been slow to adopt telemedicine. 2 telemedicine has had modest utilization in resource-poor countries 3, 4 and rural areas without access to neurosurgical services. 5 however, with the advent of the covid-19 pandemic, the urgent need to protect healthcare workers and patients from viral infection, 6, 7 as well as relaxation of regulatory barriers and facilitation of reimbursement in the united states, has stimulated new interest in telemedicine in neurosurgery. because of the dearth of data regarding success of telemedicine in neurosurgery, no guidelines have been published regarding its implementation during the covid-19 era. here, we aim to accomplish 3 objectives regarding telemedicine in neurosurgery. first, our primary aim is to perform a systematic literature review from 1995 to 2020 of all articles describing neurosurgical experience with telemedicine. second, we aim to report a short interval initial assessment of how our department is performing billing and coding, as well as telemedicine implementation rates as categorized by subspecialty. finally, we aim to consolidate and streamline the current telemedicine-related united states policy changes with regard for legal and financial viability for the practicing neurosurgeon. using pubmed, scopus, medline, ovid, web of science, embase, and all major neurosurgical journals, a systematic literature search was performed using the medical subject heading terms "neurosurgery" and "telemedicine" in accordance with prisma guidelines. 8 articles were limited to english. inclusion was limited to studies that specifically documented success of telemedicine visits for treatment of neurosurgical patients (including head and spine trauma, pediatric neurosurgery, stroke and vascular, brain tumors, hydrocephalus, spine surgery, and functional neurosurgery) in the prehospital, inpatient, outpatient, or hospital transfer triage settings. retrospective studies and prospective analyses were included, while editorials and commentaries were excluded. articles that described new technologies, but did not include neurosurgical consultation, and those that involved remote guidance of surgical procedures, were excluded. country of origin of the study was recorded. the last literature search was performed april 5, 2020. a flow sheet describing the number of articles screened can be found in figure 1 . of the collected studies, studies in which a telemedicine encounter was compared to an alternative form of patient encounter were identified. the included studies were carefully analyzed for reported success of management by telemedicine encounter. telemedicine encounter success was defined by achievement of the patient management goal specified by the individual study, which included the ability to evaluate a patient for transfer to a hospital with neurosurgical capabilities, ability to remotely program a neuromodulation device, ability to successfully perform a postoperative clinic visit, guide the administration of thrombolytics for stroke patients in the prehospital or hospital stage, or manage inpatients in the neurointensive care unit. the number of patients that were successfully managed by telemedicine was divided by the total number of patients, yielding a percentage of patients that were successfully treated. the patients that were unsuccessfully managed by telemedicine were identified, and the reason for telemedicine inadequacy was tabulated and reported as percentages. after identifying the studies in which a telemedicine encounter was compared to an alternative form of patient encounter, the superior medium of encounter as determined by the individual study was tabulated. our department's billing records for all outpatient clinic visits were retrospectively reviewed from 3/23/2020 to 4/6/2020 (1 wk after the telehealth portal was first implemented). visits in which modifier 95 was included were classified as telemedicine visits, and visits without modifier 95 inclusion were classified as face-to-face visits. we then reviewed the current procedural terminology (cpt) code submitted for the visit. visits coded using the face-to-face evaluation and management services cpt codes 99 201 to 99 215 or 99 024 were classified as face-to-face. visits coded using the telemedicine codes g2010 (remote image review) or g2012 (brief check-in) were classified as telemedicine visits. the identified telemedicine clinic visits were then further categorized based on attending subspecialty as either spine or cranial. weekly telemedicine clinic visits were totaled for each subspecialty. these values were then calculated as a percentage of the number of weekly total subspecialty clinic visits during the corresponding calendar week of 2019, which served as a pretelemedicine era baseline. a total of 324 studies were initially identified with no duplicates ( figure 1 ). a total of 15 studies were excluded due to nonenglish language. of the remaining 309 studies, 257 did not meet the prespecified inclusion and exclusion criteria. ultimately, our search yielded 52 articles with 45 801 patients and were included in our analysis, which are summarized in table 1 . 1, [3] [4] [5] a total of 25 studies were prospective and 27 were retrospective. a total of 13 studies were conducted in the united states and 39 were conducted in foreign countries. of these studies, 16 studies in which a telemedicine encounter was compared to an alternative form of patient encounter were identified. a variety of neurosurgical subspecialties were represented in this review. a total of 21 studies comprised data from all neurosurgical subspecialties (40.4%). the majority of studies investigating 1 neurosurgical subspecialty were focused on either trauma (9, 17.3%), stroke (14, 26.9%), or pediatric care (5, 9.6%). functional neurosurgery study, neuroicu care, and spine study were also included 1 each (1, 1.9%). a total of 28 studies (53.8%) composing of 35 105 patients evaluated the use of telemedicine for rapid transfer triage of patients. telemedicine was also used to evaluate the imaging and neurological exam of patients from regional hospitals to a hospital with neurosurgical services. following evaluation of imaging sent from regional hospitals, telemedicine consultations were often performed either live (synchronous) or store-andforward (asynchronous) or a combination of both. a total of 11 studies (21.2%) composing 5337 patients assessed the use of telemedicine for inpatient care. for inpatient visits, interviews were conducted with directed neurological examinations with consultation conducted remotely via videoconference software. often structured questionnaires were employed to standardize interviews to assess patient status and progress. a total of 8t studies (15.4%) with a total 2849 patients investigated the efficacy of telemedicine in the outpatient clinic setting. one functional neurosurgery study involved telemedicine for remote programming of a neuromodulation device using a remote robot controlled by nonexpert nurses. 28 a total of 5 studies comprised of 2510 patients assessed the use of telemedicine in prehospital outpatient urgent care, primarily for thrombolytic administration for ischemic stroke evaluation (9.6%). prehospital consultation often involved in-ambulance automated transmission of patient vitals, identification, and functional assessments, such as the national institutes of health stroke scale (nihss) stroke scale 57 to streamline patient admission and workflow. across all included studies, in 99.6% of patients, study authors found that treatment of neurosurgical patients was successful with telemedicine. telemedicine visits were unsuccessful in 162 cases, 81.5% of which were due to technology failure, and 18.5% of which were due to the provider determining that the patient required additional face-to-face treatment or evaluation at the inpatient clinic or hospital. a total of 16 studies were found comparing telemedicine encounters to an alternative form of patient encounter (table 2) ; telemedicine was equivalent or superior to nontelemedicine encounters in 15 studies. one study found that teleradiology alone to be superior to a telemedicine encounter; however, this study was severely biased by more than 30% of visits being incomplete due to technological issues. our department had 122 telehealth visits (65.9%) and 63 face-to-face visits (34.1%) over 30 d after the covid-19 lock down occurred. of the 122 telehealth visits, 115 (94.3%) visits were billed using face-to-face evaluation and management services cpt codes. a total of 4 visits were billed using the telehealth brief check-in code (g2012) and 3 visits were billed using the remote image review code (g2010). weekly subspecialty telemedicine clinic visits from 3/23/2020 to 4/6/2020 were calculated as a percentage of baseline 2019 weekly subspecialty face-to-face clinic visits and are summarized in figure 2 . the advent of the covid-19 pandemic, as well as relaxation of regulatory barriers and facilitation of reimbursement, has stimulated new interest in neurosurgical telemedicine. the results of our systematic review suggest that remote telemedicine treatment of neurosurgical patients is feasible in the prehospital, inpatient, outpatient, and transfer triage settings, at least in resource-scarce situations. in areas without access to neurosurgeons, remote neurosurgical visits may be preferable to no neurosurgical consultation at all, particularly in emergency cases. resource-poor countries 3,4 and medically underserved areas 5 have a track record of telemedicine utilization for neurosurgical diseases, often regarding the decision to transfer a patient to a setting with neurosurgical services. telemedicine-based neurosurgical visits may reduce patient travel time and costs, 34 and may save health care systems significant expenditures. 46 from our systematic review, the most common reason for telemedicine failure was technological failure (81.5%). we would expect this number to decrease over time as technology and user interface improves, and as the site becomes more familiar with its utilization. interestingly, inability to obtain an accurate neurological exam was not mentioned as a reason for telemedicine encounter failure in any case. although 18.5% of the telemedicine encounter failures were due to inability to deliver care remotely, resulting in the patient to be instructed to come to a face-to-face encounter, the ability to identify those who require a higher level of in-person care is in our opinion a success of telemedicine. we do not suggest that telemedicine be used to replace face-to-face visits, but rather to triage those who should be called in. of the 16 studies that compared telemedicine encounters to other methods of patient encounters, 15 found that telemedicine encounters were equivalent or superior to the alternative patient encounter medium. wong et al 39 found teleradiology encounters (in which the neurosurgeon was able to remotely view a patient's imaging, but not video of the patient's neurological exam) to have superior favorable outcome rates and reduced mortality rates compared to a telemedicine encounter in which a patient's imaging and video were available. however, these results are difficult to interpret, as a very high failure rate (30.1% failure rate) of the telemedicine technology was experienced. for the decision to administer thrombolytic therapy to patients with ischemic stroke, the american heart association/american stroke association recommends that if stroke site expertise is not physically available, a stroke expert should provide a recommendation via telemedicine. 58 it is likely that telemedicine at best provides acceptable, near-equivalent clinical information as a face-to-face encounter, and at worst is able to identify patients who should be brought in for in-person evaluation. it is possible to perform a near-full neurological exam remotely via telemedicine. 59, 60 a remote exam may be augmented with the remote guidance of an in-person health care provider, which may be particularly important in situations where the patient cannot comply with directions such as in comatose states or in the pediatric population. in fact, the american heart association/american stroke association suggests a telemedicine nihss assessment is comparable to a bedside nihss assessment. 58 however, the telemedicine exam should be considered a screening tool, not the definitive neurological exam. if physical exam findings sound worrisome, the neurosurgeon should call in the patient to the clinic and/or emergency room for an in-person evaluation. in the united states, new legislation has removed several regulatory hurdles, greatly facilitating telemedicine to be a legally and financially viable solution in neurosurgery. much of what is driving whether telemedicine is adopted is billing. prior to march 6, 2020, the centers for medicare & medicaid services (cms) did not reimburse telephone calls, and telemedicine reimbursements were restricted to those performed for rural outreach. however, on march 6, 2020, access to telemedicine services has been greatly augmented on an emergency and temporary basis under the 1135 waiver authority and coronavirus preparedness and response supplemental appropriations act. 61 under these new provisions, visits conducted through a telemedicine portal will be reimbursed by cms with the same rate as with a faceto-face visit. in fact, the same evaluation and management codes as a face-to-face visit may be specified and the place of service code should be the same as it would have been for a face-toface visit (ie, 01 for medicare). billing specialists should utilize a 95 modifier on evaluation and management codes to indicate that the service was rendered via telehealth. because cms may continue to change how telemedicine services are billed, practitioners should continue to monitor for such changes and modify their billing practices accordingly. additionally, cms has waived the requirement that out-ofstate providers be licensed in the state where they are providing services, further increasing the availability of telemedicine for treating neurosurgery patients out of state. 62 because telemedicine portals are a new technology that has not been rigorously proven to provide equivalent care to a face-toface visit, providers should perform a verbal consent to treatment by telemedicine treatment, to which the patient must verbally agree. this consenting process should be documented. clinicians must consider that as telemedicine is a new and rapidly evolving field, malpractice litigation in telemedicine could occur. misdiagnoses or failure to identify pressing issues at home may create legal implications. hipaa-compliant technological availability was previously a major barrier to neurosurgical telemedicine adoption. however, most electronic medical record systems, such as epic (epic systems corporation, madison, wisconsin) have built-in hipaa-compliant telemedicine scripting that is able to establish a secure audio-visual conference call between computers, laptops, tablets, or smartphones. many health care systems have initiated rapid rollout of such functionality. 6 although such hipaa-compliant platforms are secure, privacy considerations are important, and part of the verbal consent process for treatment with telemedicine should include a discussion of the possibility that protected health information may be compromised. some neurosurgery patients, may require assistance with activating the telemedicine conference call. if technological challenges prove insurmountable with a patient, providers should have a low threshold to convert to a regular telephone call. if the failed attempt to initiate a telemedicine visit is documented (ie, the telehealth portal was attempted, failed, and the visit was converted to a phone call), the telephone call may be billed and reimbursed as if it were a full telemedicine visit. 61 while no studies have described patient satisfaction rates with telemedicine visits in the covid-19 era, prior telemedicine studies reported initially optimistic results. reider-deimer et al (2018) evaluated the use of telemedicine for postoperative follow-up after elective neurosurgery. in a sample of 99 patients, 100% reported satisfaction with the telemedicine appointment on postvisit questionnaires. indeed, initial reports of patient satisfaction with telemedicine appointments appear promising and may warrant further innovation and investigation. the expansion of telemedicine services under the 1135 waiver authority and coronavirus preparedness and response supplemental appropriations act were intended to be temporary measures during this emergency pandemic period. however, if the data collected during this era demonstrates favorable clinical outcomes and patient preferences, it may be possible that the regulatory expansion could be made permanent. interestingly, we report variation among the neurosurgical subspecialties at our institution regarding telemedicine implementation in outpatient clinic visits. 63 while spine subspecialists attained almost 60% of the clinical volume as seen during the corresponding weeks in 2019, cranial subspecialists only recaptured approximately 30% of the 2019 weekly baseline clinical volume ( figure 2 ). the most likely explanation for this unforeseen disparity is that there is typically a greater outpatient clinic backlog of spine patients compared to cranial patients, as spine patients often make their clinic appointments several weeks in advance. therefore, a greater proportion of spine patients already have completed imaging studies and workups prior to being seen. like all systematic reviews, this one is limited by the quantity and quality of studies included. while we believe the sample of studies presented here is comparatively quite substantial, the quality between each investigation may be highly variable. although multiple reports included were randomized, prospective studies, most studies were of retrospective nature, which are characterized by their own inherent limitations. additionally, the majority of studies were conducted at healthcare sites outside of the united states, within third-world countries as well as first-world countries with healthcare systems drastically different from the american healthcare institution. thus, whether these studies may be generalizable to the american population remains questionable. however, we hope that the lessons learned in other countries with more telemedicine experience may be utilized in the united states as implementation becomes more widespread following policy changes. because of the substantial differences in study design, patient population, and variables reported among studies, it is difficult to directly and objectively compare the quality and degree of bias of each study; however, we believe the large number of studies and patients included in the systematic review analysis will compensate for any intrastudy heterogeneity in quality and/or bias. another limitation is the complexity in comparing results of telemedicine studies within neurosurgical subspecialties. although we tabulated telemedicine encounter success as achievement of the individual study's goals, encounter success has many facets including patient satisfaction, adequacy of care, physician evaluations, or percentage of transferred patients that ultimately required surgery, all of which are difficult to capture. furthermore, methodology on how telemedicine visits were conducted varied greatly between each group. because telemedicine has been implemented for a relatively short period of time, interpretation of the data regarding our initial experience is limited. we are currently compiling our long term institutional data regarding our telemedicine experience, and anticipate it will inform future clinical and hospital decisions. our systematic review suggests that remote telemedicine visits for neurosurgical patients appears promising in the prehospital, inpatient, outpatient, and transfer triage settings, at least in resource-constrained situations. further large-scale prospective randomized studies are required to determine equivalence of telemedicine visits compared to face-to-face visits. at the least, telemedicine is likely an acceptable screening tool to triage patients with concerning neurological exam and/or imaging findings to report for face-to-face visits with a neurosurgeon. the authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. acute ischemic stroke and thrombolysis location: comparing telemedicine and stroke center treatment outcomes neurosurgery and telemedicine in the united states: assessment of the risks and opportunities telemedicine and neurosurgery: experience of a regional unit based in south africa pediatric neurosurgery telemedicine clinics: a model to provide care to geographically underserved areas of the united states and its territories letter: academic neurosurgery department response to covid-19 pandemic: the university of miami/jackson memorial hospital model letter: surgical management of brain tumor patients in the covid-19 era preferred reporting items for systematic reviews and meta-analyses: the prisma statement telemedicine for neurotrauma prevents unnecessary transfers: an update from a nationwide program in albania and analysis of 590 patients effect of teleradiology upon pattern of transfer of head injured patients from a rural general hospital to a neurosurgical referral centre: follow-up study the impact of a telehealth webbased solution on neurosurgery triage and consultation the french mobile neurosurgical unit management of patients with traumatic intracranial injury in hospitals without neurosurgical service outcome of head injuries in general surgical units with an off-site neurosurgical service integration of image transmission into a protocol for head injury management: a preliminary report telemedicine for neurotrauma in albania: initial results from case series of 146 patients effect of teleradiology upon pattern of transfer of head injured patients from a rural general hospital to a neurosurgical referral centre point-of-care programming for neuromodulation: a feasibility study using remote presence telemedicineassisted treatment of patients with intracerebral hemorrhage stroke team remote evaluation using a digital observation camera in arizona: the initial mayo clinic experience trial efficacy of telemedicine for stroke: pooled analysis of the stroke team remote evaluation using a digital observation camera (stroke doc) and stroke doc arizona telestroke trials efficacy of site-independent telemedicine in the stroke doc trial: a randomised, blinded, prospective study time gain needed for in-ambulance telemedicine: cost-utility model acute stroke trial enrollment through a telemedicine network: a 12-year experience ambulance-based assessment of nih stroke scale with telemedicine: a feasibility pilot study intravenous tissue plasminogen activator administration in community hospitals facilitated by telestroke service telemedicine for safe and extended use of thrombolysis in stroke: the telemedic pilot project for integrative stroke care (tempis) in bavaria reach: clinical feasibility of a rural telestroke network a web-based telestroke system facilitates rapid treatment of acute ischemic stroke patients in rural emergency departments long-term outcome after thrombolysis in telemedical stroke care telemedicine in acute stroke: remote video-examination compared to simple telephone consultation telemedicine through the use of digital cell phone technology in pediatric neurosurgery: a case series mobile pediatric neurosurgery: rapid response neurosurgery for remote or urgent pediatric patients socioeconomic patient benefits of a pediatric neurosurgery telemedicine clinic use of telemedicine during interhospital transport of children with operative intracranial hemorrhage postoperative monitoring with a mobile application after ambulatory lumbar discectomy: an effective tool for spine surgeons utilization of a mobile videoconferencing tool (facetime) for real-time evaluation of critically ill neurosurgical patients tailoring teleconsultation to meet the current needs of neurosurgical services: a multimodality oriented neurosurgical consultation the comparative impact of video consultation on emergency neurosurgical referrals neurosurgical teleconsultations in northern norway the impact of telemedicine in the postoperative care of the neurosurgery patient in an outpatient clinic: a unique perspective of this valuable resource in the developing world -an experience of more than 3000 teleconsultations use of viber app: a fast, easy and cost effective method of communication in neurosurgery telemedicine in urgent neurosurgery the comparative impact of video-consultation on neurosurgical health services does teleradiology improve inter-hospital management of head-injury? can utilization and cost savings of a wide-area computer network for neurosurgical consultation teleconsultation: a new neurosurgical image transfer system for daily routine and emergency cases -a four-year study the impact of teleradiology on the inter-hospital transfer of neurosurgical patients comparison of telemedicine with inperson care for follow-up after elective neurosurgery: results of a cost-effectiveness analysis of 1200 patients using patient-perceived utility scores prospective and retrospective study of videoconference telemedicine follow-up after elective neurosurgery: results of a pilot program the implementation of teleneurosurgery in the management of referrals to a neurosurgical department in hospital sultanah amninah johor bahru assessment of surgical teleconsultations in a developing country: two years of experience in djibouti telemedicine in neurosurgery: teleradiology connections in the republic of croatia teleconferencing using multimedia messaging service (mms) for long-range consultation of patients with neurosurgical problems in an acute situation teleradiology in neurosurgery: experience in 1024 cases emergency image transfer system through a mobile telephone in japan: technical note improved reliability of the nih stroke scale using video training. ninds tpa stroke study group a review of the evidence for the use of telemedicine within stroke systems of care: a scientific statement from the american heart association/american stroke association neurological examination is possible using telemedicine reliability of siteindependent telemedicine when assessed by telemedicine-naive stroke practitioners centers for medicare & medicaid services. covid-19 emergency declaration blanket waivers for health care providers letter: implementation of a neurosurgery telehealth program amid the covid-19 crisis-challenges, lessons learned, and a way forward t he authors present a timely systematic review on use of telemedicine in neurosurgical care, including both a systematic review of the literature, as well as detailing their own single-institution experience after covid precautions were enacted. a total of 45,801 patients were analyzed and telemedicine was found to be successful in 99.6% of patients. in the remaining cases, technology failure was found to be the most common cause of a failed visit while the need for in-person clinical examination was found to be a factor in some cases. their results demonstrate that neurosurgical telemedicine encounters appear to be a promising avenue to deliver care in resource-scarce times such as the covid pandemic. while the authors analyze the results by subspecialty for their own practice, future studies evaluating the success of telemedicine should also aim to provide failure rates in each neurosurgical subspecialty. in addition, future studies might also investigate the surgical outcomes and patient satisfaction for cases that eventually go on to get operated. finally, the reimbursement for telemedicine is an important consideration, particularly if we expect it telemedicine to grow in adoption in the post-covid era. rochester, minnesota key: cord-259395-ytj21cit authors: hoyo, javier del; aguas, mariam title: implementing telemedicine in inflammatory bowel disease: is covid-19 the definitive trigger? date: 2020-05-15 journal: gastroenterol hepatol doi: 10.1016/j.gastrohep.2020.05.002 sha: doc_id: 259395 cord_uid: ytj21cit nan the pandemic, we already lived times of overwhelmed consultations with financial constraints, and the promise of telemedicine for improving access to better health services at lower costs drew attention to its use. paradoxically, the exponential increase in the number of articles over years led to an asymptotic evolution that rarely reaches the implementation of telemedicine in daily practice and policy [1] . the use of information and communication technologies (icts) for health practice faced several challenges explaining why many telemedicine projects fail to scale-up, despite the technical advances made since the term "telemedicine" was coined about 50 years ago. then, will this pandemic trigger a deep implementation of telemedicine never seen earlier? during the first steps of modern telemedicine, the limitations were mainly technical or procedural, with high costs associated to the communication tools that only allowed their use in restricted settings such as spatial or military applications. over time, the digitalization in telecommunications and the progressively wider access to the internet offered an opportunity to reorganize healthcare services. the increase of data transmission and storage capacity, as well as the evolution of mhealth with the development of wireless communications, provided us a broad range of easy-to-use devices adaptable to many aspects of our practice remotely. furthermore, the incorporation of artificial intelligence and big data to analyze massive volumes of information could potentially improve healthcare systems to facilitate tailored medicine. it has been a long way to go, and still the development of more powerful and cheaper communication tools turns technical challenges into legal, ethical, economical and professional issues. unlike the use of icts in other fields (streaming entertainment services, grocery delivery, e-banking, etc.), telemedicine interventions deal with the need to integrate patient-generated data into electronic health records, while privacy is essential in the processing of these sensitive data. moreover, the efficacy of telemedicine on health outcomes is inconsistent across different programs used in inflammatory bowel disease (ibd), and their value is difficult to establish when only few economic data are available. thus, decision-makers have difficulties to support the implementation and investment on telemedicine due to a lack of solid evidence. in addition, these decisions become even more complicated in areas were reimbursement is an important factor in the setup of clinical activity. at this point, are we ready to transform covid-19 crisis into a revolution? as other disasters, the pandemic leads to a surge in demand for healthcare services, which directly and indirectly could collapse health systems. to solve this problem, telemedicine offers two main advantages. on the one hand, the classical benefit of providing healthcare at a distance may serve to start-up efficient triage services without exposure to sars-cov2 [2] . on the other hand, components like tele-education and telemonitoring that provide action plans can promote patients´ empowerment and self-management. the combination of these two benefits could alleviate our previously overwhelmed healthcare capabilities not only during the pandemic, but also in our daily practice. in this sense, our research group developed a web-based platform called teccu ("telemonitorización de la enfermedad de crohn y colitis ulcerosa" or telemonitoring of crohn's disease and ulcerative colitis). in a previous pilot trial, teccu showed to be a safe strategy to improve health outcomes of complex ibd patients [3] , with a high probability of being more cost-effective in the short term compared to standard care and telephone care [4] . in view of these results, a new project in collaboration with other hospitals and investigators from the spanish working group on crohn´s disease and ulcerative colitis (geteccu) and the confederation of associations for patients with crohn's disease and ulcerative colitis of spain (accu) is currently underway (image 1). in any case, to reorganize ibd health practice definitely we should waive the previous brakes in the adoption of telemedicine, but we must also know how to drive the new situation (image 2). first, it is necessary to standardize remote medical practice. in the us, the interstate medical licensure compact was created to increase efficiency in multistate licensing of physicians [5] , but such a proposal is lacking in europe. second, those organizations that previously investigated the value of telemedical innovations should lead this revolution [6] , with the collaboration between centers and regions to develop the european health strategies. third, institutions lacking telemedicine programs can outsource these services, but the provision of remote health safely also requires a uniform legal framework regarding medical liability. finally, in order to maintain adherence to follow-up it is essential to adapt telemedicine programs according to patients´ requirements. maybe the pandemic has reduced reluctance amongst physicians to use telemedicine, but funders, policy-makers, providers and patients need to align their interests to implement remote healthcare successfully. as an example, on march 6, 2020 it was signed into law an emergency bill of more than $8 billion passed by the us congress to face covid-19. periods act of 2020 [7] , in order to temporarily lift certain restrictions on medicare telemedicine coverage in the efforts to contain the virus. page 4 of 4 j o u r n a l p r e -p r o o f therefore, telemedicine offers many opportunities to overcome healthcare challenges posed in the management of ibd during the covid-19 outbreak, as long as we know how to use these resources properly. in spite of the use of telephone and e-mail in many centers, the development of mature telemedicine programs integrated with electronic health records requires further collaborative efforts between different investigators. telemedicine intends to reorganize (not to replace) healthcare systems, and decisionmakers still need more evidence on the efficacy and cost-effectiveness of its use in ibd prior to perform important changes. even if we assume that the pandemic could reduce reluctance to use telemedicine, specific european regulation is required to protect remote medical practice and to lift some existing legal barriers. why do entrepreneurial mhealth ventures in the developing world fail to scale? british society of gastroenterology guidance for management of inflammatory bowel disease during the covid-19 pandemic a web-based telemanagement system for improving disease activity and quality of life in patients with complex inflammatory bowel disease: pilot randomized controlled trial telemonitoring of crohn's disease and ulcerative colitis (teccu): cost-effectiveness analysis virtually perfect? telemedicine for covid-19 6074, coronavirus preparedness and response supplemental appropriations act key: cord-267400-3mrqiofw authors: ray, kristin n; mehrotra, ateev; yabes, jonathan; kahn, jeremy m title: telemedicine and outpatient subspecialty visits among pediatric medicaid beneficiaries date: 2020-04-08 journal: acad pediatr doi: 10.1016/j.acap.2020.03.014 sha: doc_id: 267400 cord_uid: 3mrqiofw objective: live-interactive telemedicine is increasingly covered by state medicaid programs, but whether telemedicine is improving equity in utilization of subspecialty care is not known. we examined patterns of telemedicine use for outpatient pediatric subspecialty care within state medicaid programs. methods: we identified children ≤17 years old in 2014 medicaid analysis extract data for 12 states. we identified telemedicine-using and telemedicine non-using medical and surgical subspecialists. among children cared for by telemedicine-using subspecialists, we assessed child and subspecialist characteristics associated with any telemedicine visit using logistic regression with subspecialist-level random effects. among children cared for by telemedicine-using and non-using subspecialists, we compared visit rates across child characteristics by assessing negative binomial regression interaction terms. results: of 12,237,770 pediatric medicaid beneficiaries, 2,051,690 (16.8%) had ≥1 subspecialist visit. of 42,695 subspecialists identified, 146 (0.3%) had ≥1 telemedicine claim. among children receiving care from telemedicine-using subspecialists, likelihood of any telemedicine use was increased for rural children (or 10.4, 95%ci 6.3-17.1 compared to large metropolitan referent group) and those >90 miles from the subspecialist (or 13.4, 95% ci 10.2-17.7 compared to 0-30 mile referent group). compared to children receiving care from telemedicine non-using subspecialists, matched children receiving care from telemedicine-using subspecialists had larger differences in visit rates by distance to care, county rurality, zip code median income, and child race/ethnicity (p<0.001 for interaction terms). conclusion: children in rural communities and at distance to subspecialists had increased likelihood of telemedicine use. use overall was low, and results indicated that early telemedicine policies and implementation did not close disparities in subspecialty visit rates by child geographic and sociodemographic characteristics. over 36% of us children have at least one chronic health condition. 1 many of these children may benefit from the care of subspecialists, but families face substantial ongoing obstacles to accessing such care. the supply of pediatric subspecialists is limited and largely concentrated in urban areas, 2-4 creating significant geographic and socioeconomic barriers in access. [5] [6] [7] [8] [9] [10] [11] [12] over 28% of children in need of subspecialty care have difficulty accessing this care, 1, 12 with children living in poverty, children identified as racial or ethnic minorities, and children living in rural communities disproportionally affected. [5] [6] [7] [8] 13 telemedicine, broadly defined as remote medical care through telecommunication technology, 14 may expand access to pediatric subspecialty care and improve health outcomes. live audiovisual telemedicine is one form of telemedicine which allows patients and physicians to communicate in real-time. live interactive telemedicine has the potential to deliver subspecialty care feasibly and safely and can generate improved health outcomes. 15, 16 the american academy of pediatrics notes that telemedicine is an essential strategy to reduce healthcare disparities, 16 and many state medicaid programs now cover some uses of live interactive telemedicine for pediatric care, with coverage rapidly expanded further in the context of the covid-19 pandemic. 17 however, restrictions on telemedicine use remain, with state medicaid regulations and state policy varying in details of use (e.g., facilities where patient is located; minimum distances between patient and subspecialist). 17 many pediatric health systems offer some subspecialty telemedicine, but the volume and services offered vary. 18 studies within systems and institutions that support telemedicine have found that use of telemedicine by individual clinicians and patients can still be highly variable, even when system-level infrastructure is in place. 19 our objective, then, was to examine subspecialist and child-level factors associated with telemedicine utilization within state medicaid programs with telemedicine coverage. during this phase of early adoption of telemedicine, we hypothesized that we would observe both potentially warranted variation in use of telemedicine (e.g., variation associated with geographic variables) and potentially unwarranted variation in use of telemedicine (e.g., variation associated with child race or ethnicity). we examined 2014 medicaid analytic extract (max) data from 12 states, including all fee-for-service and managed care claims. these data represented the set of states with the most recent max data available from the centers for medicare and medicaid services at the time of our data acquisition in 2019. this study was determined to be exempt from human subjects review by the university of pittsburgh institutional review board. identifying subspecialist visits. using the max "other services" record, which excludes inpatient stays and pharmacy records, we identified outpatient visits and consultations using common procedural terminology (cpt) evaluation and management codes (e.g., 99201-99205; 99211-99215; 99241-99245). we identified visits to medical or surgical subspecialists by linking billing national provider identifiers (npis) for each visit with national plan and provider enumeration system (nppes) data. using the provider specialty taxonomy codes, we categorized a provider as a subspecialist if at least one listed taxonomy code was a medical subspecialty or surgical specialty. we then identified a small number of additional subspecialists (<1% of identified subspecialists) using medicaid specialist codes. we excluded specialties with limited patient contact (e.g., radiology, pathology), and we excluded psychiatrists because telemedicine policy related to mental health care is quite different. identifying telemedicine visits and telemedicine-using subspecialists. among these visits, we identified telemedicine encounters by using billing modifiers "gt" or "gq" or cpt code 99444, in keeping with prior studies. 20, 21 these modifiers, designed to indicate telemedicine encounters, have high sensitivity and specificity for outpatient telemedicine. 22 we examined the data for any use of telemedicine place of service codes as an alternative means of identifying telemedicine encounters, but found none of these codes. we labeled a subspecialist as "telemedicine using" if they had ≥1 identified telemedicine encounter. subspecialists with no telemedicine encounters were labeled "telemedicine non-using." we identified all children who received care from telemedicine-using subspecialists, regardless of whether the child received care via telemedicine. subspecialist and patient characteristics. we used nppes data to determine subspecialist gender and enumeration date. most clinicians (85%) had enumeration dates consistent with the launch of the npi system in 2007, and we could not further discern years in practice prior to this date for this group. using taxonomy codes, we broadly categorized subspecialists as surgical versus medical subspecialists and as pediatric versus non-pediatric trained. child age, gender, medicaid eligibility category (financial versus medical/disability), and months of enrollment in 2014 were obtained from the person summary file. race and ethnicity were also obtained from the person summary file. due to small cell sizes, we grouped race/ethnicity into 4 categories: non-hispanic white; non-hispanic black; hispanic or latino/a/x; and "other, multiple, or unknown." among children categorized as "other, multiple, or unknown" (15% of the overall sample), 20% were identified as asian, 13% as american indian or pacific islander, 7% as multiple races, and the rest had unknown race/ethnicity. we determined zip code median income using census data (categorized by federal poverty level for a family of four) and county rurality using rural-urban continuum codes. 23 medicaid plan type (fee-for-service versus managed care organization) was encoded with individual visits, so was only available for children with at least one visit. for children with visits with a specific subspecialist, we determined the straight-line distance between the patient's zip code centroid and the subspecialist's primary practice location zip code centroid. straight line distance provides a reasonable approximation to on-road travel time, 24 and was used because actual child street address was not available for more precise travel time. study cohort. we included children 17 years of age and younger. we originally reviewed 17 states of max data, but 5 states had no telemedicine-using subspecialists. because of our interest in subspecialist and child-level factors associated with telemedicine use within state medicaid programs where telemedicine occurred, we excluded these 5 states from further analysis, leaving a sample of 12.8 million children across 12 states (appendix figure 1) . we further excluded children with <1 month of enrollment (2%) or missing geographic variables (2%). among included states, the percentage of people living in rural areas ranged from 5% to 51.3%, and the percentage of children covered by the medicaid program ranged from 21.6% to 46.6% (appendix table 1 ). included states had varied state medicaid telemedicine policies in 2014, with prior analyses noting that eleven of these states had documented telemedicine policies or regulations; five included language specifically indicating that outpatient services were covered; two mandated payment parity for telemedicine services; and two specifically addressed geographic limitations of telemedicine use (appendix table 1 ). 17, 25 during this time period, the federal medicare program limited telemedicine origin sites to health care facilities in rural communities. statistical analysis. our objective was to examine subspecialist and child-level telemedicine utilization, including subspecialist use of telemedicine, child receipt of telemedicine visits, and frequency of overall visits when cared for by subspecialists who use telemedicine. to contextualize these results, we also first described child-level use of subspecialty care. children with subspecialist visits. we described pediatric medicaid beneficiaries with no subspecialty visits and with at least one subspecialist visit, with statistical differences tested using logistic regression with state-level cluster-robust standard errors. subspecialists with telemedicine use. we compared subspecialist characteristics associated with any vs. no telemedicine use through logistic regression with a penalized maximum likelihood method (firth correction) to account for rarity of telemedicine use (n=146 clinicians use telemedicine); we selected this approach because it effectively addresses the potential for complete separation in samples as small as 30 as shown in simulation studies. 26, 27 children with telemedicine visits, among those cared for by telemedicine-using subspecialists. next, we examined child and subspecialist characteristics associated with at least one telemedicine visit, limiting this analysis only to children receiving care from a telemedicineusing subspecialist. we used multi-level logistic regression including both child and subspecialist characteristics as independent variables and subspecialist-level random-effects. for children cared for by more than one telemedicine-using subspecialist, we sampled the childsubspecialist dyad with the most total visits. we examined the overall significance of each independent variable through separate wald tests. we hypothesized that geographic barriers to in-person subspecialty care (i.e. increased travel time, rural county) would be associated with increased likelihood of a telemedicine visit, while non-geographic barriers to in-person subspecialty care (e.g., lack of continuous insurance) be associated with decreased likelihood of a telemedicine visit. subspecialists. to examine visit patterns among patients seen by telemedicine-using versus nonusing subspecialists, we used descriptive statistics to describe the distribution of patients visit rates during 2014. next, to compare visit rates by patient characteristics among patients of telemedicine-using and non-using subspecialists, we used coarsened exact matching to match child-subspecialist dyads. we matched on child age group, gender, race, medicaid eligibility category and plan type, zip code median income level, county rurality, distance to care, months enrolled, subspecialist characteristics, and state. in coarsened-exact matching, 28 observations are matched many-tomany with weights then applied to each matched set to achieve covariate balance. the multivariate imbalance measure, when subtracted from 1, represents the percentage of the density of overlap between histograms of two samples. our prematch l1 statistic of 0.862 improved to a post-match l1 statistic of 0.032, indicating an effective match. we then used negative binomial regression on the matched dataset to examine visit rates. we included child and subspecialist characteristics as independent variables, with model offset for the number of months of enrollment. we incorporated matching weights with robust standard errors. we tested the significance of interaction terms between each child characteristic and subspecialist telemedicine status (telemedicine-using vs. non-using), testing all interaction terms together and each interaction term separately. because these interaction terms together yielded a significant wald test, we subsequently ran stratified negative binomial models for children cared for by telemedicine-using versus non-using subspecialists to estimate incident risk ratios. using predictive margins, we then estimated adjusted visit rates, allowing comparison across models of adjusted annual visit rates by child characteristic. in this analysis, we focused on two child characteristics associated with specifically geographic barriers to care (distance to care, rural/urban status) and two characteristics associated with disparities in access not specifically due to geographic barriers (neighborhood income, child race). we hypothesized that compared to telemedicine non-using subspecialists, telemedicine-using subspecialists would have smaller differences in visit frequency across geographic variables, but persistent differences in visit frequency by neighborhood income and child race. analyses were conducted in stata 16 mp (statacorp, college station, texas). children with subspecialist visits. of were more likely to be identified as white, reside in small metropolitan counties, be eligible for medicaid based on medical need rather than financial criteria, and be continuously enrolled. children identified as hispanic and children residing in large metropolitan counties were underrepresented among children receiving subspecialty care. subspecialists with telemedicine use. of 42,965 subspecialists identified in these claims, 146 used telemedicine in 2014 (0.3%). odds of any telemedicine use by a subspecialist were lower for surgical subspecialists (or 0.59, 95% ci 0.41-0.85 compared to medical subspecialist referent group) and non-pediatric trained subspecialists (or 0.49, 95% ci 0.33-0.71 compared to pediatric trained referent group, appendix table 2 ). among subspecialists who used telemedicine, telemedicine visit volume ranged from 1 to 829 telemedicine visits with pediatric medicaid beneficiaries during the year (median: 4 telemedicine visits per telemedicine-using subspecialist, interquartile range: 1-13). of 23,583 children cared for by telemedicine-using subspecialists, telemedicine was used within 3,365 child-subspecialist dyads (14% regarding subspecialist-level characteristics within dyads involving telemedicine-using subspecialists, odds of telemedicine use within a dyad were higher for dyads with subspecialists who were more recently trained (or 19.0, 95% ci 4.5-80.2), who were in surgical fields (or 4.39, 95% ci 2.19-8.81), and who were not specifically designated as pediatric-trained (or 5.38, 95% ci 2.20-13.14; table 2 ). subspecialists. both telemedicine-using and non-using subspecialists saw a similar percentage of their patients only once during the year (64% of telemedicine-using subspecialist patients vs 61%) and four or more times during the year (9%, both). while this overall distribution of visit frequency was similar, visit frequency varied for children by sociodemographic and geographic characteristic ( table 3) . compared to children receiving care from telemedicine non-using subspecialists, matched children receiving care from telemedicine-using subspecialists had larger variation in incident rate ratios by distance to care, county rurality, zip code median income, and child race/ethnicity (p<0.001 for each interaction term). we used predictive margins to estimate adjusted visit rates from these models across these four variables (figure 1 ). compared to children who received care from telemedicine non-using subspecialists, adjusted visit rates were higher for children living >90 miles from the subspecialist (+0.16 difference in annual visit rate) and children living in zip codes with the lowest median income (+0.36 difference in annual visit rates) who received care from telemedicine-using subspecialists. compared to children who received care from telemedicine non-using subspecialists, adjusted visit rates were lower for children from large metropolitan areas (-0.27 difference in annual visit rate) and children identified as non-hispanic black (-0.20 difference in annual visit rate) who received care from telemedicine-using subspecialists ( figure 1 ). during a period of early adoption of telemedicine, our goal was to describe how telemedicine is being used for subspecialty care for children. we found that use of telemedicine for subspecialty care was uncommon in these 2014 data, with only 0.3% of subspecialists using telemedicine, and these subspecialists, in turn, completing telemedicine visits with only 14% of their patients. within the context of low use overall, however, we identified significant variation in use of telemedicine at the child and subspecialist level during early adoption within state medicaid programs that may inform future strategies to guide appropriate telemedicine use and more equitable distribution of subspecialty care. focusing first on children characteristics associated with telemedicine use, we identified that likelihood of a child receiving a telemedicine visit varied by not only child geographic proximity to in-person care but also by child race/ethnicity. we also observed that the association between subspecialist visit rates and child geographic and non-geographic characteristics varied when cared for by telemedicine-using versus non-using subspecialists. children in rural counties and children living at distance to care are often identified implicitly or explicitly as the target audience for telemedicine programs and policies. our findings indicate that among subspecialists who use telemedicine, telemedicine is more likely to be used for visits with the children for whom current policies have directed its use, as expected. adjusted visit rates were substantially higher for children living >90 minutes from the subspecialist cared for by a telemedicine-using subspecialist rather than a telemedicine non-using subspecialist. this finding indicates that telemedicine availability improves likelihood of ongoing care for children at greatest distance. however, when adjusted for distance, rural designation did not have quite as straightforward of a relationship with visit frequency. compared to telemedicine non-using subspecialists, matched patients of telemedicine-using subspecialists had slightly higher visit rates among children in smaller metropolitan communities, but minimal increase in visit rates among children in the most rural communities. one possible contributing factor to this finding may be that some telemedicine programs are directed primarily at specific telemedicine facilities due to insurer payment policies. use of telemedicine facilities also allows may have clinical benefits by incorporating peripheral devices (e.g., tele-otoscope), nurse tele-presenters, and access to laboratory facilities. however, if telemedicine facilities are intentionally located with an eye to adequate volume, this could also result in the finding that the near-rural rather than the real-rural may see more benefit. because important differences in access and unmet need for subspecialty care also exist by child non-geographic variables, we also examined telemedicine use by child race/ethnicity and neighborhood median income. among children cared for by telemedicine-using subspecialists, children identified as hispanic were less likely to receive a telemedicine visit. additionally, differences in visit rates were wider for black versus white children cared for by telemedicineusing subspecialists compared to matched black and white children cared for by telemedicine non-using subspecialists. because telemedicine policy has been designed to reach rural populations, it has the potential to exacerbate racial or ethnic disparities in areas or states where minority populations are predominantly urban. additionally, restricting telemedicine use to beneficiaries living at specific distances does not address transportation barriers facing many urban medicaid beneficiaries, including lack of a personal vehicle, indirect bus lines, multiple family obligations, and time constraints which can make traveling even within urban areas a formidable task. as noted previously, when regional telemedicine is delivered primarily at specific telemedicine facilities, where these facilities are located could also have implications for access by race and ethnicity. additionally, clinician decision-making may also contribute to racial/ethnic disparities. for example, subspecialists may be less likely to offer telemedicine if a caregiver has low english proficiency if interpreter services are not adequately integrated. it is worth noting, however, that with intentional, community-partnered design, telehealth services can achieve high uptake and satisfaction even among families facing language barriers. 29 focusing on subspecialist characteristics, we observed first that overall use of telemedicine among subspecialists remains low, even among subspecialists caring for children in this subset of state medicaid programs where at least some forms of payment for telemedicine services existed during the study period. because few subspecialists used telemedicine, we were unable to compare use across specific subspecialties, and focused instead on broad categories (medical, surgical). we noted that surgical subspecialists and non-pediatric trained subspecialists were less likely to have ever used telemedicine, but that the likelihood of a child receiving a telemedicine visits, conditional on receiving care from a telemedicine-using subspecialist, was increased for more recently trained, surgical, and non-pediatric subspecialists. these results suggest that there is a larger group of pediatric medical subspecialists who have used telemedicine at least once, but a smaller group of non-pediatric or surgical specialists who are more likely to use telemedicine for a given clinical encounters. these results suggest that factors influencing likelihood of any use telemedicine do not necessarily translate into increased likelihood of using telemedicine for an individual child, and that supporting initial adoption by an individual clinician is not adequate to promote regular use with patients. overall, our finding show that as of 2014 telemedicine policy was achieving its intended goal (increasing utilization for children in specific geographic areas), but with important limitations (limited adoption overall and not increasing utilization for those in the most rural counties), and possible unintended consequences (perpetuating disparities for urban and minority patients). these findings have implications for telemedicine policy, where state-specific medicaid restrictions abounded prior to and even into the covid-19 pandemic. as of 2018, 6 state medicaid programs still placed geographic restrictions on which beneficiaries can receive telemedicine (e.g., greater than 60-minute travel time), 23 state medicaid programs required that patients receiving telemedicine must be physically located at a designated facility, 16 allow schools to serve as the originating site for telemedicine visits and only 14 state medicaid programs specifically allow telemedicine visits to occur with the patient at home. 17 each of these restrictions limit opportunities for telemedicine use, and prioritize the transportation barriers experienced by rural populations over the transportation barriers experienced by urban populations. reducing these restrictions, as is being done during the covid-19 pandemic, could allow telemedicine to be used more broadly for families facing a range of transportation, logistic, and time barriers, potentially enhancing both overall use and equity in use. of note, because some argue that removing geographic restrictions to telemedicine may result in over-use of services, ongoing evaluation of policy impact is necessary. alignment of clinician payment and incentives with high-value telemedicine use (e.g., accountable care organization models as opposed to fee-for-service models) may be a way to promote judicious use among clinicians as geographic restrictions are removed. additionally, given the low overall use, state medicaid programs wishing to overcome access barriers may also wish to consider alternative types of telemedicine (e.g., remote patient monitoring or store-and-forward electronic consultations 30 ), which further reduce barriers by avoiding the need for a real-time visit, but are less frequently covered in state medicaid programs. 17 many state medicaid programs have altered these restrictions during the covid-19 pandemic. it will be important to assess the impact on equity of access and utilization as policies continue to evolve. key limitations of this analysis warrant comment. first, in this claims analysis, we lack clinical data to identify unmet need for subspecialty care. instead we highlight variation in use of telemedicine among children receiving subspecialty care and among children receiving subspecialty care from a telemedicine-using subspecialist. we recognize that individual children with specific clinical needs may require different frequency of visits. second, this claims analysis did not assess the quality of care delivered during telemedicine visits, focusing instead on questions of utilization. third, our data were limited to medicaid claims, such that we cannot assess subspecialist care patterns for children with commercial insurance. we may underestimate total telemedicine use as we do not capture grant-funded programs or telemedicine payments by other insurers. fourth, our analysis is cross-sectional. longitudinal analysis of the impact of telemedicine adoption on visit patterns would provide additional insight to the relationship between new adoption, access, and utilization. fifth, we recognize that we included data from states with different regulatory environments. to account for variation in overall telemedicine use by state, we used state-level random-effects and state-level matching in our analyses; between-state variation in use of telemedicine for pediatric subspecialty care should be assessed in future work. finally, we note that these data are from 2014, and telemedicine use and regulations continue to evolve. thus these data do not reflect the current state of telemedicine use, but rather offer insight into patterns of early adoption of telemedicine for pediatric subspecialty care and opportunities to continue to center equity in future evaluations of telemedicine policy. in conclusion, we found low use of telemedicine among subspecialists caring for pediatric medicaid beneficiaries in 2014, but increased likelihood of telemedicine use among children in rural communities and at distance to subspecialty care. within panels cared for by telemedicineusing subspecialists, children in smaller metropolitan counties and at distance to care had increased subspecialist visit rates, but geographic and sociodemographic variation in visit rates persisted. evolving telemedicine policy, both during the covid-19 pandemic and beyond, should be evaluated on its ability to improve equity in access and utilization for pediatric medicaid beneficiaries in need of subspecialty care. figure 1 : adjusted annual visit rates among patients cared for by telemedicine-using versus telemedicine non-using subspecialists by patient characteristics figure 1 legend. adjusted annual visit rates among matched patients cared for by telemedicine non-using subspecialists (gray) and telemedicine using subspecialists (black). adjusted annual visit rates determined through predictive margins based on stratified negative binomial models with independent variables including listed variables (distance to subspecialist, county rurality, zip code median income, child race/ethnicity) as well as child age, child gender, insurance characteristics (eligibility category, medicaid program type) and subspecialist characteristics (clinician years in practice, clinician gender, medical v surgical subspecialist, pediatric v non-pediatric subspecialist). abbreviations, fpl, federal poverty level. legend. we compared pediatric medicaid beneficiaries with no subspecialty telemedicine visits and with at least one subspecialist visit, with testing for statistical differences using logistic regression with state-level cluster-robust standard errors. abbreviations: fpl, federal poverty level. legend. incident risk ratios for children cared for by telemedicine-using and non-using subspecialists, determined through negative binomial regression on children matched through coarsened exact matching with child and subspecialist characteristics as independent variables, model offset for the number of months of child enrollment during 2014, and coarsened-exact matching weights with robust standard errors. in addition to listed characteristics, independent variables included subspecialist years in practice, gender, subspecialtist type (medical vs. surgical), and pediatric training (pediatric vs. non-pediatric). in a full model, we tested the significance of all interaction terms together (p<0.001) and each interaction term separately (provided in last column). because all interaction terms together yielded a significant wald test, final irrs provided here were estimated through stratified negative binomial models. abbreviations: irr, incident risk ratio; ci, confidence interval; fpl, federal poverty level. data resource center for child & adolescent health. national survey of children's health interactive data query pediatrician workforce policy statement disparities in geographic access to pediatric subspecialty care distance to care and relative supply among pediatric surgical subspecialties unscheduled referrals and unattended appointments after pediatric subspecialty referral unmet need for routine and specialty care: data from the national survey of children with special health care needs primary care pediatricians' satisfaction with subspecialty care, perceived supply, and barriers to care inequities in health care needs for children with medical complexity he only takes those type of patients on certain days": specialty care access for children with special health care needs barriers to specialty care and specialty referral completion in the community health center setting supply and utilization of pediatric subspecialists in the us a national and state profile of leading health problems and health care quality for us children: key insurance disparities and across-state variations the effects of rural residence and other social vulnerabilities on subjective measures of unmet need interactive telemedicine: effects on professional practice and health care outcomes the use of telemedicine to address access and physician workforce shortages state telehealth laws and medicaid program policies: a comprehensive scan of the 50 states and district of columbia the current pediatric telehealth landscape clinician attitudes toward adoption of pediatric emergency telemedicine in rural hospitals assessing telemedicine utilization by using medicaid claims data utilization of telemedicine among rural medicare beneficiaries validation of use of billing codes for identifying telemedicine encounters in administrative data a nationwide comparison of driving distance versus straight-line distance to hospitals legal mapping analysis of state telehealth reimbursement policies bias reduction of maximum likelihood estimates a solution to the problem of separation in logistic regression causal inference without balance checking: coarsened exact matching a telehealth-enhanced referral process in pediatric primary care: a cluster randomized trial electronic consultations (e-consults) to improve access to specialty care: a systematic review and narrative synthesis zip median income 0-138% fpl 139-200% fpl 201-300% fpl >301% fpl 1 key: cord-270153-krhkqcev authors: khosla, seema title: implementation of synchronous telemedicine into clinical practice date: 2020-08-04 journal: sleep med clin doi: 10.1016/j.jsmc.2020.05.002 sha: doc_id: 270153 cord_uid: krhkqcev synchronous telemedicine allows clinicians to expand their reach by using technology to take care of patients who otherwise may not be seen. establishing a telemedicine practice can be daunting. this article outlines how to implement a synchronous telemedicine practice into an existing workflow. telemedicine-specific considerations are discussed, as well as guidance regarding practice assessment, financial feasibility, technical considerations, and clinical guidance to translate in-person visit skills into an effective virtual visit. seema khosla, md, fccp* when entertaining the idea of telemedicine, the first step is to assess whether this type of clinical visit is appropriate for the clinician and the clinical practice. the american academy of sleep medicine (aasm) released a position statement on the use of sleep telemedicine in 2015 and this may help clinicians who are contemplating adding sleep telemedicine to their practice. part of this assessment includes an honest evaluation of the clinician's comfort level both with pursuing something new and with technology itself. if the clinician is initially apprehensive about either one, it is often helpful to identify the specific issues that lead to the discomfort. for example, the clinician may be intimidated by the software or the hardware required to perform a synchronous telemedicine encounter. there are classes available in person or online that may ease this discomfort. the clinician should consider being coached or trained by someone with technical expertise. perhaps the clinician is concerned about learning how to use an examination extender, such as an electronic stethoscope, and how to coordinate a physical examination with a telepresenter. often there are educational resources provided by the vendor with a support team who can provide troubleshooting tips. the better the source of the discomfort can be identified, the more likely it is that a specific resolution exists. is the clinician uncomfortable with the idea of engaging with a patient remotely? there are classes and blogs available to teach about web-side manner, such as this webinar created by the national consortium of telehealth resource centers (https://youtu.be/ipf9gw9ozqq). an algorithm to consider following is provided in fig. 1 . once the clinician has become more comfortable with the idea of telemedicine, the second step is to objectively look at the clinic workflow. is it already overbooked? how long is the patient wait time? if the practice is currently overwhelmed with patients, then realistically there is no room for telemedicine patients. if the clinician is planning to transition current in-person patients to a telemedicine model, or if it has been determined that there is room in the clinic schedule, the next step is to assess the financial feasibility of a telemedicine practice. this assessment involves an evaluation of both fixed costs (eg, start-up costs) and recurring costs (monthly costs). these costs depend on the level of sophistication of the system. if there is a geographic area that will be served, a determination needs to be made regarding telemedicine versus establishing a satellite clinic. a sample cost analysis worksheet is provided in tables 1-3. an important consideration is whether or not medicare will reimburse for the remote visits. this consideration has recently changed with the covid-19 pandemic. because it is unclear whether current reimbursement guidelines will continue, this article includes some resources in case regulations revert back to the pre-covid-19 situation. a helpful web site is http://datawarehouse.hrsa.gov/ telehealthadvisor/telehealtheligibility.aspx, which is based on the geographic location of the originating site (where the patient is). once these fields have been populated and totals tabulated, a fiscal decision needs to be made regarding the feasibility of a telemedicine practice. if this makes financial sense for the practice, it is time to involve the clinical staff. the next step requires an objective look at the staff. will they be champions or will they create barriers? the staff's attitude toward telemedicine is critical. it is important to include them in the decisionmaking process. telemedicine may initially seem like a way to streamline the clinic personnel but, in reality, the staff will have shifting responsibilities. a nurse will still be needed to room the patient and obtain vital signs. the scheduling staff will need to schedule telemedicine visits, unless a platform that will automate this process is used. the information technology (it) staff will need to be involved in the telemedicine setup. they will need to ensure a health insurance portability and accountability act (hipaa)-compliant visit that satisfies the regulatory aspects of telemedicine. they are all already part of the team but now will likely work more closely on the telemedicine project. when staff members recognize the value of telemedicine, they often instinctively become telemedicine champions, especially when they see how patients benefit from this technology. it is vital to discuss the intent with the team and assess their willingness to embrace synchronous telemedicine. listen to and acknowledge their concerns. a successful telemedicine program requires the support of the team. as dr singh points out earlier in this issue, synchronous telemedicine is an audiovisual, real-time visit between the patient and provider. as such, the staff need to treat this as any other clinic visit including previsit and postvisit duties. the aim of a telemedicine visit is to mirror the in-person visit as much as possible. if there is paperwork that needs to be completed before the visit, the same will need to be completed before a telemedicine visit. this requirement also applies to documentation after the visit and checkout procedures, including scheduling a test or arranging for durable medical equipment (dme). the next consideration is with respect to the potential patients. will they be amenable to a telemedicine visit? some patients are rapid adopters of technology; others are more reluctant. will the patients be willing to be seen via telemedicine? in our telemedicine practice, we initially assumed, as did many others, that younger patients would be more amenable to telemedicine visits. 1 we were surprised that our patient population had a bimodal distribution. we had many younger patients but also had a significant number of older patients who were of retirement age. it is important to recognize that this group of patients grew up with a television in the home. they are pleased with their electronic tablets. they are comfortable engaging in a telemedicine encounter. 2 in our experience, they were very satisfied with a telemedicine clinic offering. as the investigators of this study 2 noted, telemedicine brings medicine back to the narrative description of the presenting complaint (history of present illness) and the clinician's observational skills. the ability to communicate with a patient is an essential skill necessary for a successful telemedicine encounter. providers need to show that they are listening to their patients to help earn their trust. this study concluded that telemedicine was more reminiscent of traditional doctor-patient interactions that relied more on communication and trust rather than primarily depending on test results. synchronous telemedicine can be performed in several ways. the 2 major models are center-tocenter (c2c) and center-to-home (c2h). c2c requires the patient to be seen in an approved clinical location. 3 this location may be the primary care physician's office, the dental office, 4 or in some states the school. 5 there are trained personnel who will greet the patient, set up the telemedicine visit for the patient, and take vital signs and appropriate clinical history. this process is similar to an in-person visit and current previsit duties performed by the nurse or medical assistant. there is someone available if there are any issues that arise during the visit. the health care practitioner conducting the telemedicine visit is physically in the practitioner's own clinic. the patient is physically at a health care facility (originating site) that is closer to the patient's home. this arrangement reduces travel time for the patient. this type of visit is recognized by many insurance payors and most states have parity for these visits, 3 which means that the reimbursement for a telemedicine visit must be the same as for an inperson visit as mandated by state legislation, although there are nuances in this legislation and variances between states. c2h allows the patient to be seen in a nonclinical setting, such as the home or place of work. there are no trained personnel with the patient and the patient navigates through the telemedicine visit alone. many telemedicine platforms offer immediate assistance in case of technical issues and the platforms are usually straightforward and uncomplicated. these visits have historically not been covered by insurance payors; however, with the national emergency created by covid-19, these visits are now being reimbursed by most payors. with the 1135 waiver, c2h telemedicine has suddenly become mainstream. at the time of this writing, readily available audiovideo platforms such as skype and facetime are able to be used. it is unclear whether reimbursement will continue after the coronavirus emergency. it is also unclear whether these platforms will continue to be accepted. realistically, an hipaacompliant model will need to emerge. the c2h model has been gaining popularity among the direct-to-consumer models for several years. these models are typically hosted by a telemedicine platform company. patients pay for this directly. fees are paid to the health care practitioner with part of the fee going to the telemedicine company. sometimes these fees are submitted to insurance companies by the patient or they are taken out of a health-savings account. data show that patients are willing to pay for this convenience. 6, 7 there has also been a shift toward e-visits in health care systems as well as with certain insurance carriers. 8 these e-visits are hosted on the insurance company's web site or on the web site for a hospital system. insurance coverage for these visits is variable and often depends on the specific plan. 9 health care systems seem to be moving toward interchangeable in-person and telemedicine visits with consistent providers, 10 and this has long been a criticism of telemedicine. there have been a few companies who have offered virtual visits with mostly out-of-state physicians using a direct-to-consumer model, which did not always allow for longitudinal care and often directly opposed primary care models, although not universally. data show that patients prefer to be seen by their own providers via telemedicine than a new provider via telemedicine, even if that new provider is within the same health system. 11 by larger health systems offering electronic visits with their own providers, patients benefit from a shared electronic health record as well as continuity of care. they are able to schedule a visit online, upload relevant information or paperwork, and engage in a telemedicine visit with their own health team from their home or place of work. these visits are now routinely performed during the covid-19 pandemic and costs have either been waived or covered under payor policies. some differences in these two models are outlined in fig. 2 . there are also 2 models of scheduling patients. if staff are traveling to the patient location (originating site) and using dedicated equipment (such as a telemedicine robot or telemedicine cart that is the property of the practice), it may be prudent to devote the entire day to that particular site. this approach allows higher efficiency because staff are traveling to set up the equipment and serve as the telepresenter. if staff are shared with the originating site, it is then feasible to place those patients into existing clinic slots (any day) that are more convenient for the patients. it is then possible to quickly switch from in-person visits to virtual visits, which is particularly helpful if the telemedicine platform being used is web based with plug-and-play equipment such as the camera, e-stethoscope, speakers, and microphone that remain at the originating site. this model is often used when starting out with a telemedicine practice because the financial outlay is significantly lower. this model can also be used for the direct-to-consumer c2h telemedicine model (minus the e-stethoscope), although some clinicians prefer to have a dedicated day for these patients as well. by incorporating virtual visits with in-person visits, any patient no-show can potentially be filled by a virtual last-minute visit. 12 many telemedicine the most basic requirements for a telemedicine visit are a video camera, a microphone, and a high-speed internet connection. the telemedicine platform must provide a secure connection. the technology has improved so rapidly that the minimum standards can be satisfied with a typical smartphone or tablet device, 13 although authentication may be required 14 for security. there are no current hipaa requirements for smartphone authentication, but this is likely to be updated. 15 one important consideration is the telemedicine platform itself, which must be a secure, hipaacompliant private connection. recently, these requirements have been loosened under the 1135 national emergency waiver but will likely revert back to requiring a hipaa-compliant system. the specific platform largely depends on the clinician's preference. there are companies that offer monthly subscriptions and supply all of the necessary training. some interface with the existing electronic medical record (emr). the features offered vary. some include the ability to take notes and generate a pdf of the visit that can be directly uploaded into the emr. some include the ability to take credit card information from the patient before the visit and provide billing services. some submit billing to insurance for reimbursement. the levels of service are variable and are apparent in the cost structure. if the clinical visit will require more than the minimal technology, there are varying levels of sophistication available for telemedicine. there is a telemedicine robot 16 that can be manipulated remotely to maneuver through clinic hallways. this robot has a video camera, microphone, and screen. often there are drawers that can be opened in order to use examination extenders, such as an electronic stethoscope or oral camera. these can be placed into position by the telepresenter or by the patient with the clinician's guidance. the sounds are transmitted through the software and audio system. there is often the ability to record these sounds and place them into the health record, although there is little reason to do so. because this is not routinely done with an inperson visit, there is no compelling reason to do this for a telemedicine visit. the purpose of the telemedicine visit is to mirror the in-person visit. if it is something that would not be routinely done in person, there is likely no reason to do it during a telemedicine visit. examination extenders are also available without a telemedicine robot. they are add-on pieces of equipment that either plug into the computer (usually via usb port) or are stand-alone devices with internal power and memory. there are oral cameras 17 that send the image via the video connection directly. these images can be shared with the patient or seen by the provider alone. these images can be saved into the electronic health record if so desired (ie, preoperative evaluation for adenotonsillectomy or to share images with a consultant; eg, a dentist for oral appliance therapy [oat]). these more robust technologies carry a higher price tag but, depending on the practice, many prove to be invaluable. choosing hardware and software that interface with the current system may be wise. communicate with the it staff, as well as the administrators and fellow clinicians, to determine the most realistic setup for the practice. it is often helpful to create a telemedicine troubleshooting contact list. this list is a quick reference containing contact information for it support, the originating site (where the patient is), the internet provider, and (most importantly) the telepresenter's contact information. it is vital to be able to reach the telepresenter throughout the patient visit in case there are technical issues or if there are clinical issues requiring immediate intervention. the information should also be readily available for the telepresenter, and a similar troubleshooting contact list should be available at the originating site. these lists are often physically placed beside the computer monitor for easy access or are adhered to the monitor itself. they should be updated on a regular basis as part of the telemedicine policy guidelines. a sample troubleshooting contact list is provided in fig. 3 . this brief article is not meant to be a comprehensive legal review. clinicians should consult their attorneys because this article is not intended to be legal advice. according to the american telemedicine association, 18 a synchronous telemedicine visit is perfectly legal as long as clinicians abide by official guidelines. these guidelines vary from state to state. some important considerations before implementing a telemedicine practice revolve around these issues: 1. can a doctor-patient relationship be established via telemedicine? 2. can medications be prescribed for patients seen via telemedicine? 3. can testing be ordered for patients seen via telemedicine? 4. can dme treatment be prescribed for patients seen via telemedicine, including positive airway pressure (pap), oat, and nasal expiratory pap devices? the answers to these specific questions depend on the state. telemedicine is patient-centric. the rules apply to the state where the patient is, but health care practitioners must also be in compliance with their home state regulations regarding the practice of telemedicine. this requirement is a little simpler for practices where the provider and the patient are in the same state, which is often a good place to begin. the interstate medical licensure compact 19 has continued to grow and helps to streamline the application process if multiple state licenses are desired. it is not a national license but aims to remove barriers and share information to facilitate licensure in multiple states. there are also nuances to these legal questions. for example, in states where a doctor-patient relationship cannot be established via telemedicine, clinicians are often able to provide telemedicine services to the established patients. it is common, in these circumstances, for the initial visit to take place in person with all of the followup done via telemedicine. this situation is also an excellent opportunity to query the patients on their willingness to engage in follow-up telemedicine visits. this would satisfy centers for medicare & medicaid services (cms) regulations 20 regarding the physical examination, which must be documented in order to script pap therapy (body mass index, neck circumference, focused cardiopulmonary and upper airway system evaluation). 21 no matter how altruistic the clinicians' intentions, a telemedicine practice cannot survive if telemedicine visits are not reimbursed. billing for a telemedicine visit is straightforward but must be done correctly. the visit is billed with a typical evaluation and management (e&m) code for professional services along with a telemedicine modifier code. 22 the telemedicine modifier is gt q3014. gt indicates that the synchronous telemedicine occurred via interactive audio and video. the video component must be present. cms (centers for medicare and medicaid services) asks for a 95 modifier to be used instead. there is a gq code, which indicates that the service was asynchronous. as of january 2020, there were only 16 states that did not recognize synchronous telemedicine visits. 23 it is also important to note that, during the 1135 covid-19 waiver, these modifiers are changing rapidly with significant differences between payors. it is vital to check with local payors to ensure appropriate payment for services. telemedicine visits between a clinician and a patient must mirror the in-person visit. the billing also mirrors billing for an in-person visit. billing can be done for time or via a traditional e&m code plus a gt modifier. it is important to recognize that this is not a reduced fee modifier. synchronous telemedicine visits are reimbursed at the same rate as the in-person visit in most states 24 where parity legislation has been passed. there is also a facility fee that can be charged in addition to the e&m code. although this facility fee is not always reimbursed, when it is, it also allows the clinician to recoup expenses for telemedicine equipment and/or room rental at the originating site. billing is the critical component of a telemedicine practice; if this part is not executed correctly, the practice will not survive. billing and reimbursement are discussed elsewhere in this issue. the emphasis thus far has been to show that telemedicine is not a new way of practicing medicine, it is simply a tool that allows the practice of medicine remotely. the patient visit is the same, with few exceptions. the history taking is the same, and the laboratory review and decision-making processes are the same. however, the differences are important to recognize. it is vital to take the time to create an appropriate clinical experience for both the patient and the clinician, which involves setting up the environment and paying attention to specific details that will allow the clinician to execute a successful telemedicine encounter. these details are outlined in fig. 4. 1. be mindful of the clinical environment. this requirement pertains mostly to the c2c model, where the patient's surroundings can be controlled. although this is also important in the c2h model, the clinician has less control over the patient's space. before the c2h visit, educational, assistive materials should be provided to the patient to ensure a private, quiet room with good lighting and minimal disruptions. the same requirement applies to the c2c visit. it should be treated the same as an in-person visit. the telepresenter should ensure that the door is closed and that there are no distractions (eg, loud noises, frequent disruptions, conversations in the hallway) during the visit. privacy should be ensured and patients treated in a professional manner. 2. pay attention to the details. the space should be well lit for both the patient and the clinician. it is helpful to do a trial run before the visit to ensure that the audio and video are of good quality ahead of time. 3. be mindful of the equipment. the audiovisual equipment should be positioned unobtrusively. the microphone should be placed in close proximity to the patient. the speakers should be adjusted to a comfortable level. the patient should be able to quickly forget about the equipment as the visit continues. 4. pay attention to the eyeline. maintaining eye contact is an important part of any clinic visit. patients often think that clinicians are not paying attention if they are not maintaining eye contact throughout the visit. 25 this requirement is much easier to do in person than via a virtual visit. it is therefore important for clinicians to be mindful of where their eyes appear to be looking. it is helpful at the beginning of the visit for clinicians to assure their patients that they are looking at them on the monitor but that they may have to avert their eyes in order to take notes. it is worthwhile to have the telepresenter sit in the patient's seat before the visit to provide feedback about the eye position. pay attention to both the horizontal and the vertical eyelines. once the telepresenter has confirmed where the eyes should be, place a marker on the screen to serve as a reminder of where to look. if picture in picture is available on the platform, it is helpful to move the thumbnail view into that location so as to be able to quickly look the patient in the eye while also making sure that the expression is appropriate and conveys engagement in the visit. 5. minimize the e-mail and turn off phone notifications. this session is a patient interaction that mirrors the in-person interaction. clinicians do not check e-mails during visits when a patient is in the office and they should not check them during an e-visit. 6. prepare ahead of time. test the connection. check the lighting and the sound. make sure the telemedicine platform is functioning appropriately, including the screen-share feature. 7. ensure that no other patient information is on the computer if the intention is to share the screen; this is another reason why e-mails should be turned off or minimized with notifications turned off. 8. clinicians can choose which of the monitors to share. it is often helpful to move the specific information related to the patient to the external monitor and then share that screen with the patient. this ability allows clinicians to then have the emr pulled up on the primary monitor. they can then move the selected documents that they wish to share. 9. clinicians may wish to have the patient upload information before the visit, such as sleep logs or sleep tracker information. they can also complete the regular paperwork ahead of time and upload this information for the review. 10. above all, remember that a telemedicine visit is a regular patient visit that is done remotely. relax. once the clinician has practiced and worked out the details, it should flow the same way as the regular in-person clinic visits. clinical algorithms respond to evolving technology. what used to require fully attended polysomnography can now be accomplished in the patient's home faster and in a more costeffective manner. 26 clinicians are able to reach patients who would otherwise never be seen by using telemedicine technology. 27 this, in turn, helps to keep communities healthier and keep health care dollars within those communities. the practice of sleep medicine continues to change with an arc toward patient-centricity. patients are becoming health care consumers. health care has evolved from a paternalistic approach to one of shared decision making. patients expect more convenience 28 and this often results in more ondemand knowledge (patients can access their electronic health records), faster communication (they can communicate directly with their health care practitioners via secure messaging), and access to new information (via the internet). many of these health care consumers also expect to be able to have a face-to-face visit with their clinicians on demand in the convenience of their homes or places of work. telemedicine has become an expectation. 29 studies have also shown that patients are willing to pay for this convenience. 6,30,31 many companies have embraced a direct-to-consumer approach, as described earlier in relation to telemedicine models. health care systems have also seen the cost savings of telemedicine. 32,33 they have also been able to apply this technology to population health management. large systems are able to mine their data and identify patients who are at a high risk of sleep apnea. they are then able to deploy questionnaires and engage with those patients. those patients are then evaluated by a clinician, either via questionnaire or an e-visit. testing is ordered and the results are reviewed by the overseeing physician. treatment can be ordered and follow-up is also done via telemedicine. by managing large populations, health care systems can improve the overall health of their covered entities. this ability results in a reduction in health care spending, which can then benefit the system as a whole. 34 artificial intelligence (ai)-assisted algorithms can be applied to the electronic health record to further evaluate which patients may be appropriate for further evaluation and testing/ treatment. 35 as the electronic health record and ai both improve, this may become standard for large health systems or those who are selfinsured. insurance companies may also apply ai-assisted algorithms to their covered entities in an attempt to reduce overall health care spending by identifying patients at high risk. much more patient-initiated testing is now being done. the ubiquity of consumer sleep technology, such as fitness trackers, has increased the awareness of the importance of sleep. it has also drawn attention to the prevalence of underlying sleep disorders. consumers who find abnormalities in their sleep, as determined by their sleep technology, are often encouraged to seek further evaluation. they may seek the counsel of their primary care physicians or sleep physicians. they are also looking online for answers to their questions. this technology may be a useful tool to engage patients 36 and may allow patients to be more aware of their sleep. patients who use consumer sleep technology may have an affinity for technology and, as such, may be more willing to pursue a telemedicine interaction. some consumer sleep technology companies have described a future in which consumers will be alerted to a possible sleep disorder via their wearable trackers, and will be able to launch a telemedicine visit via an app on their phones. 37 this vision may be closer to reality now. there are several tele-sleep clinics that currently operate using the direct-to-consumer model. they charge a fee for consultation and testing, and then are able, if they deem it to be appropriate, to provide a prescription for a medication or device. these fees can often be reimbursed by the patient's health insurance. this system allows tele-sleep clinicians to work with lower operating expenses while still providing appropriate care to their patients. tele-sleep clinicians may be clinicians who only see patients via telemedicine or they may be clinicians who also see patients in person. longitudinal relationships can be maintained via telemedicine, although typically in the direct-toconsumer model the patients are evaluated, treated, and then sent back to their primary care physicians. if issues arise, they can reconsult the tele-sleep clinician but usually these relationships are episodic. for patients with straightforward obstructive sleep apnea (osa) who do well on pap therapy, this model works well. implementing a telemedicine program may seem daunting. it is important to recognize that telemedicine is simply another method of delivering medical care. it is not a new way to practice medicine; clinicians are able to practice medicine as they currently do, but it allows them to connect with their patients using technology. this technology allows clinicians to expand their current reach and, more importantly, allows them to reach patients who may not have ever been seen because of geographic or travel limitations. 38 technology helps clinicians to deliver care into areas that are underserved. by providing health care to these populations, the overall health of the communities improves. 38 sleep medicine suffers from a lack of urgency. when people have chest pain, they recognize that they need to go to the emergency room (er) to be seen. there are public service announcements teaching about the signs and symptoms of a stroke so people can identify it sooner and seek treatment more quickly. very few people go to the er to be evaluated for snoring. the current model of osa diagnosis leaves 80% of patients undiagnosed. 39 this system is extremely fragmented with numerous bottlenecks along the algorithm. one common barrier is the need to travel to be seen by a sleep specialist, particularly in rural communities. this situation creates yet another barrier to care. untreated sleep disorders carry with them significant morbidity. 40 clearly, the current paradigm is far from ideal. telemedicine is one way to reduce barriers for patients. by eliminating the need for them to travel great distances, they are more likely to undergo testing and treatment of their underlying sleep disorders. consumer sleep technology may be another way to identify those at higher risk of a sleep disorder. those consumers may then pursue further evaluation and treatment. ai algorithms applied to large populations may identify more patients at high risk of a sleep disorder. perhaps all of these modalities will help clinicians to improve their ability to identify and treat the immense number of patients who have an undiagnosed and therefore untreated sleep disorder. telemedicine is just another tool in the toolkit. it is up to clinicians to decide how they want to use this technology to reach their patients before nonclinicians make those decisions instead. embracing this technology, which has been around for decades, may allow the gaps in the current health care algorithm at last to be bridged. the covid-19 pandemic has been an ignition event for telemedicine. now is the time to embrace this technology and build a sustainable telemedicine program. the author has nothing to disclose. practice guidelines for live, on demand primary and urgent care mhealth data security: the need for hipaa-compliant standardization intouch-health-irobot-an nounce-customers-install-rp-vitatm home-vs. laboratorybased management of osa: an economic review consumer sleep technology: an american academy of sleep medicine position statement phd, speaker at the aasm sleep disruptors conference key: cord-321030-isc3p46t authors: rodriguez socarrás, moises; loeb, stacy; teoh, jeremy yuen-chun; ribal, maria j.; bloemberg, jarka; catto, james; n’dow, james; van poppel, hendrik; gómez rivas, juan title: telemedicine and smart working: recommendations of the european association of urology date: 2020-07-10 journal: eur urol doi: 10.1016/j.eururo.2020.06.031 sha: doc_id: 321030 cord_uid: isc3p46t context: telemedicine provides remote clinical support using technological tools. it may facilitate health care delivery while reducing unnecessary visits to the clinic. the coronavirus disease 2019 (covid-19) outbreak has caused an abrupt change in our daily urological practice, converting many of us to be reliant on telehealth. objective: to provide practical recommendations for effective use of technological tools in telemedicine. evidence acquisition: a medline-based and gray literature search was conducted through april 2020. we selected the most relevant articles related to “telemedicine” and “smart working” that could provide important information. evidence synthesis: telemedicine refers to the use of electronic information and telecommunications tools to provide remote clinical health care support. smart working is a model of work that uses new or existing technologies to improve performance. telemedicine is becoming a useful invaluable tool during and even beyond the covid-19 pandemic. it is time for us to formalize the place of telemedicine in routine urological practice, and it is our responsibility to adapt and learn about all the tools and possible strategies for their optimal implementation during the pandemic to ensure that the quality of care received by patients and the outcomes of patients and their families are of the highest standard. conclusions: telemedicine facilitates specialized urological clinical support at a distance, solves problems of limitations in mobility, reduces unnecessary visits to clinics, and is useful for reducing the risk of viral transmission in the current covid-19 outbreak. furthermore, both personal and societal considerations may favor continued use of telemedicine, even beyond the covid-19 pandemic. patient summary: telemedicine in urology offers specialized remote clinical support to patients, similar to face-to-face visits. it is very useful for reducing unnecessary visits to the clinic, as well as reducing the risk of contagion in the current coronavirus disease 2019 (covid-19) pandemic. 1. the current coronavirus disease 2019 (covid19) pandemic is creating huge pressure on our health care systems and has led to dramatic changes in our daily lives. many countries have enforced strict controls on movement and socializing in an effort to manage the pandemic. protective measures have dramatically changed the way we practice clinical medicine and the expectations of our patients. health care must adapt quickly and recommendations have been published to aid triage the priority of urological surgeries [1] [2] [3] [4] [5] [6] . many centers are rapidly converting their on-site care activity to telemedicine, which has rapidly become a reality in many new settings [7] . it is expected that many patients will spend long periods of confinement at home, so the occurrence/exacerbation of urological symptoms or the interruption of follow-up may generate anxiety and a feeling of helplessness. nowadays, one of 10 individuals in the world is older than 60 yr; by 2050 this number will double to one in five [8] . although urological diseases affect a broad spectrum of age groups (from prenatal to advanced age), many urological diseases are found in persons at the highest risk of adverse outcomes from covid-19 (advanced age and male gender) [9] . as such, it is desirable to reduce unnecessary face-to-face medical visits, hospital emergency visits, and home emergency calls in order to avoid unnecessary contacts; to protect patients; and to reduce the burden of care and consumption of resources. it is evident that some aspects of health care delivery can be solved through the use of technology [5] . as telemedicine has been used in previous epidemic outbreaks, it has rapidly been incorporated into solutions to manage covid-19 patients and in several countries for continuation of specialty care such as urology. examples include isolation of patients in taiwan during the severe acute respiratory syndrome (sars) epidemic in 2003, h1n1 pandemic influenza in 2009, as well as h7n9 influenza infecting patients in 2013 in china [5, 10] . many legal, privacy, and billing issues are involved, but they are being rapidly adapted due to the covid-19 crisis [11, 12] . the actual situation due to the covid-19 epidemic is exceptional, and telemedicine is becoming a useful tool during and even beyond the pandemic. it is difficult to predict how long the pandemic will last, and social distancing may become the "new normal" behavior for a long time. even after the pandemic, telemedicine offers many potential advantages such as patient convenience and a reduction in transportation-related emissions. it is time for us to formalize the place of telemedicine in routine urological practice, and it is our responsibility to make efforts to adapt and learn all the tools and possible strategies for its optimal implementation. our aim is to provide practical recommendations for appropriate and effective use of technology tools in virtual medicine. this review will cover the current scenario in which telemedicine is used for daily urological practice. we conducted a comprehensive english-language literature research for original and review articles using the medline database and gray literature through april 2020. we searched for the following terms: "covid-19 outbreak" or/and "smartworking" or/and "telemedicine" or/and "telehealth" or/and "urology." the combination of "covid-19 outbreak" with each of the other terms found 149 related articles. the consistency of these recommendations is affected by the inherent lack of robust evidence in urology. telehealth refers to the use of electronic information and telecommunication tools to provide remote clinical health care support, professional and public health education, and health administration [5, 12, 13] . telemedicine is used as a synonym or used in a more limited sense to describe remote clinical services, such as diagnosis and monitoring [14, 15] . smart working is a model of work that uses new or existing technologies to improve performance; it is linked to the concept of flexibility and teleworking. any innovative idea is applicable, and the concept of working from anywhere including cafeterias, coworking spaces, and especially home is advocated. smart working is used by companies in different areas such as finance, support services, and consultancy [16, 17] air pollutants emitted by commuting traffic contribute to respiratory disease. emissions from cars and other forms of transportation contribute to the greenhouse gases that lead to climate change. when used to replace some travel to and for work, work from home (wfh) avoids these emissions and can help improve regional air quality and protect the environment [19] . buildings use energy to heat, cool, and light offices and to run equipment. office buildings account for nearly one-fifth of all commercial energy consumption, and nearly threefourths of that is used for lighting, heating, cooling, and powering office equipment. if the amount of office space is reduced, emissions from electricity use are likely to be lowered as well. the net savings depend on the changes in the use of space and equipment at both the office and the telework location. wfh is one way to increase the pace of developing and delivering products and services whether by avoiding time lost to emergencies or transportation delays. smart working can increase productivity by allowing workers to avoid distractions as well as replace some commuting time with working time [20] . how to pursue telemedicine and smart working in urology? telemedicine is a coordinated team effort that includes urologists, nurses, secretaries, and administrative staff and interdisciplinary coordination with other services, such as laboratory, radiology and oncology, and health care it technicians. records and data must be electronic in compliance with privacy and data protection regulations. in the european union (eu), this must be in compliance with the general data protection regulation (gdpr), which is a regulation law on data protection and privacy. it also addresses the transfer of personal data outside the eu. the gdpr aims to give control to individuals over their personal data and simplify the regulatory environment for international business by unifying the regulation within the eu [21] . each country, region, health system, and hospital has its own program for managing, in a safe way, data from medical records, images, and diagnostic and laboratory tests. it is desirable that this can be accessed from any computer/ device and place, even from home; if this option is not available, the hospital administration should consider providing remote access to the virtual private network (vpn). it is desirable to provide different methods for patients to schedule their visit, including websites, e-mails, phone numbers, or mobile applications. a prior call from the clinic team, text messages, or e-mail reminders are recommended to verify that the patient knows how to access the visit and has any necessary records available. patients can upload medical records directly to their chart via a smartphone or pc, so that doctors can see their tests or imaging results from other facilities during consultation. a patient agenda must be generated and managed with the help of the telenursing team and administrative staff. with telemedicine, scheduling of patients can be done in a flexible way. how to contact patients and make a televisit? patients can be contacted via a simple call, video call, e-mail, text message, specific software, or mobile application. the most interactive way to make a televisit seems to be a video visit; you can document a limited physical examination by guiding the patient through it. however, platforms with the capacity to carry out video visits with secure data protection may be limited in many countries, due to privacy, billing, and cost issues. furthermore, some patients may have difficulty connecting to a video visit for technical issues. in such a case, a telephone call may be the best option. telemedicine applications alone are usually less interactive and may not have enough support when compared with a telehealth platform (fig. 1 ). how to perform telemedicine triage? performing the best teleconsultation is based on managing a good triage. classifying patients into groups is crucial, for example, (1) patients on first consultation or follow-up for oncological versus nononcological pathologies, (2) patients with an acute consultation reason (eg, urinary infection, flank pain, and hematuria), (3) patients who potentially need a complementary face-to-face study (eg, for cystoscopy or imaging tests, such as ultrasound or computed tomography), (4) patients who really need to go to the emergency room or outpatient office for a procedure (eg, catheterization for acute urinary retention and renal colic with fever), and (5) patients with a diagnosis who potentially need a surgical intervention. in a globalized world, patients might require interpretation services. currently, this is not available directly within some telemedicine platforms such as epic. however, institutions should strive to contract a "language line" telephone service or other options to facilitate translation services. it is important to document all data in the clinical record such as a face-to-face consultation within the best clinical practices. the note should include a disclaimer, such as "teleconsultation is provided with the consent of the patient." in a clinical environment, the request for laboratory tests or diagnostic images can be managed through the virtual private network. however, in an outpatient or telemedicine setting when the patient is from another geographical area, it may mean sending the corresponding requests via a secure encrypted e-mail. many patients will need requisitions for laboratory or imaging tests, some of them with relative urgency. it is important to be able to send files safely, through secure e-mails on a regular basis. one example of a secure encrypted application is doximity. it offers different ways to reach patients from mobiles, without sharing private number. the doximity application integration into epic haiku allows doctors to call patients directly from their charts [22] . the covid pandemic is exceptional, with limited patient mobility and health resources. the request for complementary examinations must be made in a rational way, considering that many outpatient imaging departments and laboratories are working under exceptional conditions and serving primarily covid-19 patients during this critical time period. consideration should be given to deferring nonurgent laboratory and imaging tests depending on the clinical urgency of the test, patient age and health status, and the local covid-19 situation [7, 23, 24] . at the follow-up visit, the telemedicine team should make sure that the results of the complementary tests being requested are available to the doctor. after the results are available and clinical decisions can be made, it is recommended to send the reports to the patient and the visits should be scheduled, although in some countries these are visible to the patients within their electronic records. in the current pandemic, it is understandable that follow-up visits in low-risk patients may be scheduled later than usual. a platform that integrates secure data management and access into electronic records, as well as the ability to allow video visits in an integrated way, is desirable. there is a need for integrated telehealth platforms in many european countries (within a legal frame). currently, there are commercially available platforms such as epic (epic, verona, wi, usa) medical record system and nhs attend anywhere [7] . during the outbreak, epic is being used successfully in the usa. however, the response capacity for rapid implementation of platforms such as these during a e u r o p e a n u r o l o g y x x x ( 2 0 1 9 ) x x x -x x x crisis such as a pandemic is limited in many countries due to costs and regulations (table 1) . how to interact with other telemedicine team members? continuous communication with the team is crucial. regular channels such as calls, e-mails, and messaging are used. online applications such as zoom, hangouts, and skype can be used for video conferences, although this may depend on country restrictions and special care should be taken in terms of data sharing. zoom usage has increased during the covid-19 pandemic; with millions of people around the world working from home, this practice has brought attention to privacy. by the time of this recommendation, the zoom service does not support end-to-end encryption for video and audio content [25] . some paid corporate packages, such as microsoft teams and g suite, offer e-mail services with business domains, storage capacity, and spreadsheets that allow real-time updates, chat channels, agendas, calendars, and business group video conferencing tools, which offer better performance than free versions with an increasing number of users. the recommendation of this panel is to use safe applications in terms of privacy and make secure encrypted databases for patient follow-up tasks, which can be updated and made available to the entire team. check with your clinical administrators and become familiar with current local regulations prior to adopting these technologies. working from home requires self-discipline, order, and organization. it is advisable to make schedules of activities and patient agenda, and respect the time as if it is a face-toface consultation. prepare an adequate work area at home, including appropriate surroundings that protect the patient's confidentiality, with available technology including a computer, internet connection, video camera, and microphone, as well as professional attire. maintain good communication and enthusiasm with the team. maintaining healthy habits and routines helps improve productivity [16, 17] . the year 2020 is an exceptional year as the annual congresses of the european association of urology (eau) and the american urological association were physically suspended and have become entirely virtual due to the covid-19 pandemic. now it is crucial, more than ever, to keep learning and sharing knowledge through virtual platforms [26, 27] , including social media channels such as twitter, facebook, and instagram, as well as urological webinars organized by the different associations [28] [29] [30] [31] . several platforms can be used to create webinars and congresses, for example, logmein (https://www. logmeininc.com/) offers platforms such as gotomeeting, gotowebinar, and gototraining, which allow us to organize webinars, meetings, and virtual congresses in a relatively simple way, with accessible prices and complying with the european regulation on secure data protection. however, even simple ideas such as live streaming through online applications and platforms such as facebook, instagram, or zoom can be an option to broadcast a video conference. privacy must be respected fully throughout these processes. adherence to the data privacy policy is essential. it is advisable to use secure communication channels to protect the confidentiality of patient data. platforms provided by the institution are most recommended [13] . privacy and billing regulations vary across different regions and countries, which have been complicated further by the rapidly changing covid-19 situation [11, 12] . once again, it is strongly advised to check the local regulations with your clinical administrator. a limitation of televisits is that a conventional physical examination cannot be performed. on the contrary, a selfexamination directed by the physician may be a reasonable option, especially in video visits [4, 11] . in addition, it is not possible to obtain ancillary tests (such as urine dipstick, postvoid residual urine measurement, and laboratory testing) during the encounter; therefore, any important tests that are required have to be conducted separately. billing telehealth has been described as an important issue. billing conditions vary in each country and are complicated; however, changes in telemedicine regulations and wfh policies are being considered, and we should be encouraged to study and adapt to each country and region. confidentiality is another problem; however, by following recommendations, and using proper channels and common sense, we can solve them. regulatory considerations on confidentiality are also being addressed. patients should be notified of what protections are in place and a disclaimer should be included in clinical documentation. some urologists may not have previous experience with smart working and telehealth; potential challenges include scheduling televisits, team meetings, self-discipline, dise u r o p e a n u r o l o g y x x x ( 2 0 1 9 ) x x x -x x x tractions from wfh, feelings of loneliness, loss of motivation, depression, disruptions from family life inside the home, and creating a professional work environment remotely. reviewing strategies on how to deal with wfh can be very helpful. good practice recommendations on telemedicine and smart working these recommendations attempt to provide best practices for applying telemedicine in urology. the covid-19 pandemic is changing rapidly, and these recommendations will need to be updated regularly: 1 keep up-to-date on innovative strategies and learn to manage platforms and tools that allow communication with patients, communication with other team members, and safe data sharing. 2 provide patients with different methods for scheduling of visits. contact them in advance to agree on the schedule of consultation and provide instructions on how to access the visit. provide a telephone number for urgent consultation and red flag symptoms, and avoid unnecessary visits to the hospital. 3 during video visits, have a quiet and private environment, and make sure that the patient has it too. preferably the patient should be alone or with a relative who may help with technical issues. laptops and desktop computers are preferable to cell phones. ensure a quiet, nondistracting background and adequate lighting with good audio. the camera should be placed at the eye level. try to wear professional "work" clothes. manage your body language and analyze the patient's body language. offer advice to perform a guided physical self-examination. for patients who cannot establish a video visit for technical reasons, a phone call may be an alternative [4] . 4 not having a specific application is not a reason for not doing telemedicine. even a simple phone call and access to medical records, managed by a urologist or nurse, can help temporize urological issues and concerns during a pandemic emergency. 5 hospital phones should be used for phone calls. if you use your personal mobile, it is better to set it up in the phone configuration and settings not to show your personal number. the doximity application is an option, for example. 6 triage patients using common and clinical sense [1] [2] [3] . 7 send reports and prescriptions, conduct laboratory and imaging tests, and schedule face-to-face procedures (eg, cystoscopies) if necessary, with the support of a nursing and/or administrative telemedicine team. 8 maintain constant communication with the team during a televisit. 9 familiarize yourself with the available options for email, video conferencing, calendars, social media, packages, telehealth platforms, and webinar platforms. check with administrators about the local regulations prior to adopting these technologies. 10 comply with the privacy and billing regulations in your country and region. 11 if you wfh, self-discipline is crucial. set schedules and avoid distracting factors when you are working, like a faceto-face job [4] . create healthy routines and keep motivation high. find a balance with any family member at home. 12 keep yourself updated academically by following the virtual congresses, webinars, guidelines, and articles from the official channels of urological associations (https://uroweb.org/). exchange knowledge and ideas through social media [12, 13] . 13 arrange update and scientific meetings by videoconference. discuss relevant clinical cases and new strategies with evolving situations. 14 try to generate and share quality content for the population and patients. remember, you are a health professional, and there is a substantial need for dissemination of high-quality health information particularly during a public health crisis. try to adhere to recommendations, follow your local policies, and avoid misconducts ( table 2 ). in the current scenario, we must make efforts to ensure the feasibility of telemedicine and smart working. these tools are useful during this crisis and probably are here to stay. it is the duty of national and regional associations, as well as the table 2 -inappropriate telemedicine behaviors. not asking for consent to televisit not informing change from face-to-face visit to televisit at the beginning of the consultation communicating sensitive information through improper channels informing a diagnosis of cancer through a text message not using proper channels under the privacy and billing laws of the countrybilling a consultation as face to face using channels or applications outside of the country's laws not sending reports and prescriptions that have been offered not sending treatment prescription taken on a regular basis inappropriate televisit and wfh wearing informal clothes, and using a nonprivate environment to inform the patient not properly managing a patient who needs face-to-face care not recommending face-to-face care to a patient with lumbar pain and fever wfh = work from home. e u r o p e a n u r o l o g y x x x ( 2 0 1 9 ) x x x -x x x urology departments of each institution, to find strategies adapted to their local setting. we must look for simple and effective strategies in the short term, and think about mediumand long-term strategies. no one currently knows how to return to "normal clinical practice" when the incidence of covid-19 drops. everything seems to suggest that face-toface consultations are going to be restricted for an indeterminate period of time, and we have to evolve with telemedicine and virtual medicine quickly. an important issue is access to health care, which can be problematic for individuals in rural areas; this is another population that may benefit in the long term from greater expansion in telemedicine [32] . institutions should build up telemedicine programs according to each department's needs. this includes defining the types of services to offer (eg, first consultations, follow-ups, rapid test reading, or imaging) and how telemedicine will be delivered. after defining the needs, the planning phase, where timelines and task lists are created to launch and maintain the telemedicine program, is defined. this includes the following: 1 define the target of patients and pathologies to be included in the telemedicine program and schedules to be followed (eg, low-risk prostate cancer follow-up, benign prostatic hyperplasia with low to moderate symptoms, etc.) 2 select enthusiastic and motivated people and give specific training. 3 determine the hours necessary to complete the tasks and create an implementation timeline. 4 discuss and create the materials necessary to shape the telemedicine program. the final stage is implementation and feedback. implementing of a telemedicine program implies an organizational change in the departments, and similar to all changes, it is about people. technology is a cornerstone of telemedicine programs; however, successful implementation requires the ability to build the best team. telemedicine and smart working provide specialized clinical support for urologists at a distance using technological tools, as a logistically feasible alternative to face-toface consultation. this novel way of medical practice reduces unnecessary visits to medical facilities, and it is useful for reducing the risk of transmission in the current covid-19 pandemic. furthermore, both personal and societal considerations (eg, greenhouse emissions and greater efficiency) may favor continued use of telemedicine when applicable, even beyond the covid-19 pandemic. author contributions: juan gómez rivas had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. study concept and design: rivas, socarrás, bloemberg. acquisition of data: socarrás, rivas. funding/support and role of the sponsor: none. european association of urology guidelines office rapid reaction group: an organisationwide collaborative effort to adapt the european association of urology guidelines recommendations to the coronavirus disease 2019 era considerations in the triage of urologic surgeries during the covid-19 pandemic endourological stone management in the era of the covid-19 telemedicine in the time of coronavirus global telemedicine implementation and integration within health systems to fight the covid-19 pandemic: a call to action bolstering the surgical response to covid-19: how virtual technology will save lives and safeguard surgical practice covid-19 pandemic-is virtual urology clinic the answer to keeping the cancer pathway moving? united nations. department of economic and social affairs, population division. world population ageing baseline characteristics and outcomes of 1591 patients infected with sars-cov-2 admitted to icus of the lombardy region telemedicine: potential applications in epidemic situations department of health and human services, office for civil rights. faqs on telehealth and hipaa during the covid-19 nationwide public health emergency current use of telehealth in urology: a review virtually perfect? telemedicine for covid-19 telemedicine 2020 and the next decade the smart working handbook transport for london. smarter working guide patient and clinician experiences with telehealth for patient follow-up care the impact of telemedicine on greenhouse gas emissions at an academic health science center in canada gaining the air quality and climate benefit from telework. world resources institute /679 of the european parliament and of the council of 27 april 2016 on the protection of natural persons with regard to the processing of personal data and on the free movement of such data, and repealing directive 95/46/ec (general data protection regulation) american college of cardiology. feature | telehealth: rapid implementation for your cardiology clinic pathways for urology patients during the covid-19 pandemic urology practice during covid-19 pandemic the impact of covid-19 on european health care and urology trainees impact of the covid-19 pandemic on urology residency training in italy. minerva urol nefrol online professionalism-2018 update of european association of urology (@uroweb) recommendations on the appropriate use of social media social media in urology: opportunities, applications, appropriate use and new horizons live videos shared on social media during urological conferences are increasing: time to reflect on advantages and potential harms. an esut-yau study perceived role of social media in urologic knowledge acquisition among young urologists: a european survey teleurology in the time of covid-19 pandemic: here to stay? we acknowledge all the eau personnel dedicated to keep the work going during this covid-19 crisis. key: cord-307808-0t6sw0zp authors: romanick-schmiedl, sue; raghu, ganesh title: telemedicine — maintaining quality during times of transition date: 2020-06-01 journal: nat rev dis primers doi: 10.1038/s41572-020-0185-x sha: doc_id: 307808 cord_uid: 0t6sw0zp the covid-19 crisis has accelerated the adoption of telemedicine, presenting challenges and opportunities for clinicians trying to manage diverse, and not only pandemic-related, health conditions. here, we consider some limitations of telemedicine and offer a perspective on how clinicians can adapt to working in different health-care delivery systems. originally prioritized to service remote or underserved areas, the potential for employing telehealth (the use of digital technologies to deliver medical care, health education and public health) for emergencies and disasters has been previously described 1 . to decrease transmission of sars-cov-2, the virus responsible for covid-19, while maintaining health-care access, telehealth -particularly, virtual visits in place of traditional in-person visits -has expanded rapidly around the world. although some providers are enthusiastic with this development 2 , in our opinion, the rapid adoption of telehealth provisions should not come at the cost of comfort and safety of patients or the quality of the care provided. telemedicine specifically addresses the diagnosis, treatment and monitoring of patients (including history taking and appropriate physical examination) by means of electronic technology. patient encounters aim to provide care as safely and effectively as traditional in-person visits through live, synchronous video conferencing. telemedicine offers additional electronic exchange of health information including the collection, transmission and interpretation of patient data ('store and forward'), the extraction of health data from wearable devices (increasingly worn by patients) and quick exchanges of digital information via patient portals, tablets and cell phones (allowing for updates and reminders). from the patient perspective, telemedicine may offer convenience and lower cost, relegating in-person visits to a later option for addressing their needs 3 . patients can access up-to-date technology using automated logic flows (bots) when seeking referral to nurse triage lines and to schedule video visits. although telehealth offers solutions for basic access to health care in the midst of the current pandemic, it is not yet uniformly integrated into regular health-care systems and, as a 'disruptive process' , it necessitates major adaptations to existing frameworks 4 . in the midst of these major changes, clinicians are still responsible for ensuring patients receive the care they need, as well as understand the limitations of telemedicine visits. we contest that telemedicine limits the powers of observation that guide diagnosis and treatment. for example, a common clinical challenge is the evaluation of persistent, non-specific symptoms such as pain. we (s.r.-s.) were able to diagnose 'heartburn' (which had occurred without any back pain) as the sole presentation of spinal osteomyelitis through gentle percussion of the spine -a diagnostic manoeuver not possible through a computer screen. the computer screen can also miss, for example, subtle but revealing changes such as early clubbing in fingers, early capillary changes in the nailfolds, wheezing and crepitations (crackles) and limit the ability to perform 6-minute walk testing to determine needs of supplemental oxygen and gait disturbances, amongst others. additionally, for some patients, the screen presents a physical barrier, hindering an atmosphere of trust between the patient and doctor. this challenge is particularly important for physicians to overcome when caring for those with complex health problems, in whom abnormalities may occur overtly or occultly. reassuringly, telemedicine can provide remote peripheral examination devices that can enhance video conferencing as well as store and forward. depending on clinical needs, budget and storage space, the equivalent 'net neutrality' (to assure a stable, secure internet connectivity) and the willingness for provider and patient, such tools can include video otoscopes, electronic stethoscopes, dermatoscopes, retinal imaging system and intraoral scopes. however, the lack of uniform or widespread use of such devices, and the need for individual clinics to endorse specific uses, could hinder adoption 5 . even if conditions, provisions and training are all available, each clinic must classify specific medical needs for telemedicine use to ensure patient needs are appropriately met. several excellent resources address integration of telehealth into existing health-care delivery systems 6, 7 . alongside these resources, we feel that there is a need to consider both the art and science of medical decision-making. starting with straightforward and common problems, such as simple rashes and hypertension, we suggest that these might be safely evaluated telemedicine -maintaining quality during times of transition sue romanick-schmiedl 1 the covid-19 crisis has accelerated the adoption of telemedicine, presenting challenges and opportunities for clinicians trying to manage diverse, and not only pandemic-related, health conditions. here, we consider some limitations of telemedicine and offer a perspective on how clinicians can adapt to working in different health-care delivery systems. www.nature.com/nrdp by a virtual visit. certain factors such as fever or back pain could remove suspected urinary tract infections from this category; should a dipstick or culture be necessary but unavailable at the patient's location, arrangements for testing, according to clinic protocol, would need to be arranged. many conditions, including diabetes, osteoarthritis, substance abuse, depression and attention deficit/ hyperactivity disorder, require monitoring that could be achieved using telemedicine, provided that the patient has been stable based on prior documentation and individual clinic protocol. similarly, patients on specific treatment protocols -who need to be followed up for potential adverse effects of treatment, compliance, progress or deviations from expected courses -can safely benefit from telemedicine visits. when frequent monitoring of high-risk immunosuppressive therapy is required -as in solid organ recipients or certain patients with arthritis -'standing orders' for laboratory testing can be smoothly integrated into telemedicine services. however, we feel strongly that complex medical problems involving major decision-making, such as in follow-up of organ transplant recipients who are manifesting symptoms suggestive of infection or rejection, require in-person patient evaluation. health-care providers should be prepared to interrupt digital visits or arrange timely follow-up as necessary, so that any patient identified as requiring in-person evaluation will be appropriately directed to receive timely medical attention. we also feel that new patients or existing patients with new health problems are best evaluated by in-person visits. in general, history taking for such patients is more comprehensive than for focused follow-up visits. there may be elements in the medical history or even in the family history that can influence the differential diagnosis or management. additionally, as in-person exchanges can establish the bond of trust and teamwork between patient and provider, we feel very strongly that at least the first visit should be a direct physician-patient interaction. the bond-forming element inherent in the traditional doctor-patient relationship is based on human awareness of both personal space and the healing effects generated from touch and direct face-to-face interactions. the loss of three-dimensional space by virtue of looking into a computer screen interferes with cues on a subconscious level 8 . for example, in-person visit enabled us (g.r.) to diagnose polymyositis in a patient who overtly presented with signs of interstitial pneumonia of otherwise unknown cause; only through in-person interaction supported by the patient's spouse was sufficient detail forthcoming and ultimately saved the patient an unnecessary lung biopsy 9 . ideally, acute illness requires in-person evaluation by a qualified health-care provider owing to a potential sense of urgency. telemedicine has been shown to be successful in an acute medical situation when the history and physical examination can be performed on the patient 'locally' and the subsequent findings are electronically conveyed to a remote consultant 10 . any patient experiencing progressive symptoms, for example, involving pain, dyspnoea, diarrhoea or neurological symptoms, whether such progression results from increased intensity, distribution or new onset, also requires an in-person (and quite possibly urgent) evaluation. even conditions that are usually in the low-risk category can escalate or be an 'innocuous' manifestation of a more serious disease. thus, we must caution against unrestricted use of artificial intelligence technologies, especially when triaging patients as they seek appointments. the covid-19 crisis has presented multiple barriers to health care, including patients' fears of acquiring infection through travel to health-care facilities, imposed quarantines and self-isolation, and providers' fears of acquiring infection. through the sense of urgency and crisis, the growing adoption of telemedicine presents a compromise to traditional bedside or face-to-face delivery of care. clinics and hospitals have the obligation to communicate to patients that all possible means are being taken to prevent transmission of infection while maintaining quality in the delivery of care. ultimately, the advantage of convenience from conducting a telemedicine visit has to be balanced and weighed against the benefits of direct human interactions. given that the ramifications of the covid-19 pandemic will be felt for some time, we encourage care providers to offer guidelines or best working practices on managing new patients in the era of telemedicine. the role of telehealth in the medical response to disasters virtually perfect? telemedicine for covid-19 in-person health care as option b telehealth for global emergencies: implications for coronavirus disease 2019 (covid-19) wearable health devices-vital sign monitoring, systems and technologies telehealth implementation playbook telemedicine and e-health in disaster response care in healthcare: reflections on theory and practice interactive grand round series: persistent breathlessness a telemedicine case series for acute medical emergencies in greenland: a model for austere environments the authors declare no competing interests. nature reviews disease primers thanks m. mars, a. smith and the other, anonymous, reviewer(s) for their contribution to the peer review of this work. key: cord-266371-eynmgvbd authors: baudier, patricia; kondrateva, galina; ammi, chantal title: the future of telemedicine cabin? the case of the french students’ acceptability() date: 2020-06-13 journal: futures doi: 10.1016/j.futures.2020.102595 sha: doc_id: 266371 cord_uid: eynmgvbd telemedicine could solve the problem of the lack of infrastructure and insufficient number of qualified healthcare staff in many countries/regions. the aim of this research is to investigate the futures of such solution by having a better understanding of the acceptance of the telemedicine cabin by high-educated millennials. to reach this goal, a survey was built using specific dimensions to measure the perception of telemedicine cabin, the unified-theory-of-acceptance-and-use-of-technology 2(nd) version (utaut2) and finally the personal innovativeness and the privacy concern scales. our sample was composed of 158 students from different business schools and data were analysed using a partial least approach. findings highlight the key role of all telemedicine cabin dimensions (accessibility, availability and compatibility) on performance expectancy, the importance of three utaut2 constructs (performance expectancy, price value and habit) and the negative impact of privacy concern on the intention to use a telemedicine cabin. in addition, results demonstrate that personal innovativeness does not affect the intention to use telemedicine cabin. to adress these subjects, following questions were raised: r1: what dimensions of the telemedicine cabin impact the performance-expectancy? r2: what constructs of utaut2 influence the intention to use telemedicine cabin by students? r3: is the telemedicine cabin the future solution for student's healthcare? a survey was administered to students from different business schools and universities in france. the article is organized as follow. first, we present the literature review on the mobilized constructs and the hypotheses. second, we explain our methodology and analyse the sample. third, we present the findings and discuss the results highlighting the theoretical and managerial implications. finally, we suggest some limitations of the study and propositions for future research. during the past decade, a change of paradigm, within developed countries, was highlighted moving from the right of patients to be treated to their duty to stay healthy (gille & houy, 2014) . based on hancock (1999) the health care system of the 21st century must provide individual with solutions to maintain or improve their health fighting against inequalities in health management and insuring that hospital will be considered only as an emergency option. e-health concepts including telecare, telehealth, teleconsultation and telemedicine cabin are summarized in the table 1 . in previous research, the role of technology was highlighted to enhance independence & autonomy and improve quality of life (rogers and mitzner, 2017) . from september 15 th of 2018, the french health insurance has decided to reimburse medical consultations by videoconferences, using or not a telemedicine cabin at the same rate than a physical consultation. this strong signal demonstrates the importance of such solution for the french government. they expect the number of medical acts to move from 500 000 in 2019 to 1.4 million in 2022 1 . indeed, telemedicine solutions are already well implemented in united states of america, canada but also in smaller european countries such as switzerland with more than 4 million patients 1 . a survey realized by ipsos (2018) 2 , investigated the physicians and patients' motivations to use telemedicine solutions. regarding the healthcare staff, more than ¾ of physicians and specialists are for the implementation of telemedicine solutions and 68 percent of physicians already have remote interactions with their patients using mail, sms or telephone. regarding french patients, 60 percent admit they have sometimes decided not to consult mainly due to the waiting times too long for an appointment in relation with the urgency of the health problem encountered, the lack of time or the date proposed that didn't fit with their agenda. nevertheless, 38 percent considered that this difficulty to access to a physician could have been the cause of a worsening health problem. in addition, 1/3 of the french patients declare that they have already contacted their physician by phone for an advice. thus, based on this study, both physicians and patients considered that 50 percent of the consultation can be done using telemedicine solutions. telemedicine cabin starts to be installed in health centres, pharmacies, public places and even in working environment with the approvals of the regional health agency (ars), the national union of complementary health insurance organizations (unocam), and the national commission for informatics and liberties (cnil). nevertheless, this solution is not yet implemented in business schools or universities. telemedicine proposes benefits for young adults that represent digital natives, the generation of people born and grown up with digital technology (baudier, ammi & deboeuf-rouchon, 2020) . digital natives are used to receive information fast (prensky, 2001) , so they can reduce time spent on medical tests and consultations with telemedicine; they prefer graphics before text, and they work better by networking (prensky, 2001) , thus telemedicine provides quick results and connects the patient and practitioner. the key benefits of a telemedicine cabin highlighted by the literature are (1) the capability to remotely and easily access to physician, (2) the availability of the services (time saving) and (3) the fact that using a telemedicine cabin can fit with their way of life and expectancies. (1) accessibility for healthcare is related to the degree to which a patient believes the use of telemedicine service will simplify healthcare for individuals living far away from physicians or with mobility issues. (2) availability is key for the adoption of healthcare solutions for both practitioners and patients answering their need to consult, when available (bruno et al., 2018) . (3) compatibility is the degree to which technology is perceived by users as consistent with their values, experience, and needs. compatibility is an important characteristic that positively influences the performance expectation of a technology (jang et al., 2016) . by using a telemedicine cabin, patients may consider that their performance can be enhanced by those three variables and thus have a positive impact on performance-expectancy. therefore, we hypothesize that the dimension of accessibility (h1), compatibility (h2) and availability (h3) of telemedicine cabin has a direct, positive and significant impact on performance-expectancy. several theories have been developed in order to measure the acceptance of new technologies. the utaut (venkatesh et al., 2003) and its extension the utaut2 (venkatesh et al., 2012) were based on different theories and models on technology acceptance such as the innovation of diffusion theory (rogers, 1962) , the technological-acceptance-model (davis, 1989; venkatesh & davis, 2000) or the theory of reasoned action (fishbein & ajzen, 1975) . many researchers examined the acceptance of e-health or telemedicine services using the utaut (alazzam et al., 2015; gajanayake et al., 2016; bawack & kamdjoug, 2018; duarte & pinho, 2019) . the seven items of the utaut2 were mobilized to measure their impact on intention-to-use telemedicine cabin. effort-expectancy is defined as the degree of simplicity associated with the use of a technology (davis, 1989; venkatesh & davis, 2000; venkatesh et al., 2012) . even if, according to gao, li & luo (2015) effort-expectancy has no direct and significant impact on the intention-to-use wearable technology for fitness purposes, its impact is significant for medical reasons. other researchers demonstrate that effort-expectancy can impact the intention-to-use new technologies in the health domain such as electronic health record (pulidindi, jinkab & priyac, 2016) , telemedicine equipment (kohnke, cole & bush, 2014) , mobile health (sun et al., 2013) . we postulate that: h4: effort-expectancy has a positive direct effect on intention-to-use telemedicine cabin. facilitating-conditions are defined as the degree to which an individual believes that an organizational and technical infrastructure exists to support the use of a technology (venkatesh & davis, 2000; venkatesh et al, 2012) . the construct includes aspects of the technological and/or organizational environment that are designed to remove barriers to use technology. facilitating-conditions have significant influence on the behavioral intention, but also direct impact on the use. according to venkatesh et al (2003) this predictor is strong in older generations, but on the other hand might be important for the medical context of use, when people even of younger generation are more worried about the technology performance (schomakers, lidynia & ziefle, 2018; duarte & pinho, 2019) . we postulate that: habit has been defined as the extent to which people tend to perform behaviors automatically because of learning (limayem, hirt & cheung, 2007) . habit is important for the information technology use (lally, van jaarsveld, potts & wardle, 2010) . since individuals use today the information technology for shopping, payments, information, gaming, communication, we assume, that the targeted population (digital natives) has developed the habit for online (tele) communication and will adopt quickly the telemedicine services. thus, habit should positively influence telemedicine cabin's adoption as demonstrated in recent studies on ehealth (tavares & oliveira, 2017) . we suggest that: hedonic-motivation is defined as the fun or pleasure derived from using a technology, and it has been shown to play an important role in determining technology acceptance and use (venkatesh et al., 2012) . nevertheless, users of technology related to health can be concerned about their health or be already impacted by health issues. therefore, in such context, the influence of hedonic-motivation on the intention-to-use could be less important than for other technologies (tavares & oliveira, 2017) . nevertheless, due to the targeted population, the telemedicine cabin can arouse curiosity or the enjoyment of being in trend. we assume that: originally, performance-expectancy is defined as the degree to which an individual believes that using a technology or system would improve his or her job performance (venkatesh et al., 2003; venkatesh et al., 2012) . in the context of this research, performance-expectancy presents the degree to which an individual believes that using a telemedicine cabin would improve his/her health and productivity by saving time. based on gao et al. (2015) , intention to use wearable technology for medical reasons is directly impacted by performance-expectancy seen as key for the adoption of e-health services (sun, wang, guo, & peng, 2013; lee & lee, 2018) . therefore, we postulate that: h8: performance-expectancy has a positive direct effect on intention-to-use telemedicine cabin. the price-value is positive when the benefits of using a technology are perceived to be greater than the monetary cost and such price value has a positive impact on intention-to-use. gao et al. (2015) demonstrate the direct, positive, and significant influence on intention-to-use internet-of-thing (wearables) for wellbeing purposes. thus, we hypothesize that: social-influence is defined as the degree to which an individual perceives that others believe he or she should use a technology (davis, 1989; venkatesh & davis, 2000; venkatesh et al, 2003; venkatesh et al, 2012) . social-influence is a direct determinant of behavioral intention. several studies confirmed the impact of social-influence on intention-to-use innovative products in the health domain such as healthcare telemedicine equipment (kohnke et al., 2014) , mobile health services (sun et al., 2013) , wearable technology (gao et al., 2015) . we suggest that: personal-innovativeness can be defined as an extent to which an individual is innovative by his or her perception of new idea or technology. this notion was introduced by agarwal and prasad (1998), who j o u r n a l p r e -p r o o f concluded that users whose personality can be described as innovative (e.g. people with interest towards innovation and/or new technologies) would rather try new technology as soon as possible (baudier et al., 2020; jackson, mun, & park, 2013) . since, the targeted population is comfortable with new smart technologies, we propose the following hypothesis: the use of digital technology increases the level of uncertainty (mcknight & chervany, 2002) especially if individuals must disclose personal information. privacy in telemedicine services refers to the extent to which using such services will disturb personal privacy (tavares & oliveira, 2017) . previous research showed that the privacy-concern differs between contexts and that users perceive the highest level of risk for a healthcare context influencing the behavioral intentions (schomakers et al., 2018; xu, 2019) . the lack of confidence of patient on potential privacy issue could be a key issue for the adoption of telemedicine. despite, all the advantages provided by such technology few studies focused on the privacy-concern issue. thus, we postulate that: a sample of 159 valid answers was collected ( table 2 ). all respondents were from the digital native's population, born after 1981 and considered as more sensitive to and knowledgeable about innovative technologies (bennett, maton & kervin, 2008) thus lest reluctant to adopt such technology (howe & strauss, 2000) . the aim of the research was to analyse how they perceived the telemedicine cabin and how this new technology could address their expectations. due to the size and the characteristics of the sample, the moderator effects cannot be analysed. indeed, the male population (45) is to small compared to the female one (114). in addition, the respondents are from the same generation, students, preparing a master's degree in business schools therefore age and experience don't moderate the relationships of our model. a quantitative approach was selected, and the research model was built using and adapting existing scale (appendix a) as the utaut2 variables measuring the acceptance of new technologies (venkatesh et al., 2012) , personal-innovativeness (bloch, brunel & arnold, 2003) , privacy-concern (featherman & pavlou 2003) , availability (moores, 2012) , accessibility (farahani et al., 2018) , compatibility (taylor & todd, 1995) . the survey, using five-point likert scale, was administrated to students from different business schools, preparing a master's degree and volunteers to participate. a partial least square approach was mobilized using smartpls3 to analyse the relationships between the constructs of the model. the loadings of the variables, the composite reliability and cronbach's alpha, mobilized to control the reliability of the model, were above the recommended threshold of 0.7. the discriminant validity of all constructs was controlled by verifying that the square root of the average variance extracted (ave) of the construct was superior to the correlations of this construct with the other constructs. convergent validity was confirmed as all the values of the ave were above the recommended threshold of 0.50. thus, results of on the analysis of the outer model confirm the validity and reliability of the research model. the inner model was tested by controlling the value of r 2 , f 2, and q 2 of the endogenous variables. the relationships between constructs were controlled using the following parameters: t-value at more than the recommended threshold at 1.96, and p-value below 0.05 (figure 1) . to explain the variance of the constructs, the r 2 were examined. our model explains 67.4 percent of performance-expectancy , determined by accessibility (h1: path-coef=0.198, t=3.031, p=0.002), compatibility (h2: path-coef=0.332, t=4.752, p=0.000) and availability (h3: path-coef=0.444, t=6356, p=0.000). the size effect (f 2 ) confirm the huge impact of availability (0.303) and compatibility (0.213) on performance-expectancy. with a r 2 at 0.712, our model explains 71.2 percent of intention-to-use determined by three of the utuat2 variables : habit (h6: path coef=0.165, t=2.454, p =0.014) and price-value (h9: path-coef=0.147, t=2.354, p=0.019), both with a low impact ( f 2 =below 0.05) and by performance-expectancy (h8: path-coef=0.534, t=6.791, p=0.000) with a huge impact on intention-to-use as f 2 =0.404. privacy-concern impact negatively intention-to-use (h12: path-coef=-0.098, t=2.262, p=0.024). the other variables of the model such as effort-expectancy (h4), facilitating-conditions (h5), hedonic-motivation (h7), social-influence (h10), personal-innovativeness (h11) don't impact intention-to-use telemedicine cabin, thus these hypotheses are rejected. the blindfolding procedure was mobilized to calculate the stone-geisser's q 2 . the q 2 of both performance-expectancy (0.415) and intention-to-use (0.526) greater than zero, indicate an acceptable predictive relevance of the model. finally, the high value of the goodness-of-fit index at 0.71 confirms the quality of the model. in summary, seven hypotheses were validated and five rejected. this study aimed to check the future of telemedicine cabin and measure the acceptance of such solution on a specific target: the students from the digital native population. the findings of the current research demonstrate several unexpected effects giving a new vision on the digital natives behavior. first, the results, that are aligned with previous studies, confirming that compatibility positively influences the perceived-usefulness of a health technology and its performance-expectancy (wu, wang, & lin, 2007; lin, tsai, wang & chiu, 2011) . indeed, the use of a telemedicine cabin is considered as easy and obvious. patients just need to integrate the distance aspect, as they must communicate with a physician remotely. individuals can use this service, for example, when physicians are not available, when they have limited mobility, when they want to reduce waiting time (lazar, goldstein & taylor, 2015) or in case of major pandemic. the simplicity to use the telemedicine cabin has a positive effect on the digital accessibility and the degree of its performance-expectancy (moser, 2006) . thus, accessibility, one of the main advantages of telemedicine, affects positively the attractiveness of a medical product or service therefore also influences performance-expectancy. furthermore, the reimbursement of the telemedical acts by the national french social security permits to offer these services without financial limitations (stienstra, watzke & birch, 2007) . the availability of the telemedicine cabin (everywhere and anytime) is in adequation with the actual tendency to consume and to act without the limitations of time or location (buchanan, sainter & saunders, 2013) and is key to fit with patient's performance-expectancy. privacy-concern, which refers to the potential disturbance of personal privacy (schomakers et al., 2018; tavares & oliveira, 2017) , has a direct and negative j o u r n a l p r e -p r o o f impact on the intention-to-use. our results confirmed the prior research especially in the healthcare context (bansal, zahedi, & gefen, 2015) particularly concerning vulnerable data. second, among the variables issued from the utaut2, the hypotheses regarding the impacts of performance-expectancy, habit and price-value on the intention-to-use a telemedicine cabin have been validated and are consistent with previous research on same topics or on e-health domain. thus, performance-expectancy has a considerable influence on the individual's intention-to-use telemedicine cabin (im, hong & kang, 2011) confirming its utilitarian role. habit is not limited to mere repetition of past behavior (fischbein & ajzen, 2010) and routine behavior but includes often characteristics such as unintentionality, uncontrollability, lack of awareness, and efficiency (verplanken, 2010) . in our study, the link between habit and intention-to-use, validated by previous research (ajzen, 2002) , is also confirmed. price-value has usually a positive impact when the perception of the benefits of using a technology is greater than the cost. the telemedicine cabin is hindered by no additional cost following the compensation of the tele medical acts by the national french social security in 2018, therefore this hypothesis was validated in our study. third, the impact of fours variables of the utaut2 and personal-innovativeness on intention-to-use, often confirmed in the context of new technologies acceptance, is not validated for the adoption of the telemedicine cabin. we discuss these effects successively: (1) effort-expectancy (davis, 1989) is key for the adoption of an innovative technology. indeed, the convenience in using the technology and the compatibility of system influence positively the intent to use a technology (prasanna & huggins, 2016) . the direct and positive relationship with the intention-to-use is, normally, validated especially for health products and services (jang et al., 2016) . this research was conducted among digital natives, who maybe do not feel that using such technology will need specific efforts. thus, this variable seems not relevant for this population. (2) based on several studies facilitating-conditions have a direct and positive relationship with the intentionto-use (venkatesh & davis, 2000; venkatesh et al., 2012) . users are more motivated to adopt new technologies when they could have access to a technical expertise, training and a higher level of organizational support. despite the confirmation of this relationship in many research, our results do not confirm a positive relation but are consistent with previous research (baptista & oliveira, 2015) supporting that facilitating-conditions has more influence in the case of actual usage rather than intention-to-use. another reason provided by venkatesh et al. (2003) is, linked to the profile of our sample, as facilitating-conditions are often stronger within older generation. (3) research demonstrates the direct and positive impact of social-influence on the intention-to-use (chang, 2015) . indeed, individuals could be influenced by relatives for the adoption of a new technology or a new technological product (chaouali, 2016) . in contrary of many previous research (venkatesh et al., 2012) , our results indicate a non-significant relation between social-influence and intention-to-use a telemedicine cabin. even if digital natives are considered as "networked" generation (prensky, 2001) , who prefers to connect and support various social relations, the context of medical treatment is still the one that is very personal and individual, therefore social-influence has perhaps little or no impact. (4) hedonic-motivation has usually a positive link with intention-to-use (childers, carr, peck & carson, 2001) . our results, which do not confirm this positive relationship, are supported by other research and could maybe be explained by the nature of the service from the health sector. a telemedicine cabin cannot be considered as a pleasure-oriented service but more perceived as an utilitarian solution. prior research identified two types of central determinants of consumer buying behavior: hedonic-motivation focused on entertaining, fun and delightful aspects (park, kim, funches & foxx, 2012; verhagen & van dolen 2011) and utilitarian-motivations (e.g. telemedicine cabin), focused in searching information about the usefulness of the product or service regarding the technology or the product (babin, chebat & michon, 2004) . (5) personal-innovativeness, introduced by agarwal and prasad (1998), describes innovative people with strong interest towards innovation and/or new technologies (baudier et al., 2020; jackson et al 2013) . however, our results do not confirm this positive relationship for the intention-to-use telemedicine cabin. to explain this result, we can point out some research, which make the distinction between two levels of innovativeness: (i) open-processing (or general) innovativeness associated to a general predisposition to innovate from a cognitive perspective (joseph & vyas, 1984) and (ii) domain-specific innovativeness limited to an area or a specific behavior (goldsmith & hofacker, 1991) . digital natives have a high degree of innovativeness, but based on our findings, not on services related to e-health and telemedicine cabin. moreover, our results are supported by the suggestions of agarwal and prasad (1998) who found specific relations between the individual's weight of innovativeness and the effort-expectancy. our findings confirmed that both variables have been rejected. therefore, the implementation of telemedicine cabin within business schools or universities could be a good alternative. according to rees, crampton, gauld and macdonell (2018) , the future health systems will have to integrate social changes and health staff will have to change their working method. despite of the growing interest in e-health, few studies focussed on the concept of the telemedicine cabin and its acceptance. the trending topic refers to the opportunity to consult a remote physician within business schools or universities. the students, sometimes, need to face some specific problems such as finding (1) a physician in case they are far away from their region of origin (accessibility issue) or (2) a gap in their agenda to visit him as they often have an active social daily life (availability and compatibility issues). thus, they often wait until last minute before taking an appointment with a physician. consequently, their health could be impacted, and the recovering cost could be higher for both the patient and the french administration. the results reveal that while telemedicine cabin can partially solve the issue of government to reduce the health expenses by allowing student to easily and quickly access to medical care, deeper exploration regarding the acceptability of such solution need to be investigated. indeed, the future of such solutions must be seriously studied as telemedicine cabin or teleconsultation could be a solution in case of pandemic period such as the covid-19 where all contacts between physicians and patients need to be avoided and reserved to critical situations. in fact, in case of major contagion, hospitals cannot treat all patients and must focus on vital urgencies. thus, the accessibility, availability and ease-of-use of telemedicine cabin or teleconsultation can be part of the government plan to reduce the level of contamination by doing distant consultations even from home. teleconsultation could protect all citizens. indeed, the findings provide wide possibilities for the future research to check the perceptions of (1) physicians (2) hospital staff (3) patients and (4) government. 1. physicians: in case of huge infection, physicians are often on the front line. using distant solutions to consult could be for them an alternative to respect their hippocratic oath, to protect themselves against contamination in order to be available to treat a maximum of patients. some companies offering remote consultation services through internet proposed free trail to french physicians to test their solution during the covid19 infection. thus, a study on their perception could be interesting as the more the physician will accept the technology and spread it, the more it will be accepted by individuals. 2. hospital staff: in case of major contagion, due to panic situations, contaminated people could go to the hospitals and contribute to extend the virus when staff must focus on patients in vital urgency. the physicians also need to protect themselves against a potential contamination, all medical staff must be on board. therefore, an analysis of their perception of teleconsultation after the pandemic could be useful. finding are aligned with the analysis published by costa-font and sato (2012) on the health future systems. indeed, their recommendations, to address future health challenges, were to increase the adoption of innovative health solutions, followed by the ability to prevent global diseases by improving prevention and finally to adjust financial models to healthcare insurances constraints. indeed, research must considere the globalization' effect especially in case of pandemic (martens, 2002) and world health organization should reinforce the global surveillance of infectious diseases (sapirie & orzeszyna, 1995) . finally, the study has some limitations that can be regarded as opportunities for future research. first, the survey focused only on digital natives, and particularly students of french business schools or universities, so the model should be tested using other samples such as other digital natives (labor force) or digital immigrants (labor force or retired). indeed, teleconsultation could enhance elderly autonomy (rogers & mitzner, 2017) . in addition, due to the covid19 infection, future research should also control if after the pandemic period, the same population (students) reacts in the same way or if covid19 had on impact on results. and secondly, it will be accurate to do an international study to check if results are the same depending on culture such as asian or american cultures. this last point is critical especially due to the covid-19 contamination at a worldwide level. use of sensors to improve security at home (including sensors to detect gas, smoke etc.). telehealth telehealth a sub-dimension of telecare, using sensors to measure health. papa et al. 2018 teleconsultation remote consultation with a physician using devices such as a computer, tablet or mobile phone. gajanayake et al. 2016 telemedicine cabin the telemedicine cabin is a combination of telehealth (medical equipment inside the cabin) plus a remote consultation with a physician (teleconsultation) simon, 2016 understanding mobile banking: the unified theory of acceptance and use of technology combined with cultural moderators smart home: highly educated students' acceptance adequacy of utaut in clinician adoption of health information systems in developing countries: the case of cameroon the 'digital natives' debate: a critical review of the evidence individual differences in the centrality of visual product aesthetics: concept and measurement wearable technology in epilepsy: the views of patients, caregivers, and healthcare professionals factors affecting faculty use of learning technologies: implication for models of technology adoption exploring mobile application customer loyalty: the moderating effect of use contexts hedonic and utilitarian motivations for online retail shopping behavior once a user, always a user: enablers and inhibitions of continuance intention of mobile social networking sites health systems futures: the challenges of technology, prevention and insurance perceived usefulness, perceived ease of use, and user acceptance of information technology user acceptance of computer technology: a comparison of two theoretical models the effects of gender and age on health related behaviors a mixed methods utaut2-based approach to assess mobile health adoption towards fogdriven iot ehealth: promises and challenges of iot in medicine and healthcare predicting e-services adoption: a perceived risk facets perspective belief, attitude, intention and behavior: an introduction to theory and research an insight into the adoption of accountable-ehealth systems-an empirical research model based on the australian context an empirical study of wearable technology acceptance in healthcare the future of health care demand in developed countries: from the "right to treatment" to the "duty to stay healthy measuring consumer innovativeness health care reform and reform for health: creating a health system for communities in the 21 st century millennials rising: the next great generation an international comparison of technology adoption: testing the utaut model an empirical test of three mediation models for the relationship between personal innovativeness and user acceptance of technology effect of u-healthcare service quality on usage intention on a healthcare service concurrent validity of a measure of innovative cognitive style incorporating utaut predictors for understanding home care patients' and clinician's acceptance of healthcare telemedicine equipment how are habits formed: modelling habit formation in the real world ensuring digital accessibility through process and policy factors that influence an individual's intention to adopt a wearable healthcare device: the case of a wearable fitness tracker cultural orientations and information systems success in public and proviavte hostitals: preliminary evidences from italy how habit limits the predictive power of intention: the case of information systems continuance modeling it relationship quality and its determinants: a potential perspective of network externalities in e-service health transitions in a globalizing world: towards more disease or sustained health? futures what trust means in e-commerce customer relationships: an interdisciplinary conceptual typology towards an integrated model of it acceptance in healthcare disability and the promises of technology: technology, subjectivity and embodiment within an order of the normal e-health and wellbeing monitoring using smart healthcare devices: an empirical investigation apparel product attributes, web browsing, and eimpulse buying on shopping websites factors affecting the acceptance of information systems supporting emergency operation centres digital natives user acceptance of electronic health records: cross validation of utaut model rethinking health workforce planning: capturing health system social and power interactions through actor analysis diffusion of innovations. the free press of glencoe envisioning the future for older adults: autonomy, health, well-being, and social connectedness with technology support who's health futures consultation exploring the acceptance of mhealth applications-do acceptance patterns vary depending on context des pratiques de télémédecine pour structurer le projet médical partagé d'un groupement hospitalier du territoire la télémédecine n'est pas du e-commerce mais de la médecine clinique a three-way dance: the global public good and accessibility in information technologies understanding the acceptance of mobile health services: a comparison and integration of alternative models electronic health record patient portal adoption by health care consumers: an acceptance model and survey understanding information technology usage: a test of competing models a theoretical extension of the technology acceptance model: four longitudinal field studies user acceptance of information technology: toward a unified consumer acceptance and use of information technology: extending the unified theory of acceptance and use of technology the influence of online store beliefs on consumer online impulse buying: a model and empirical application beyond frequency: habit as mental construct an empirical study of patient's privacy concerns for health informatics as a service mobile computing acceptance factors in the healthcare industry: a structural equation model the authors would like to express their warmest thanks the editor-in-chief, professor ted fuller, the guest editors, professor francesco schiavone & professor marco ferretti and the anonymous reviewers for their valuable comments that helped to improve drastically the quality of their article. agarwal, r. & prasad, j. (1998) key: cord-354885-fkgr2o9i authors: hoffer-hawlik, michael a.; moran, andrew e.; burka, daniel; kaur, prabhdeep; cai, jun; frieden, thomas r.; gupta, reena title: leveraging telemedicine for chronic disease management in lowand middle-income countries during covid-19 date: 2020-09-15 journal: global heart doi: 10.5334/gh.852 sha: doc_id: 354885 cord_uid: fkgr2o9i in response to the covid-19 pandemic, many lowand middle-income countries (lmics) expanded access to telemedicine to maintain essential health services. although there has been attention to the accelerated growth of telemedicine in the united states and other high-income countries, the telemedicine revolution may have an even greater benefit in lmics, where it could improve health care access for vulnerable and geographically remote patients. in this article, we survey the expansion of telemedicine for chronic disease management in lmics and describe seven key steps needed to implement telemedicine in lmic settings. telemedicine can not only maintain essential medical care for chronic disease patients in lmics throughout the covid-19 pandemic, but also strengthen primary health care delivery and reduce socio-economic disparities in health care access over the long-term. in response to the covid-19 pandemic, many low-and middle-income countries (lmics) expanded access to telemedicine to maintain essential medical care when face-to-face visits are unsafe. although there has been attention to the accelerated growth of telemedicine services in the united states and other high-income countries, the telemedicine revolution may have an even greater benefit in lmics, where it could improve health care access for vulnerable and geographically remote patients [1, 2] . lmic patients with chronic noncommunicable diseases such as hypertension, diabetes, or chronic obstructive lung disease have increased risk of severe covid-19 [3] . before the pandemic, patients with chronic diseases living in rural regions had to travel long distances, at considerable out-of-pocket cost, to reach the nearest health care facility. during the covid-19 pandemic, in-person clinical care is often limited by governmentimposed travel restrictions, strains on facility infection control measures, and advice to people with chronic illness to reduce contacts with others. postponed outpatient clinic visits and prescription renewals may exacerbate chronic diseases, accelerate acute complications, further increase risk of severe covid-19 illness, and thereby increase the stress on already-overwhelmed hospitals [4] . new telemedicine-promoting policies and ubiquitous mobile phone access in many lmics now raise the possibility that telemedicine could help bridge gaps in care for chronic medical conditions. even after covid-19 is controlled, telemedicine has the potential to address persistent obstacles to primary health care in lmics, including scarcity of trained health care workers, difficulty of patient transportation, and in-person care costs. as lmics implement or broaden telemedicine services, a systematic approach will ensure safe and equitable access to essential chronic disease care both during and after the covid-19 pandemic. seven key components are required for lmic health systems to adopt telemedicine (figure 1 ) [5] . until recently, clear government regulations to both enable and provide the boundaries of telemedicine services did not exist in many lmics [6] . as covid-19 spread, many governments expanded regulatory permissions rapidly, and some incorporated reimbursement policies to facilitate conversion of in-person visits to telemedicine consultations. in february 2020, the chinese central government released guidelines that increased reimbursement coverage for follow-up online medical consultations and promoted doorstep delivery of prescriptions acquired through 'internet hospitals' [7] . india's ministry of health and family welfare released national telemedicine practice guidelines in march 2020 [8] . this framework provided instructions for prescribing medications and conducting follow-up care for chronic diseases, thereby enabling patients to consult from home with medical providers via telemedicine services. conversion of scheduled office appointments to telemedicine visits with existing providers has maintained continuity of care for many patients while limiting both patient and clinician travel exposure. leveraging currently employed clinicians to conduct teleconsults allows practices to use existing human resources, figure 1 : seven key components needed to implement telemedicine in low-and middle-income countries [5] . referral networks, and provider workflows. an alternative approach, exemplified by the indonesian health platform halodoc, is to hire or contract with a telemedicine-dedicated pool of clinicians who provide consultations for health care workers in the community or patients at home [9] . implementing telehealth call centers provides flexible staffing capacity, leading to more real-time visits and faster response times. health care systems which use electronic health records are well suited to telemedicine, as clinicians can access patient files remotely. despite the workforce efficiencies of telehealth call centers, extensive investment is required to provide management oversight and to create new clinical protocols and safety monitoring procedures. in the short-term, low-cost and widely-used communication platforms such as whatsapp or wechat are a means to rapidly expand telemedicine services in lmics. alternatively, dedicated mobile telemedicine applications allow patients to quickly and easily schedule appointments and communicate in real time with providers via video and audio capabilities on their personal devices. china's fu wai hospital 'hypertension doctor' smartphone app, which can be downloaded on ios or android mobile operating systems, provides two-way communication between patients and physicians for home blood pressure measurements, education, medication dose titration, and prescription refills [10] . for resource-limited countries implementing new or adapting current telemedicine programs, it is essential to demonstrate long-term financial value to health care payors, health systems, physicians, and patients [11] . lmic health care systems that operate under global budget or capitation models may find more seamless integration of low-cost telemedicine initiatives compared to systems with predominantly fee-forservice health insurance models. where telemedicine consultations result in a fee, physicians should state expected costs with patients at the onset of the encounter to align patients' health care goals and financial expectations. in lmics, practices must consider existing health care provider roles, practice functions, reimbursement, and regulatory compliance when designing telemedicine workflows. in the philippines, the taguig city government designed a telemedicine system around previous patient triage protocols for both suspected covid-19 and non-covid-19 chronic disease patients. after a telephone interview by representatives at the centralized city health office, patients are referred to the appropriate health care provider and offered contactless prescription deliveries [12] . despite the advantages of telemedicine for treating chronic, nonurgent medical problems, there must be a clear pathway to referral for in-person care when a face-to-face physical examination or procedure is indicated. the resolve to save lives global hypertension control initiative recently developed two telemedicine workflows-'hub and spoke' and 'direct to patient'-to both maintain continuity of care and address emergency situations for established hypertension patients (figure 2 ) [5] . engaging health care providers and patients is critical to creating a sustainable telemedicine program. clear and simple 'playbook' training instructions facilitate rapid adoption by medical staff. integrating a monitoring and evaluation framework will recognize care gaps and drive continuous quality improvement. digital literacy training, access to interpreters or clinicians who speak local languages, and active outreach to highrisk individuals are cornerstones of patient-centered care that should be employed to promote telemedicine uptake and limit disparities among vulnerable populations. encouraging lmic patient utilization of telemedicine services through text messaging or online marketing efforts will limit spread of infection during the covid-19 pandemic and lay the groundwork for ongoing health care improvement. telemedicine can play a key role not only in maintaining essential health services for chronic disease patients in lmics during the covid-19 pandemic, but also in long-term primary health care strengthening. as telemedicine spreads in lmics, it will be important to monitor its impact on quality of care and address socio-economic disparities in telemedicine adoption. covid-19 has catalyzed rapid expansion of telemedicine, but its longevity will hinge not on technology alone, but on government regulations, payment policies, and health system redesign. with concerted efforts, expansion of telemedicine can sustain and extend the reach of primary health care in lmics during covid-19 and beyond. virtually perfect? telemedicine for covid-19 global telemedicine implementation and integration within health systems to fight the covid-19 pandemic: a call to action. jmir public health and surveillance people who are at higher risk for severe illness has covid-19 subverted global health? the lancet leveraging technology to improve health care during the covid-19 pandemic and beyond 2020 global preparedness against covid-19: we must leverage the power of digital health guiding opinions of the national health insurance commission of the national medical insurance bureau on promoting the "internet +" medical insurance service during the prevention and control of the new coronary pneumonia outbreak ministry of health and family welfare, government of india. telemedicine practice guidelines review and analysis of current responses to covid-19 in indonesia: period of strategy of blood pressure intervention in the elderly hypertensive patients (step): rational, design, and baseline characteristics for the main trial medical and economic benefits of telehealth in low-and middle-income countries: results of a study in four district hospitals in mali. bmc health services research taguig launches 'telemedicine' program amid covid-19 the authors have no competing interests to declare. mhh conceived of this article, performed the unstructured literature review, and wrote the first draft of the paper. rg and aem conceived of the article and reviewed and edited the manuscript after the first draft. trf, pk, jc, and db reviewed the final version of the paper and provided content and editorial input. key: cord-345949-6aehkrsm authors: north, steve title: telemedicine in the time of coronavirus disease and beyond date: 2020-06-27 journal: j adolesc health doi: 10.1016/j.jadohealth.2020.05.024 sha: doc_id: 345949 cord_uid: 6aehkrsm nan the coronavirus disease 2019 (covid-19) pandemic and the resulting orders regarding social distancing have spurred health care providers to address patient access and their own financial sustainability by transforming how they deliver care. telemedicine, defined by the centers for medicare and medicaid services as two-way audioevideo communication between a physician or other health care provider and a patient, has been at the forefront of this transformation [1, 2] . in 2016, only 11.8% of family physicians and pediatricians in the u.s. worked in a practice that used telemedicine [3] . after 2 months of the covid-19 pandemic, only 9% of primary care physicians worked in a practice that did not offer telemedicine [4] . federal and state policies regarding licensure, equipment security requirements, locations of service, the roles of federally qualified health centers and rural health centers, and the ability to prescribe controlled substances changed rapidly to accommodate the surge telemedicine use [5] . telemedicine has been used effectively to meet the needs of adolescents in schools, inpatient settings, and primary care practices for the past decade [6, 7] . the dramatic increase in care afforded by telemedicine provides new opportunities for expanding the reach of multidisciplinary adolescent health care while simultaneously raising concerns regarding adolescent confidentiality and the impact on health disparities and health equity. telemedicine provides the ability to transform care from being practice centric, where patients and families must adhere to clinic schedules and physical location, to patient centric by decreasing travel and missed school and work [8] . however, telemedicine has come under significant scrutiny in the pediatric community since ray et al. [9] demonstrated that direct-toconsumer telemedicine providers followed antibiotic prescribing guidelines much less frequently than primary care prescribers (59% vs. 78%, respectively). it is important to note that the telemedicine providers in this study were employed by a large national telemedicine company, as opposed to working collaboratively with a patient's medical home. integrating telemedicine into a patient's medical home or within a network of collaborating providers may both decrease barriers to access and improve the overall quality of care [10] . this month, the journal features two articles that illustrate the abilities of two academic programs to quickly scale telemedicine programs to maintain access to care for adolescents in the context of the covid-19 pandemic [11, 12] . both articles identify issues commonly raised by adolescent medicine professionals when discussing telemedicine implementation. these include maintaining patient confidentiality, the impact on office-based care models, and the potential impact of telemedicine on health disparities and health equity. there is also a shared call for increased research regarding the use of telemedicine in adolescent health care. confidentiality can be compromised when an adolescent's responses are limited or coerced because of the presence of parents or others during the encounter or when the technology itself offers inadequate security. the american telemedicine association's operating procedures for pediatric telehealth recommends establishing who is with the patient, both on and off camera, but does not extend its guidance to the degree that is seen in many practices [13] . barney et al. [11] identified seven of 322 (2.1%) visits, and wood et al. [12] identified two of 392 (.51%) visits, where confidentiality was not able to be maintained. the authors recommend the use of headphones and chat functions as ways to provide confidential care in settings where privacy cannot be guaranteed. adopting telemedicine requires evolving patient care workflows and potentially redefining the patient encounter. when transportation barriers are removed, brief, more frequent interactions with a patient may allow for a more comprehensive clinical picture of an adolescent. wood et al. [12] were able to move quickly to multidisciplinary visits as their technology evolved, highlighting the benefit of the team's ability to have frequent contact with a patient with an eating disorder and her parents. concerns regarding the limits of a video-only physical examination may be addressed through partnerships that expand the geographic reach of an adolescent medicine practice. a community pediatrician or family physician could undertake the physical examination, screening, laboratory testing, and immunization portion of an adolescent well visit, whereas partners in adolescent health could provide expertise for complex reproductive health needs, gender-affirming therapy, or mental health services. the ability to guide a patient to a higher level of care is an essential component of a comprehensive telemedicine program. when telemedicine is not able to meet the health care needs of an adolescent because of the need for a genital examination, laboratory testing, or a procedure, the responsibility for making this transfer lies with the medical provider and not the patient. stand-alone direct-to-consumer telemedicine, including insurance-funded "on-call" services, often does not automatically share records and can lead to more fractured care. as the specialty of adolescent medicine expands its use of telemedicine, technology must improve collaboration rather than create silos. significant concerns exist across health professions that the rapid adoption of telemedicine may exacerbate health disparities. nouri et al. [14] recently proposed four key actions that must be taken when developing new telemedicine programs: "(1) proactively explore potential disparities in telemedicine access; (2) develop solutions to mitigate barriers to digital literacy and the resources needed for engagement in video visits; (3) remove health systemecreated barriers to accessing video visits; and (4) advocate for policies and infrastructure that facilitate equitable telemedicine access". applying an adolescent health perspective to these four key actions will facilitate the development of a framework for incorporating telemedicine into adolescent health care and assist in defining an advocacy agenda. there is currently little research regarding the use of telemedicine in adolescent health or large-scale studies within the specialty of pediatrics. the supporting pediatric research in outcomes and utilization of telehealth (sprout) research network is focused on establishing an evidence base for pediatric telehealth [15] . the sprout-ctsa collaborative telehealth research network, a national institutes of healthefunded program housed at the american academy of pediatrics, is a resource for research support and can assist in the development of research projects. adaptive policy and reimbursement changes created in response to the covid-19 pandemic may be rolled back as the pandemic resolves, and programs will need to be prepared for more regulatory requirements. ideally, the changes in the ryan haight act allowing for controlled substances for opioid use disorder treatment will remain intact, along with the new ability of federally qualified health centers and rural health centers to bill medicaid and medicare as providers of telemedicine. the loosening of security measures that allowed facetime to be used for telemedicine may be reversed, as more focus is placed on patient safety and security. as the adolescent health community becomes more proficient at meeting patient needs through telemedicine, there are opportunities to explore the use of other modalities of virtual care, such as digital therapeutics and remote monitoring technology, to improve the scope of our care. the development of adolescentfocused clinical care, policy, and research frameworks will help to ensure that all adolescents benefit from new technologies, and that future implementations do not require the same intensity of effort as outlined in the excellent articles in the current issue [11, 12] . steve north, m.d., m.p.h. spruce pine, north carolina rapidly converting to "virtual practices": outpatient care in the era of covid-19 the use of telemedicine by physicians: still the exception rather than the rule quick covid-19 primary care survey, series 9|the larry a. green center covid-19 telehealth policy changes | center for connected health policy telehealth no longer an idea for the future broadening the frontiers of adolescent health through telemedicine and online networks impact of a university-based outpatient telemedicine program on time savings, travel ccosts, and environmental pollutants antibiotic prescribing during pediatric direct-to-consumer telemedicine visits telemedicine: pediatric applications the covid-19 pandemic and rapid implementation of adolescent and young adult telemedicine: challenges and opportunities for innovation outcomes of a rapid adolescent telehealth scale-up during the covid-19 pandemic american telemedicine association operating procedures for pediatric telehealth addressing equity in telemedicine for chronic disease management during the covid-19 pandemic key: cord-294487-hcuzxhb3 authors: shenoi, susan; hayward, kristen; curran, megan l.; kessler, elizabeth; mehta, jay j.; riebschleger, meredith p.; foster, helen e. title: telemedicine in pediatric rheumatology: this is the time for the community to embrace a new way of clinical practice date: 2020-10-31 journal: pediatr rheumatol online j doi: 10.1186/s12969-020-00476-z sha: doc_id: 294487 cord_uid: hcuzxhb3 background: the use of telemedicine in pediatric rheumatology has been historically low. the current covid 19 global pandemic has forced a paradigm shift with many centers rapidly adopting virtual visits to conduct care resulting in rapid expansion of use of telemedicine amongst practices. body: this commentary discusses practical tips for physicians including guidance around administrative and governance issues, preparation for telemedicine, involving the multidisciplinary care team, and teaching considerations. we also outline a standard proforma and smart phrases for the electronic health record. a proposed variation of the validated pediatric gait arms legs spine examination (pgals) called the video pgals (vpgals) as a means of conducting virtual pediatric rheumatology physical examination is presented. conclusion: this commentary provides a starting framework for telemedicine use in pediatric rheumatology and further work on validation and acceptability is needed. the covid-19 pandemic has forced rapid changes in the way that medical care is delivered worldwide. virtual care models with remote clinics and video visits (e-visits or telemedicine) have become widespread practice overnight. the adoption of telemedicine in pediatric rheumatology has been limited historically [1] and the importance of physical examination cited as a barrier [2] . furthermore, regulatory complexity, decreased reimbursement rates and technical limitations have hampered robust development of telemedicine. however, for many providers and families the pandemic has resulted in a need for pragmatism often in the absence of formal training or sophisticated technical support. the unique need to balance social distancing with providing ongoing care to an often immunosuppressed patient population combined with relaxation of regulatory demands has enabled rapid expansion of video visits. the american college of rheumatology position statement on telemedicine also reflects this rapidly evolving need (https://www.rheumatology.org/portals/0/files/telemedicine-position-statement.pdf). this commentary describes practical creative approaches based on our experiences and discusses the potential for telemedicine to address unmet needs in the wider context of pediatric rheumatology. guidance for telemedicine clinics is available (table 1) albeit governance considerations differ between countries and institutions may also have specific requirements. in both the united states (usa) and european union (eu), credentialing of providers to provide telemedicine is entrusted to the remote site where they are physically located [3, 4] and providers must be licensed to practice at the remote site and the originating site (where the patient is located) [3] . consent is important and specific concerns relate to the lack of a 'hands on' in-person physical examination and more universal concerns regarding privacy and technology issues. patient privacy and confidentiality is paramount and needs to be addressed in the technological requirements with access (at both originating site and remote sites) restricted to individuals essential to facilitate patient care. this may include an in person telepresenter, multiple virtual support staff to help coordinate after visit care, and, other specialists and members of the multidisciplinary team (mdt). many electronic health record (ehr) systems have compliant telehealth modules (e.g. health insurance portability and accountability act (usa) and general data protection regulation (eu). for circumstances in which an ehr module is not available, several commercial vendors (e.g. zoom, telehealth) offer 'standalone' privacy compliant video platforms. issues related to data ownership and security vary in different regions of the world, depending upon whether telemedicine is considered to be a healthcare service or an information service. it is important to review the contract for services, as different vendors may also have different policies. both standalone telemedicine platforms and ehr modules offer the ability to capture still images (photographs) or have the capacity for asynchronous communication. the billing systems used for inperson visits are also used for telemedicine visits. limitations in the observed physical examination make timebased billing more rewarding in many circumstances, but the complexity of pediatric rheumatology medical decision make it a viable alternative in our specialty. preparation is essential and includes provider related tasks, incorporating the broader mdt and ensuring that family are supported with the requisite equipment and information. we provide resources and practical tips in table 1 . patient selection for video visits will be influenced by individual site and situational factors. generally speaking most established patients can be seen by video visits at least on an intermittent basis. young patients (< 3 years) are more challenging to keep on task with a virtual joint exam, but a care-giver only visit to discuss symptoms or medication side effects is often feasible. guidance for consideration of urgent in-person evaluations during the ongoing pandemic is available (https://www.rheumatology.org/portals/0/files/guiding-principles-urgent-vs-non-urgent-services.pdf) and include new patient evaluations when the consulting or referring provider indicates urgency, acute flare or ongoing disease activity of a known disease. the virtual exam section requires creativity depending on the location of the family/patient, consideration of the exam sequence, technical issues and how to cue the family and child to gain optimal views ( table 1 ). the pgals assessment is a validated simple basic musculoskeletal (msk) examination [5] and a proposed variation, called video-pgals (v-pgals table 1 ) includes maneuvers from pediatric regional examination of the musculoskeletal system (prems) [6] and suggestions from the authors. v-pgals offers a structured approach to a cursory overview msk exam with a focus on range of movement and symmetry. utilizing the parent or caregiver to feel the joint in question for obvious warmth/ swelling or to palpate for point of maximal tenderness can add important information. our experience suggests that for patients with myositis or muscle complaints, the childhood myositis assessment score (cmas) [7] is fairly easy to administer across the virtual platform. the actual visit. effective video visits require adequate clinical staff and administrative support. a call ahead of the scheduled visit helps to prepare the family regarding technology needs and to gather information (e.g. medications, allergies and recent weight). at the start of the visit, obtaining consent is important and a brief scaffolding statement helps to ease anxiety and set expectations. documentation of discussions with the family and mechanisms to ensure follow up tasks are coordinated and carried through is critical. we provide suggested ehr dot phrases and a recording proforma (table 1) . multidisciplinary clinics. some platforms have capability to invite multiple providers and other staff in the virtual visit room. this is useful to have individuals who may be in a different location on the visit, from a different specialty or members of the mdt (e.g. nurse, physical therapist) or other key persons (e.g., social worker, interpreter, or psychologist). teaching opportunities. telehealth clinics provide novel educational opportunities (practical tips table 1 ). in the virtual visit, both the trainee and attending can be present simultaneously for the entirety of the visit providing bi-directional opportunity for direct observation and coaching for the trainee (history taking, physical exam, communication skills) and trainee observation of key points that the attending gathers or style of attending counselling. published tools for assessment that work well in this context are available [8, 9] . the typical precepting model can be reproduced in the virtual setting by temporarily placing the patient and family in the virtual waiting room while the trainee and attending confer and then having the family rejoin the virtual visit with both providers in attendance. alternatively, for many patients, the trainee can review their assessment and plan with the attending within the video visit while the family is present as a method to confirm the information gathered and demonstrate transparency in the precepting process. this option also allows for the benefit of capturing attending time spent evaluating the patient and this may be important if using time-based billing as only attending physician time can be counted. the covid-19 pandemic has provided an opportunity to expand telerheumatology and address workforce challenges around the world [10, 11] . telemedicine in rheumatology has advantages but the limitations ( table 2 ) need to be addressed to enable adoption into routine clinical practice. there is need to evaluate the validity and acceptability of the overall quality of care, family and provider experience as well as virtual exam techniques such as v-pgals and cmas. there are inherent costs of technology and provider training but once set up, the model may well be cost effective. there is huge potential for networking, education and training, especially in areas of the world with no local specialist provision. the pandemic has undoubtedly brought much health and economic distress to the world and has necessitated pragmatic solutions to clinical care. such experience has focused minds and provided opportunity for collaboration between providers, clinicians, and families to develop a model of care utilizing technology to complement traditional health care delivery and improve access to care to more children. advantages increased access to specialist opinion for families living in rural/ remote areas [12] and ability for mdt members to join from different locations in same visit reduced travel time (caregivers and physicians) reduced missed work (caregivers) [13] , reduced missed school (patients), cost savings (families) [1] video visits can be efficient especially when the provider links directly to the patient some ehr systems provide ability for families to complete questionnaires beforehand education and training. trainees, including residents, fellows, allied health and medical student teaching could be incorporated to improve exposure to pediatric rheumatology at training centres where this expertise in not available. potential for outpatient or inpatient e-consults to remote hospitals where pediatric rheumatologists are not on staff subtle exam findings can be missed. a potential solution is the use of a trained telepresenter (e.g. family doctor, pediatrician, physiotherapist or nurse) or training parents to facilitate the examination. families express preference for in-person visits, even when travel is inconvenient [2] challenges in developing rapport especially with new patients complex or medically serious visits need in person assessment [14] participation in research studies which historically have required in person evaluations (might require creative solutions) shortfalls in network, hardware and software capabilities, either on the provider or patient end can cause inability/ difficulty with connecting, or poor video resolution equipment and training of providers is often costly and timeconsuming, with decreased provider acceptance [15] . equity issues: limited access for some families with poor or no internet access or limited data plans, low bandwidth capacity, limited language proficiency, health literacy and technological literacy [15] lack of or inadequate insurance coverage geographic boundaries may be bound to different telehealth rules based on government and hospital restrictions internet and software platforms may not have security to ensure privacy of video or healthcare data [15] . decreasing patient cost and travel time through pediatric rheumatology telemedicine visits telemedicine and other care models in pediatric rheumatology: an exploratory study of parents' perceptions of barriers to care and care preferences adminstering a telemedicine programm telemedicine: the legal framework (or the lack of it) in europe pgals -paediatric gait arms legs and spine: a simple examination of the musculoskeletal system pediatric regional examination of the musculoskeletal system: a practice-and consensus-based approach development of validated disease activity and damage indices for the juvenile idiopathic inflammatory myopathies. ii. the childhood myositis assessment scale (cmas): a quantitative tool for the evaluation of muscle function. the juvenile dermatomyositis disease activity collaborative study group tools for direct observation and assessment of clinical skills of medical trainees: a systematic review twelve tips for implementing tools for direct observation of medical trainees' clinical skills during patient encounters policy challenges for the pediatric rheumatology workforce: part ii. health care system delivery and workforce supply improving musculoskeletal health for children and young people -a 'call to action rural health issues in rheumatology: a review tele-rheumatology to regional hospital outpatient clinics: patient perspectives on a new model of care telerheumatology: a technology appropriate for virtually all. semin arthritis rheum telemedicine: pediatric applications publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. kh and ss wrote the first draft and all co-authors reviewed and revised the manuscript.availability of data and materials not applicable.ethics approval and consent to participate ethical approval was not deemed appropriate for this study. consent from patients is not applicable in this study. all authors give consent for publication. the authors declare that they have no competing interests. the authors have no financial relationships relevant to this article to disclose. funding: this work had no specific funding support. key: cord-285277-8w03car3 authors: hare, nathan; bansal, priya; bajowala, sakina s.; abramson, stuart l.; chervinskiy, sheva; corriel, robert; hauswirth, david w.; kakumanu, sujani; mehta, reena; rashid, quratulain; rupp, michael r.; shih, jennifer; mosnaim, giselle s. title: covid-19: unmasking telemedicine. date: 2020-06-27 journal: j allergy clin immunol pract doi: 10.1016/j.jaip.2020.06.038 sha: doc_id: 285277 cord_uid: 8w03car3 abstract telemedicine adoption has rapidly accelerated since the onset of the covid-19 pandemic.1 telemedicine provides increased access to medical care and helps to mitigate risk by conserving personal protective equipment and providing for social/physical distancing in order to continue to treat patients with a variety of allergic and immunologic conditions. during this time, many allergy and immunology clinicians have needed to adopt telemedicine expeditiously in their practices while studying the complex and variable issues surrounding its regulation and reimbursement. some concerns have been temporarily alleviated since march 2020 to aid with patient care in the setting of covid-19. other changes are ongoing at the time of this publication. members of the telemedicine work group in the american academy of allergy, asthma & immunology (aaaai) completed a telemedicine literature review of online and pub med resources through may 9, 2020 to detail pre-covid-19 telemedicine knowledge and outline up to date telemedicine material. this work group report was developed to provide guidance to allergy/immunology clinicians as they navigate the swiftly evolving telemedicine landscape. the covid-19 pandemic led to an unprecedented change in clinical operations, motivating 91 physicians and healthcare systems worldwide to rapidly implement telemedicine programs to 92 reduce or replace in-person visits. 1 telemedicine has allowed for increased workforce 93 sustainability, limitation of clinician direct exposure to patients, overall reduction of personal 94 protective equipment (ppe) use, and may reduce clinician burnout. it has also facilitated staffing 95 of both large and small facilities that are overwhelmed with pandemic-related patient overload. 2 96 in addition, telemedicine has been used for surge control or "forward triage" -the triaging of 97 patients before they arrive in the emergency department (ed). direct-to-consumer (dtc) visits 98 have allowed patients to be efficiently screened while protecting patients, clinicians, and the 99 community from exposure. 3 100 this rapid need for telemedicine visits has generated the demand to effectively educate 101 allergists/immunologists on how to optimize utilization. prior to the pandemic, telemedicine was 102 often reserved for patients with decreased access to care. it is quickly becoming the preferred 103 mode of delivering care for both follow-up and new clinic patients. 3, 4 recognizing telemedicine 104 as a growing field for the practicing allergist/immunologist, the american academy of allergy, 105 asthma and immunology (aaaai) health informatics, technology and education (hite) 106 committee established a telemedicine work group (twg) to review multiple aspects of 107 telemedicine including utility, adoption procedures, billing, security, electronic medical record 108 (emr) integration, education, and state specific issues. 109 110 traditional rationale for telemedicine: convenience of care, increased access, and cost 111 telemedicine has been shown to decrease costs of travel for patients in both time and money. 113 by making it more convenient for them to obtain care, telemedicine has increased access for 114 patients who might not otherwise be able to receive care or be seen at a given practice. 5, 6 115 prior to the covid-19 pandemic, patients who may have benefited from telemedicine included 116 poor, elderly or disabled patients, or those who simply lived too far away to travel for an in-117 person visit. 5 telemedicine is well-suited to large rural states or medically underserved urban 118 areas. a 2019 study found that telemedicine in the veteran's health administration (vha) has 119 likely improved access to care for veterans who live in rural areas. 7 120 this convenience is also applicable in emergency and hospital settings where specialists may 121 not be on site. virtual consultations can limit the need for transportation of ed patients to other 122 facilities for care and hospital transfers. 8, 9 as early as 2007, estimates predicted that 123 teleconsultations could obviate the need for up to 850,000 transfers and save us$537 million 124 dollars per year. 8 125 a 2016 retrospective study done in the vha looking at data from 1997-2008 found that, for the 126 clinics studied, the mean no-show rate for doctor appointments was 18.8%. the average cost 127 of a no-show visit in the vha in 2008 was us$196. 10 telemedicine may help improve patient 128 compliance and decrease the associated financial cost to practices and clinicians of no-show 129 visits by reducing barriers to care. 11 cost-benefit analysis data for the use of telemedicine is 130 minimal at this time. however, recent studies conducted in tele-dermatology and telemedicine 131 in the pre-hospital care setting have recently shown promising results. 12, 13 132 133 despite the exponential growth of telemedicine in the past five years in the united states, the 135 adoption of these services by the allergist/immunologist community was minimal prior to the 136 pandemic . 14 several factors contribute to the rationale for growth of telemedicine during the 137 covid-19 pandemic. first, the public health emergency (phe) has led to the development of 138 guidelines for quarantine as well as for social and physical distancing . 15 steps involved in starting a telemedicine program 154 the first step in setting up a telemedicine program is determining the types of patients that will 155 be seen. assuming that federal, state, malpractice, and insurance guidelines are taken into 156 account, these may include initial consultations, established visits, and patients at a distance. it 157 is important to know the limitations of telemedicine, as there are certain visits that can be 158 challenging to perform through telemedicine. procedures and procedure-related visits, such as 159 allergy skin tests, immunotherapy and/or biologic injections, food and/or drug challenges, in 160 general are difficult to accomplish except in the case of a facilitated visit where a trained 161 clinician is present at the patient's site who is adequately trained and is able to accept 162 responsibility for treating the patient if a systemic allergic reaction occurs. 163 the next step is to decide whether the telemedicine visits will be through a synchronous or 164 asynchronous approach. asynchronous telemedicine is communication with a patient separated 165 by distance and time. synchronous telemedicine is where the clinician and patient are 166 connected at the same time in a live interactive audiovisual exchange. 167 synchronous telemedicine is further classified into direct-to-consumer (dtc) visits or facilitated 168 visits (fv). a direct-to-consumer (dtc) visit occurs between the patient and clinician at a non-169 medical facility, such as the home, where communication is directly through the patient's 170 smartphone or computer. a facilitated visit (fv) requires a facilitator to operate equipment and 171 guide the patient through the video visit. 172 the equipment needed at the origination (patient) site depends on whether the appointment is a 173 facilitated visit (fv), a dtc visit, or a telephone visit. please refer to the online supplement for 174 specific technology guidelines. for a fv, there should be a specific room in which the patient 175 can be seen (often a regular examination room). most origination sites have a "telemedicine 176 cart", which contains the hardware, software and other equipment needed for a telemedicine 177 with the patient, establishing their role and connection with the patient is recommended. 196 once the platform and equipment are in place, the next step is to organize the scheduling of 197 patients. guidelines for patients best suited for telemedicine should be established. pre-clinic 198 huddles can be effective forums for identifying patients suitable for telemedicine visits. initially, 199 consider scheduling the same amount of time for a telemedicine visit as an in-person visit to 200 allow a buffer for technology issues that may come up. documentation in the emr can be done 201 at the same time as talking to the patient. the scheduling of telemedicine visits among in-202 person visits depends on practice efficiency, notification system, and workflow. this can be 203 adjusted as needed. 204 one important aspect to developing a successful telemedicine program is adequate training. software. if that fails, one may have a backup, encrypted independent platform. if the first two 211 encrypted options fail, traditional phone modalities may be used (see tables ia and ib for 212 examples of encrypted and non-encrypted telemedicine platforms, respectively). flexibility and 213 versatility in dealing with technology failures in real time is paramount. 214 providing checklists or a toolkit for patients that include educational handouts on the patient's 215 expectations, an introduction to the consent process, how to contact information technology if 216 they encounter difficulties during the visit, and how the patient can prepare to ensure a stable 217 digital connection during the visit is essential. online tools including podcasts and webinars can 218 offer clinicians multiple medical education modalities. 11 please see table ii (online resources 219 for telemedicine). 220 clinic schedulers and other staff should contact patients prior to the visit to discuss preparation 221 for their telemedicine visit. included in this discussion should be a review of the devices 222 (computer with camera, smartphone, phones, digital tablets) that can be used for the remote 223 telemedicine encounter. in addition, test calls with the device are recommended to ensure the 224 patient will be able to reliably connect to the clinician for their telemedicine visit. depending on 225 the platform and the healthcare system involved, consent, required by most states, may be 226 obtained by the clinic staff or clinician and documented prior to the visit. even if obtaining a 227 patient consent for telemedicine visits is not required in a particular state, it is an advisable best 228 practice to implement in telemedicine. 19 229 a telemedicine visit starts when the patient logs into the telemedicine site. some emrs have an 230 integrated telemedicine application, thereby eliminating the need for a separate telemedicine 231 application. however, this is not a requirement; the telemedicine and emr applications do not 232 have to be linked. once a connection with the patient has been established and consent 233 obtained, the encounter can start. it may be helpful to have the patient's chart in the emr open, 234 either on the same screen or on a separate screen, to refer to and facilitate documentation 235 during the visit. the clinician may want to discuss what to do if the call drops or internet access 236 is disrupted with the patient at the start. documenting information from the patient as to their 237 current location and phone number is recommended as it can be used to contact emergency 238 medical services (ems) services if an emergency occurs during the telemedicine visit or if the 239 connection with the patient is lost. 240 the clinician should then conduct the history as they would for an in-person visit. after the 241 history has been obtained, a physical examination is performed. the depth of the physical exam 242 depends on the location of the patient. if the patient is at a medical facility, the physical 243 examination can be performed with the use of peripheral equipment (e.g. electronic stethoscope 244 and otoscope) and the facilitator. if it is a dtc visit, a physical exam can still be performed, with 245 the clinician guiding the patient to maneuver certain aspects for visualization. as expected, the 246 telemedicine exam is not as comprehensive as compared to an in-person exam. however, it is 247 not as limited as one might expect. with a little creativity, the clinician can still obtain a fair 248 amount of useful data from the telemedicine exam. (see table iii for example telemedicine 249 physical exam pearls). after the physical exam and medical decision making, an assessment 250 and plan are formulated. it is necessary to write orders, give prescriptions, and provide 251 instructions to the patient to conclude the visit. please see table iv for an overview of the steps 252 for conducting a telemedicine visit. 253 254 the utility of emr integration can depend upon the type of telemedicine that is employed. for 256 remote monitoring telemedicine, there have been studies using patient-facing technologies to 257 collect patient-generated health data that then flow into emrs (such as peak flow or frequency 258 of mdi use). 20, 21 however, these processes currently remain cumbersome and are not widely 259 implemented. for video conferencing telemedicine visits, the medical history, orders, and visit 260 notes associated with each video visit are integrated within the electronic health record (emr), 261 thus improving work flows and clinician/patient satisfaction. 22, 23 the patient-facing interface can 262 be via the vendor's mobile application or emr patient portal. emr telemedicine vendors offer 263 additional features including integration with referral management, scheduling and visit 264 reminders, patient intake, and patient communications. please refer to the e-supplement for 265 additional information on integration with emrs. 266 267 in a recent meta-analysis, combined tele-case management and teleconsultation were effective 269 telemedicine interventions to improve asthma control and quality of life in adults. 24 telemedicine 270 was also used to provide asthma education in medically underserved areas. scheduled 271 facilitated telemedicine visits with certified asthma educators over a period of one year reduced 272 the number of unscheduled visits for asthma. 25 in addition, telemedicine was shown to be non-273 inferior to in-person evaluation for asthma care. this is particularly important in medically 274 underserved areas where access to asthma specialists may not be readily available. remote 275 presence solution (rps) equipped with a digital stethoscope, otoscope, and high-resolution 276 camera was used to perform the visits in this study, with either a registered nurse or respiratory 277 therapist serving as telefacilitator. 26 a pilot study of 50 patients published in 2018 utilizing 278 telemedicine to evaluate penicillin allergy demonstrated high patient satisfaction and potential 279 savings of over us$30,000 dollars due to increased access to specialty allergy/immunology 280 care and improved antibiotic stewardship. 27 as with any benefit comes an evaluation of risk. 281 patient safety and the lack of inferiority of the quality of care with telemedicine versus standard 282 care are ongoing areas of research. 28 283 the relationship between telemedicine reimbursement rules and access to care is complex. 285 concerns about potential overuse and quality of care have caused many payers to place 286 considerable restrictions on fee-for-service telemedicine coverage. inconsistency among payers 287 and states in coverage for telemedicine services may shift costs from payers to clinicians and 288 patients, preventing adoption. the opportunity cost of non-reimbursed or under-reimbursed care 289 has been a major barrier to telemedicine implementation and prior to covid-19 prevented 290 many physicians and health systems from offering potentially valuable telemedicine services to 291 their patients. studies show that when reimbursement is limited, patients are under-served by 292 telemedicine services. 29 293 coverage 294 although parity in coverage (both in-person and telemedicine services are covered for the same 295 indication) and payment (e.g., meaning that reimbursement for telemedicine services 296 approximates that of the equivalent in-person e/m service) has never been universally 297 mandated, payment parity is the coveted norm. existing data suggest that enactment of parity 298 increases adoption of telemedicine. almost 90% of both users and non-users (of telemedicine) 299 said they would use telemedicine if they were to be reimbursed. 29 in fact, a 77.5% increase in 300 telemedicine adoption was noted after implementation of parity in michigan. 30 301 because telemedicine coverage and reimbursement are not federally regulated, there is 302 considerable variability in rules, depending on the state and insurer. no two payers or states are 303 alike in how they define or cover telemedicine services. although the covid-19 phe has 304 certainly brought increased coverage for telemedicine services, nationwide standardization of 305 coverage and payment policies is still lacking. the center for medicare and medicaid services 306 (cms) has historically placed strict limits on criteria for telemedicine reimbursement, requiring 307 patients receiving telemedicine services to reside in a rural area and travel to a designated 308 health center to receive facilitated care via a synchronous live video link. 31 however, these strict 309 limits on telemedicine services may have contributed to thwarting innovation and adoption of 310 new technologies, thereby limiting access to care. even before the covid-19 pandemic, cms 311 had pivoted to enhanced coverage of telemedicine. 312 medicaid has generally had broader telemedicine coverage than medicare, but rules vary from 313 state to state. currently, all 50 states and washington dc provide reimbursement for some form 314 of live video in medicaid fee-for-service plans. fourteen states reimburse for store and forward 315 delivered services (not including teleradiology). twenty-two states reimburse for remote patient 316 monitoring (rpm). 32 317 insurer-specific policies. currently, 40 states and washington dc have laws that govern private 319 payer telemedicine reimbursement policies. 33 some laws require reimbursement be equal to in-320 person coverage. however, most only require parity in covered services, not reimbursement 321 amount. depending on how the law is written, it may provide payers with the ability to limit the 322 amount of that coverage. unfortunately, inconsistent coverage and reimbursement policies 323 among the various insurers can lead to confusion, incorrect coding and billing, and denied 324 claims. 34 325 some patients prefer to pay a convenience fee to access non-covered telemedicine services 326 rather than come into the office for an in-person visit or forgo care. costs vary significantly but 327 tend to be lower than the routine charges for an in-person evaluation. 35 328 correct coding of telemedicine services is essential to obtaining reimbursement for care. in 330 most cases, coding for telemedicine services was done using the corresponding codes for an in-331 person e/m visit (using either time or history and medical decision-making to justify the level), 332 but with commercial insurers requiring the -95 modifier (synchronous telemedicine service 333 rendered via a real-time interactive audio and video telecommunications system) appended. 334 some insurers also accepted modifier gt in lieu of 95. medicare did not require a modifier for 335 e/m services provided via telemedicine. place of service was to be designated as "02" to signify 336 telemedicine for all payers. while medicare only covered telemedicine services for established 337 patients, some private payers permitted telemedicine visits for new patients, but not with the 338 standard new patient cpt codes. instead, they required billing with code 99499 (unlisted 339 evaluation and management code) with place of service "02". this may have been associated 340 with lower reimbursement than an in-person new patient visit. due to this variability, it had 341 always been best to check with each individual payer to determine how best to code 342 telemedicine visits. for further information about cms coverage of telemedicine services pre-343 covid-19, see table v . table vi for coding and billing 353 telemedicine visits by time. for visits that are based on exam, documentation requirements for 354 the systems that were examined is the same as for an in-person visit. please see table iii for 355 telemedicine physical exam coding guidance. 356 the covid-19 phe has rapidly ushered in expanded coverage/reimbursement for telemedicine 358 services by both cms and commercial payers. 18 one of the major changes from medicare 359 includes the lifting of geographic restrictions on patient location, making telemedicine services 360 available to medicare beneficiaries residing outside of underserved rural areas. beginning 361 march 6, 2020, medicare permitted patients to receive telemedicine services regardless of 362 location and without the need to leave their homes to visit an originating site, such as a clinic 363 that might be used for a fv. this means that, for the first time, medicare patients can receive 364 telemedicine services from the comfort and safety of their own homes. cms issued guidance to 365 use modifier -95 to designate an e/m service as telemedicine, and change the place of service 366 for all care to the location in which the service would have ordinarily been provided instead of 367 "02", thus enabling payments to achieve parity with in-person rates instead of being reimbursed 368 at the lower facility rates. although cms itself is not waiving the cost-sharing for beneficiaries 369 during the covid-19 phe, the office of the inspector general (oig) policy statement informed 370 practitioners that they will not be sanctioned for choosing to reduce or waive a patient's cost-371 share obligations. 36 during the covid-19 pandemic, medicare has continued to allow 372 telemedicine visits to be billed either by e/m (with history, physical exam, and medical decision 373 making, as per a normal in-person office visit) or by time (if billing based on time, 50% of the 374 time must be spent on counseling and/or coordination of care, as per a normal in-person office 375 visit). please see table iii for telemedicine physical exam coding guidance and table vi for 376 coding and billing telemedicine visits by time. finally, medicare temporarily has permitted new 377 patient codes to be billed for telemedicine visits and allowed telephone visits to be reimbursed 378 at face-to-face rates, enabling virtual care for those patients without access to video technology. 379 after weeks of rapidly changing guidance from commercial payers, many have now followed 380 cms's lead, and adopted many of the same telemedicine coverage expansions. this has 381 interestingly resulted in telemedicine billing/coding guidance that is significantly more uniform 382 than pre-covid-19. many commercial payers are now covering new patient visits via 383 telemedicine. additionally, many have issued guidance to bill using the place of service "11" 384 instead of "02", along with modifier -95 or -gt. in many (but not all) cases, this will result in 385 payments that achieve parity with in-person rates. see table vii for pre-and during-covid-19 386 changes based upon insurance. some states without coverage and payment parity laws have 387 issued executive orders temporarily mandating coverage (and in some cases, payment) parity 388 for telemedicine services provided for state residents. 37 it remains to be seen if the increased 389 adoption of telemedicine resulting from these changes will be maintained post-covid-19 or if 390 coverage and parity policies return to baseline. see table viii for examples of telemedicine 391 coding and billing. 392 past data has shown that health care systems average a time period of 23 months to implement 394 digital healthcare solutions. 38 with the mounting pressure to preserve clinical operations 395 remotely during the covid-19 pandemic, many health care systems were faced with 396 implementing telemedicine within a few weeks. systems that had already identified superusers 397 and who had utilized telemedicine to address medical care access issues were quick to expand 398 their telemedicine services. for any health care system, key factors of successful 399 implementation include stakeholder engagement, end user buy-in, effective educational delivery 400 programs and soliciting feedback. 38 preparing clinicians for implementing telemedicine involves 401 understanding of how telemedicine affects various aspects of the traditional clinic workflow, 402 which will look different for a large health care system vs academic setting vs 403 allergy/immunology private practice. 39 (see table v) . 404 in addition to these components of education, clinicians will require access to information 405 regarding the most suitable telemedicine platform for their current needs. they expect to be 406 able to access this information quickly as it rapidly changes during and after the post covid-19 407 pandemic. platforms will differ on the breadth of data security and privacy that is offered and will 408 vary in their ability to be integrated within the emr available to the clinician for documentation 409 and billing. 410 federal regulators announced another set of regulatory changes and waivers, particularly 412 relating to telemedicine, in response to the growing pandemic crisis throughout the united 413 states. these changes are described in the e-supplement. with, specific technology requirements, and payer specific requirements as well. this process 441 has been accelerated with the covid-19 pandemic, and many regulatory and payer issues 442 have been waived or modified to allow a rapid response to changing practice logistics, such as 443 eliminating licensing requirements for out of state telemedicine visits until the covid-19 444 pandemic emergency has diminished. 445 upon the rescinding of federal and state emergency orders related to covid-19, these 446 requirements may revert back to their prior complexity or continue to exist in a partially modified 447 form. it is therefore advisable that all of these bodies be consulted prior to beginning/continuing 448 the practice of telemedicine in order to ensure proper care, fair reimbursement, avoidance of 449 unforeseen medicolegal issues, and to provide the best care for our patients. it is also advisable 450 that clinicians regularly check laws, legislative agendas, best practice recommendations, and 451 payer policies to ensure the practice continues to be compliant. this section will provide 452 information for approaching this process and cover regulatory issues at the state level, but not 453 reimbursement or technology requirements. 454 efforts are being made by the interstate medical licensure compact commission, 44 (a branch 455 of the federation of state medical boards that joins 29 states, the district of columbia and the 456 territory of guam), to continue expansion to other states as they assist physicians with their 457 telemedicine licensing needs.this is an excellent resource for ongoing formation regarding 458 licensure. upon expiration of current emergency orders removing barriers to telemedicine 459 licensure and requirements, the lack of license portability will continue to be a barrier. there is 460 an expedited process for licensing board-certified physicians with no background issues. but 461 physicians practicing in multiple states must adhere to a variety of state-specific medical 462 practice regulations, and there are annual license renewal fees for each state license. there is 463 no national licensure at present. the exception to this is patients and clinicians working with the 464 veterans administration (va) system, where rules were in place effectively bypassing state 465 licensure laws. 45 please see the specific licensing issues in the e-supplement. 466 it is important to maintain health insurance portability and accountability act of 1996 (hipaa) 468 compliance in a telemedicine visit in the same manner as an in-person clinic visit. 469 medical professionals often mistakenly believe that communicating electronic protected health 471 information (ephi) is acceptable when the communication is directly between physician and 472 patient. often, little regard is given to the method of communication that is used for 473 communicating ephi. medical professionals who wish to comply with the hipaa guidelines on 474 telemedicine must adhere to rigorous standards for such communications to be deemed 475 compliant. hipaa requires ephi data be encrypted when they are transferred. 5 hipaa also 476 directs that a telemedicine vendor must monitor data that are stored during transfer. skype do not have a baa and thus previously did not fully comply with hipaa. some small 491 practices use these platforms for telemedicine. however, some insurers will not pay for 492 telemedicine care that uses the non-baa platforms, and some large organizations will not allow 493 their doctors to use these platforms. 49 in addition, copies of communications sent by sms, 494 skype, or email remain on the service cliniciansâ´ servers and contain individually identifiable 495 healthcare information that is not encrypted. this ephi is also not considered hipaa 496 compliant. 50 497 there are a variety of vendors that provide telemedicine technology (table ia) . because each 499 technology changes frequently, it is important to visit each vendor's website for information 500 about current offerings. it is important to check with each company to determine hipaa 501 compliance and encryption and to verify it with an it security expert. 51 other technologies to 502 consider utilizing include intrusion detection systems (ids), web application protection, and log 503 management. 504 patients have every right to be concerned about privacy and question how their information will 506 be handled during a telemedicine visit. clinicians should be prepared to educate patients about 507 the steps taken for hipaa compliance and ways to ensure the privacy of other confidential 508 information. it is important to let patients know technology is designed for this purpose and that 509 clinicians take this obligation under hipaa very seriously. 4 510 the emergency declaration by the president of the united states on march 15, 2020 removed 512 some of the hipaa and state-related barriers that required recording all telemedicine visits and 513 that those copies be maintained in an archive as part of the medical record. for the time being, 514 cms has also noted that accidental hipaa violations that occur in the course of caring for 515 patients via this method will not be prosecuted, as long as the clinician was acting in the best 516 interest of the patient. many state governors have released similar letters providing similar 517 policies for medicaid in their respective states. with the declaration, the originating site can be 518 the patient's home, nursing homes, hospital outpatient departments, and other settings and 519 across state lines. 11 520 to immediately allow clinicians to start telemedicine services, hhs office for civil rights (ocr) 521 will exercise enforcement discretion and waive penalties for hipaa violations against healthcare 522 clinicians who serve patients in good faith through everyday communications technologies such 523 zoom (zoom video communications, inc., san jose, ca), skype, and facetime, among 524 others. 52 telemedicine visits are also more flexible in that the video solution has an exception 525 for hipaa security rules requiring baa for technology. this change now also supports platforms 526 such as facetime, google hangouts, and skype which do not offer a baa. nevertheless, best 527 practice is to work toward the use of a hipaa-compliant video solution as soon as available. 528 this emergency declaration regarding telemedicine requirements is to extend through the 529 covid-19 phe. at this point it remains unclear how long these changes will remain in effect or 530 what form they will take once the covid-19 emergency ends. to dispel any confusion, 531 clinicians need to remember that hipaa regulations are still in place at this time; it is the 532 enforcement of these regulations that has been temporarily relaxed. 533 telemedicine has been shown to increase access to and decrease the cost of medical care. 5, 8, 535 10, 47, 53 many of the types of patients that we care for in the field of allergy and immunology can 536 be helped using telemedicine. past examples include the use of telemedicine for asthma and 537 antibiotic allergy and stewardship. [24] [25] [26] [27] we and our patients are therefore uniquely positioned to 538 take advantage of and benefit from telemedicine. 539 540 until recently, however, there was not widespread adoption of telemedicine. therefore, a work 541 group from the health, information, technology and education (hite) committee of the 542 american academy of allergy, asthma, and immunology was formed to investigate the 543 baseline use and needs of the allergy and immunology community with regards to 544 telemedicine. since that time, the covid-19 pandemic has led to an unprecedented 545 heightened need for telemedicine from private practices to academic centers throughout the 546 country. 2, 3, 54 there is now an opportunity to integrate telemedicine into the medical education 547 curriculum and experience telemedicine at all levels. it remains to be seen if the changes in 548 technology, regulation and reimbursement of telemedicine will be maintained long term. 549 550 hite is planning to longitudinally follow the adoption of telemedicine by allergy/immunology 551 clinicians in the context of covid-19 and afterwards. our goal is to continue the development 552 of tools to assist allergy/immunology clinicians with adoption of telemedicine and to help push 553 the boundaries of telemedicine use by the allergy and immunology community. covid-19: 557 pandemic contingency planning for the allergy and immunology clinic keep calm and log on: telemedicine for 560 covid-19 pandemic response virtually perfect? telemedicine for covid-19 department of health & human services. health information privacy tips for seeing patients via telemedicine based outpatient telemedicine program on time savings, travel costs, and environmental pollutants. 569 value in health utilization of interactive 571 clinical video telemedicine by rural and urban veterans in the veterans health administration health 572 care system american telemedicine association. examples of research outcomes: telemedicine's impact on 574 adding telemedicine to icus in va hospitals reduced transfers of sickest 579 patients prevalence, predictors and 582 economic consequences of no-shows telemedicine in the era of covid-19 586 a cost savings analysis of asynchronous teledermatology compared to face-to-face dermatology in 587 catalonia cost-589 benefit analysis of telehealth in pre-hospital care centers for disease control and prevention, department of health and human services office of inspector general. hospital experiences 600 responding to the covid-19 pandemic: results of a national pulse survey medicare-telemedicine-health-care-provider-fact-sheet. 605 19. the center for connected health policy. national policy: informed consent effectiveness of population health management using the 608 propeller health asthma platform: a randomized clinical trial an internet-based store-and-forward 611 video home telehealth system for improving asthma outcomes in children telemedicine integrated with clinical care: patient experiences telemedicine integrated with clinical care the 618 effects of telemedicine on asthma control and patients' quality of life in adults: a systematic review 619 and meta-analysis the uses of telemedicine to improve asthma control telemedicine is as effective as in-person visits for 623 patients with asthma the use of telemedicine for penicillin allergy skin 625 testing patient safety risks associated with telecare: a systematic review 627 and narrative synthesis of the literature lack of reimbursement barrier to telehealth adoption state policies influence medicare telemedicine utilization. telemed 632 j e health the center for connected health policy. state telehealth laws & reimbursement policies: a 638 comprehensive scan of the fifty states and the district of columbia patient and clinician 649 experiences with telehealth for patient follow-up care regarding physicians and other practitioners that reduce or waive amounts owed by federal health 652 care program beneficiaries for telehealth services during the 2019 novel coronavirus the center for connected health policy. covid-19 related state actions ama quick guide to telemedicine in practice the future of telehealth in allergy and immunology training what physicians need to know about cyber insurance digital platforms heighten cyber exposures coronavirus aid, relief, and economic security act veterans affairs department. authority of health care providers to practice telehealth 675 the department of health and human services, national 679 telecommunications and information administration american college of allergy 684 48. the center for connected health policy. national policy: hipaa how to start doing telemedicine now (in the covid-19 crisis telemedicine technology: a review of services, equipment, and other 692 aspects synchronous telehealth for outpatient allergy consultations: a 2-year regional 697 experience virtual health care in the era of covid-19 telehealth implementation playbook american telemedicine association. telemedicine forms utilize telemedicine: how does billing work? medicare telemedicine health care provider fact sheet hcpcs g2010). (hcpcs g2012) medicare shared savings program requirements; quality payment program; medicaid promoting interoperability program; quality payment program-extreme and uncontrollable circumstance policy for the 2019 mips payment year; provisions from the medicare shared savings program-accountable care organizations-pathways to success; and expanding the use of telehealth services for the treatment of opioid use disorder under the substance use-disorder prevention that promotes opioid recovery and treatment (support) for patients and communities act yes, if covid-related (yes, through 7/31/20)* % yes yes date range for covid-19 phe telehealth expansion (subject to modification) key: cord-321594-x5wv9p7n authors: jiang, wen; magit, anthony e.; carvalho, daniela title: equal access to telemedicine during covid‐19 pandemic: a pediatric otolaryngology perspective date: 2020-10-05 journal: laryngoscope doi: 10.1002/lary.29164 sha: doc_id: 321594 cord_uid: x5wv9p7n objectives/hypothesis: during the current covid‐19 pandemic, the demand for direct‐to‐home telemedicine services has risen to an unprecedented level. equal access to specialty care was assessed to identify potential barriers that may negatively impact telemedicine utilization. study design: retrospective case series. methods: we examined the 6‐week period between march and may 2020 when the only access to nonurgent pediatric otolaryngology service was through telemedicine and compared it to in‐person visits during the same period in 2019. we compared patient demographics, including age, gender, preferred language, zip code of residence, and primary insurance plan. results: a total of 1,495 visits were conducted through telemedicine from march 23, 2020 to may 1, 2020, and 1983 in‐person visits were completed in 2019. there was no difference in patient age and gender. the proportions of spanish‐speaking families were similar (15.8% in 2019 vs. 14.4% in 2020, p = .96). the percentage of medi‐cal‐insured patients (51.4% in 2019 vs. 49.8% in 2020, p = .73) and the mean poverty level (12.6% in 2019 vs. 12.2% in 2020, p = .38) also remained the same. spanish‐speaking families were statistically more likely to require rescheduling of their telemedicine visits (17.2%) when compared to the overall rescheduling rate of 11.9% (p = .0083). conclusions: we were able to successfully provide access to telemedicine services to our vulnerable populations during the current covid‐19 pandemic. telemedicine is likely to remain an essential mode of delivering patient care going forward. it is important to evaluate and identify potential disparities to telemedicine access and proactively implement changes to address these barriers. level of evidence: 4. laryngoscope, 2020 telemedicine utilizes electronic communication to facilitate encounters when the patient and provider are in different geographic locations. technology has been used in medicine as early as 1879 when physicians reported using a telephone to reduce unnecessary office visits. 1 in our current era, telemedicine is most commonly used for patients in rural locations with barriers to accessing medical care. the use of telemedicine for pediatric otolaryngology is well established, with institutions such as nemours children's hospital in delaware regularly using telemedicine to provide services since 2015. the university of california san diego (ucsd)/rady children's hospital medical foundation division of pediatric otolaryngology has been providing telemedicine services on a limited basis for more than 3 years, with an average of four visits per month. the recent increase in demand for direct-to-home telemedicine services secondary to the covid-19 pandemic has necessitated a rapid ramp-up in the volume of telemedicine services we provide, with the swift adoption of technology by both patients and providers. this required an evaluation of our practice to ensure that the current platform and workflows provide a seamless transition to virtual visits from in-person clinical encounters. given our geographic location at the border between the united states and mexico, the san diego county population is made up of 34.1% hispanic or latinos according to the 2019 us census. 2 a particular concern is that language and technology barriers may limit the use of telemedicine by families who are not native english speakers or have limited digital literacy due to low socioeconomic status. given the large percentage of our patients who are primarily spanish speakers, revisions in the current telemedicine platform may be necessary to correct disparities in access to care. we evaluated the percentage of telemedicine visits completed by patients whose primary language is spanish or other languages and compared it to the percentage of in-person visits completed. other factors analyzed were the poverty level of the patient's geographical residence and type of insurance (commercial vs. government supported). we conducted a retrospective review of telemedicine visits completed between march 23 and may 1, 2020 when our pediatric otolaryngology clinic was closed for routine outpatient visits due to county-mandated "stay-at-home" restrictions during the covid-19 pandemic. per institutional protocol, this study was submitted to the ucsd institutional review board (irb) and was granted exemption as no protected health information was collected. we compared the data to the same period in 2019, when all patients were seen in person. to conduct video visits in a secure environment, we implemented zoom integration with the electronic medical record (emr) system epic. using context-aware linking in epic, a link to a zoom video session is placed in an epic encounter. this enables epic users to launch zoom video interaction when using epic for documentation simultaneously. physicians are able to initiate a visit and launch directly into a video visit within the emr. patients are able to launch into zoom from their epic mychart patient portal on their personal computer or smartphone. all communications between zoom and epic, as well as zoom video sessions, use aes-256 bit encryption and are dynamic password-protected, making this integrated process secure and hipaa-compliant. however, the process is moderately technology intensive. prior to scheduling, all patients were contacted by phone, and our clinic staff obtained verbal consent for a telemedicine visit and went through the process of enabling the mychart patient portal if they were not previously enrolled. they were also required to download zoom on their personal computer or smartphone prior to the scheduled video visits. on the day of the visit, medical assistants contacted family by phone and completed the verification process to ensure that all the audio and video features were functional. they also conducted their portion of the workflow, recording vital signs and reviewing history, medication, and allergy, prior to providers joining the visit. if patients had difficulty launching zoom within the mychart portal, they were given a separate passwordprotected invite to a zoom session with the provider to complete the video portion of the encounter. due to time constraints, if there were any significant technical issues with the connection or setup, the visits were rescheduled for another session once the technical difficulties have been resolved. we analyzed this rate of rescheduling as a surrogate for technology barriers that caused delay in access to telemedicine care. to reduce the spread of covid-19, the san diego county health department issued mandates on march 19, 2020 that required the closure of our clinic for routine, nonurgent visits. the order was lifted on may 4. with the closure of the clinics, there was a rapid ramp-up period of telemedicine services where all providers and staff received training for video visits. we examined the 6-week period where the only access to nonurgent pediatric otolaryngology services for our patients was through telemedicine visits. we included all completed visits during this period and examined the rate of rescheduling, which can indirectly reflect possible barriers to access, such as lack of access to technology, lack of digital literacy, and language barriers. data were generated through reporting workbench tools available within the emr. we reported on patient demographics, including age, gender, preferred primary language, zip code of the patient's residence, and primary insurance plan. we also examined whether the visit was for a new or established patient, primary diagnosis, and whether the visit was rescheduled and how many times. the zip codes were used to obtain the poverty level of the patients' geographical residence, which is available in the 2019 us census. 2 to compare the demographics of the patients to in-person visits, we examined a similar 6-week period between march and may in 2019, evaluating for any intrinsic differences between the patient populations. comparing the same period between the 2 years helped eliminate any seasonal variability in visit patterns. statistical analysis was performed with the jmp® pro 14.2.0 by sas institute. associations between classifications were evaluated by pearson chi-square statistics. the dependence of responses on quantitative variables was analyzed by logistic regression and the corresponding receiver operating characteristic (roc) curves. in all cases, we presented the calculated significance values. descriptive statistics are presented for all variables. there was a total of 1,495 telemedicine visits conducted between march 23, 2020 and may 1, 2020 and 1983 in-person encounters in the same 6-week period in fig. 1 ). zip codes were used to evaluate the poverty level of the geographic area of patients' residence. the poverty level was reported as the percentage of households with income below the poverty threshold. in 2020, in the united states, the poverty threshold for a single person under 65 years of age was an annual income of us $12,760; the threshold for a family of four with two children was us$26,200. we compared the poverty levels of patients seen in 2019 and 2020 using data reported for each zip code, 2,3 and there were no significant differences (table ii) . the mean poverty level for patients seen in 2019 was 12.6% and 12.2% in 2020. in 2020, there were 563 (37.7%) new patients and 932 (62.3%) return patients. of all patients, 178 (11.9%) rescheduled their telemedicine visits. among patients who are spanish speaking, 37 (17.2%) required rescheduling. when testing for independence of spanishspeaking patients and patients who rescheduled their visits, we found that these two classifications were not statistically independent (chi square = 6.733, p = .0083). poverty level (p = .4), medi-cal insurance (p = .07), and new patients (p = .74) status did not statistically affect the rate of rescheduling. spanish speaking was statistically associated with poverty level as evaluated by the logistic regression of the poverty level on the classification of spanish speaking (yes/no). the area under the roc curve (auc) was 70.4% (fig. 2) . of the patients seen in 2020, 49% of them were seen for otologic diagnoses, 20% for problems with the tonsil/ adenoids, 14% for sinonasal issues, and 11% for airway/ voice problems (table iii) . the use of telemedicine in otolaryngology has been increasing steadily in the last decade with the expansion of technology capabilities and faster broadband connections accessible to the general population. previous telemedicine applications were mostly focused on providing care to rural populations such as alaska 4 and remote areas of australia 5 and to manage chronic diseases 6 where telemedicine reduces the need for frequent in-person visits. it has been shown to decrease barriers to medical care for those with limited access. the current covid-19 pandemic with many countyand state-mandated "stay-at-home" restrictions have compelled healthcare systems across the country to adopt telemedicine at an unprecedented speed to continue providing care to all patient populations from pediatrics to geriatrics and from primary care to specialty care. due to the technology requirement, our concern is that telemedicine 7 in a recently published article by nouri et al, the authors found that, in a primary care practice managing chronic diseases, a significantly smaller proportion of the visits after scaled-up telemedicine implementation was observed for vulnerable patients: age 65+ years, non-english language preference, and those insured by medicare or medicaid. 8 in contrast, we did not see any difference between the patient demographics when we compared 2019 in-person visits and 2020 telemedicine visits. patients were of similar age and gender. the proportion of non-english speakers and those with medi-cal insurance remained the same, along with the poverty level. one of the reasons for our equal access finding may be due to the nature of pediatric care. for a pediatric practice, we did not expect to observe a difference in the age and gender of the patients during the two periods. parents of children are likely to be younger (<60 years of age) and may be more likely to adopt technology when compared to older adults. using a self-administered survey, demartini et al reported a high level of digital technology access among parents in an urban pediatric primary care clinic setting with a high percentage of african american and medicaid-insured families in a low socioeconomic area. 9 of respondents, 80% reported having internet at home, and 71% had a smartphone. in that population, 70% of respondents reported that they would use healthcare information supplied digitally if approved by their child's medical provider. it is possible that the younger age of both our patients and their parents, when compared to the general population, has the greatest effect in terms of access to digital technology that may negate the effect of other language and/or socioeconomic barriers. another major reason for the lack of difference in patient characteristics may be the fact that we are a tertiary specialty care clinic. our patient population comes from referrals by pediatricians. during the scheduling process, our clinic staff proactively contacted patients who were previously scheduled for in-person visits or those with an active otolaryngology referral. this scheduling process is likely to be quite different in a primary care clinic setting, where the majority of the visits are initiated by the patients themselves. however, this may serve as an example for other pediatric specialty care practices depending on the level of resources available. there may also be an intrinsic advantage to pediatrics where parents are interested and likely to use technology for the management of their child's health. 10 it was interesting that the most common reason for a telemedicine visit was for otologic complaints. most publications regarding visits for these issues discuss the use of video endoscopy, where the physician can evaluate the patient's ears. 11, 12 we did not have these systems available, so the visits occurred without otoscopy. nevertheless, there were no complaints from the families, and limited postencounter surveys were uniformly positive. due to the limitation of the exam, we had initial concerns that patients with otologic complaints may prefer telephone encounters. however, the majority of the patients chose video visits with the ability to connect face-to-face with the providers. to continue providing telemedicine services in the post-covid-19 era, it will be essential for us to elicit feedback and review patient and provider satisfaction with both initial and subsequent visits to determine which diagnoses are best suited for video versus in-person visits. this knowledge will help us create a more nuanced triage/scheduling system to maximize the benefit of telemedicine in the future. one important barrier we identified in our population is the rate of rescheduling, which is significantly higher among spanish-speaking families. this is despite the fact that we have all spanish-speaking medical assistants and provide translation services through epic-linked zoom calls to all patients whose preferred language is not english. this finding reflects an increased difficulty with technology adoption in spanish-speaking families. the language barrier did not prevent them from accessing our telemedicine specialty service, but it did require longer time and sometimes multiple rescheduled visits to complete the encounter successfully. to provide a sustainable level of telemedicine care beyond the covid-19 pandemic era and well into the future, we need to be cognizant of the language barrier and consciously structure future encounters with increased staff support and longer allotted time and examine more efficient ways to provide digital education and translational services to this population. this may pose a financial challenge at an organizational level in this already difficult time. however, we feel that this is an essential commitment as healthcare providers to create equal access to all of our patients. our early experience with this large-scale telemedicine adoption process made us realize that, to complete a successful telemedicine encounter, the scheduling and previsit workflow is extremely labor-and time-intensive. despite the different outcomes reported, we echo the point made by nouri et al 8 that, as an organization, we need to reach out to our vulnerable patient population and provide help in terms of setting up video platforms, inclusive of the language needs, and partner with local organizations to increase the overall digital literacy of the entire patient population. in addition, in contrast to the opinion of nouri et al., that requiring patient portal enrollment presents a barrier and logistical challenge when scheduling video visits, 8 our experience indicated that patients have enthusiastically embraced the ability to sign up for the patient portal. our mychart adoption rate went from 20%-30% pre-covid to nearly 100% currently. this will have long-lasting positive effects on improving patientprovider communication. many patients, including spanish-speaking ones now, are able to enjoy the ease with which they can contact and communicate with their providers electronically through the patient portal. we will need to remain proactive and continue to strive for better adoption of the patient portal even when in-person visits resume so that we can continue to provide enhanced electronic patient-provider communication. there are several limitations to our study. first, our practice is situated in a fairly large metropolitan area with a county population of 3 million. technology usage is expected to be high in terms of internet access and broadband connections. the differences in the rate of electronic technology adoption between the vulnerable and the general population may be small and could not be detected using the current study design. findings may be different in a practice that includes more rural or remote populations. second, our unique location at the united states and mexico border with a large hispanic population may preclude the generalization of our findings to other communities. third, we used the rescheduling rate as a proxy for barriers to access due to technology, which may or may not be completely accurate. some patients may have rescheduled due to other personal reasons. we also were unable to capture those who were never able to be reached by phone, and due to the small numbers, we did not include those who were unable to successfully complete the telemedicine encounter at all. finally, we analyzed the patient population as a whole and did not assess each patient/family's level of technology availability or digital literacy. a more nuanced analysis using patient-completed surveys may be able to give us more insights into our population's digital landscape, but it is outside the scope of the current study. telemedicine developed from a need to improve access to medical care for patients residing in rural locations; however, an increasing number of patients living in urban areas have adopted telemedicine as a means to receive medical care. the current public health crisis cau-sed by the covid-19 pandemic has dramatically increased the utilization of telemedicine services when patient travel is severely restricted. in our pediatric otolaryngology practice, we found that spanish-speaking patients had a higher incidence of rescheduled visits compared to other patients. it is essential to evaluate, understand, and address potential barriers to technology-based platforms for delivering care to prevent further disparities in access to healthcare. institute of medicine & board on health care services. the role of telehealth in an evolving health care environment: workshop summary united states census bureau zip atlas. available at the alaska experience using storeand-forward telemedicine for ent care in alaska telehealth services in rural and remote australia: a systematic review of models of care and factors influencing success and sustainability impact of mhealth chronic disease management on treatment adherence and patient outcomes: a systematic review profiles of a health information-seeking population and the current digital divide: crosssectional analysis of the 2015-2016 california health interview survey addressing equity in telemedicine for chronic disease management during the covid-19 pandemic access to digital technology among families coming to urban pediatric primary care clinics the digital divide in adoption and use of mobile health technology among caregivers of pediatric surgery patients diagnostic accuracy of a general practitioner with video-otoscopy collected by health care facilitator compared to traditional otoscopy smartphone otoscopy performed by parents the authors have no funding, financial relationships, or conflicts of interest to disclose.send correspondence to wen jiang, md, rady children's hospital, 3020 children's way, mc 5042, san diego, ca 92123. e-mail: wjiang@rchsd.org key: cord-282730-pawasfh4 authors: contreras, carlo m.; metzger, gregory a.; beane, joal d.; dedhia, priya h.; ejaz, aslam; pawlik, timothy m. title: telemedicine: patient-provider clinical engagement during the covid-19 pandemic and beyond date: 2020-05-08 journal: j gastrointest surg doi: 10.1007/s11605-020-04623-5 sha: doc_id: 282730 cord_uid: pawasfh4 background: the novel coronavirus pandemic has drastically affected healthcare organizations across the globe. methods: we sought to summarize the current telemedicine environment in order to highlight the important changes triggered by the novel coronavirus pandemic, as well as highlight how the current crisis may inform the future of telemedicine. results: at many institutions, the number of telemedicine visits dramatically increased within days following the institution of novel coronavirus pandemic restrictions on in-person clinical encounters. prior to the pandemic, telemedicine utilization was weak throughout surgical specialties due to regulatory and reimbursement barriers. as part of the pandemic response, the usa government temporarily relaxed various telemedicine restrictions and provided additional telemedicine funding. discussion: the post-pandemic role of telemedicine is dependent on permanent regulatory solutions. in the coming decade, telemedicine and telesurgery are anticipated to mature due to the proliferation of interconnected consumer health devices and high-speed 5g data connectivity. the first reported severe acute respiratory syndrome coronavirus 2 (sars-cov-2) infections in the usa occurred on january 20, 2020. the corresponding disease, known as coronavirus disease of 2019 (covid19) , was soon reported in all 50 states necessitating drastic measures to reduce the rate of transmission. most states responded by suspending large gatherings, closing non-essential businesses, and encouraging citizens to shelter in place. hospitals adapted their workflow to comply with these recommendations, leading to unprecedented changes in the way healthcare was delivered. these changes involved conservation of personal protective equipment, a suspension of elective procedures, deferral of non-essential in-person clinic encounters, and a reduction in hospital-wide staffing. in turn, surgeons and other specialists who principally relied on in-person encounters were forced to find alternative ways to continue providing care while adhering to the new restrictions. to minimize interruption of crucial clinical services and the associated revenue, a rapid transition from in-person outpatient visits to telemedicine encounters was implemented by many academic medical centers and adopted by surgery departments throughout the country. telemedicine has become an important tool for surgeons during this period of restricted interaction, yet its place within surgical practices in the post-covid period remains uncertain. we sought to summarize the current telemedicine environment in order to highlight the important changes triggered by the covid-19 pandemic, as well as highlight how the current crisis may inform the future of telemedicine. the use of telemedicine for surgery patients prior to covid-19 while telemedicine represents a spectrum of medical interactions, in most instances, telemedicine refers to a real-time audiovisual interaction between patient and provider. prior to the covid-19 pandemic, telemedicine was gradually penetrating surgical practices. although the technology has been available for years, the growth of video visits has been gradual. in a report to the congress in 2016, the united states (us) department of health and human services (hhs) estimated that more than 60% of hospitals in the usa used telehealth in some form. 1 there was a substantial increase in telemedicine use between 2004 and 2017. the vast majority of gains were attributable to increases in primary care and mental health services with other specialties demonstrating only a modestly higher utilization. 2 , 3 within general surgery, including gastrointestinal surgery, reports of telemedicine use were often single-institution pilot studies that involved post-discharge care. 4 -6 prior to january 1, 2020, telehealth regulations were an inconsistent patchwork of rules that varied from state-to-state and among payers. these barriers constrained the utilization of telemedicine throughout the early 2010s. telehealth options for medicare advantage patients markedly improved in january 2020 with the enactment of the 2018 bipartisan budget act, which removed requirements with respect to the originating (patient) and distant (physician) sites. the rationale for these changes was tied to the forecast that telehealth for medicare advantage enrollees was to "produce $557 million in savings for enrollees over 10 years from reduced travel time to and from providers. 7 " in july 2019, the federal communications commission (fcc) announced the connected care pilot program, a 3-year, $100 million program intended to connect health care providers to low-income patients and veterans with broadband-enabled telehealth services. 8 these important legislative changes laid the foundation for academic surgeons to build a more diverse clinical practice via telemedicine and helped pave the way for expanded use in surgical patients. in response to the covid-19 pandemic, federal agencies have promoted telehealth both through regulatory relaxation and increased funding. the centers for medicare and medicaid services (cms) sought to decrease in-person medical visits by issuing a temporary and emergency relaxation of telemedicine rules via the 1135 waiver and the coronavirus preparedness and response supplemental appropriations act. enacted on march 6, 2020, this act allowed original medicare enrollees the same telemedicine benefits that had been extended to medicare advantage enrollees in january 2020. this waiver also established equivalent reimbursement for video telemedicine visits and traditional in-person visits. additionally, the hhs office for civil rights relaxed enforcement of software-based violations of the health insurance portability and accountability act (hipaa). this announcement was accompanied by hhs guidance regarding the degree of hipaa compliance afforded by specific telemedicine platforms (table 1) . 9 in addition, some individual states relaxed medical licensure laws pertaining to the care of patients outside state boundaries. these temporary waivers are expected to remain in effect for the duration of the covid-19 public health emergency. the federal government is also helping to fund the rapid covid-related acquisition of increased broadband data capacity, webcams, and software via the fcc's covid-19 telehealth program. this initiative approved the use of $200 million to fund projects aimed at increasing telemedicine access for low-income americans. 10 these funds will be used to provide both healthcare enterprises and patients with necessary telemedicine hardware and high-speed internet access. the distribution of monies will continue until the funding is exhausted or until the pandemic has ended. in addition, on march 13, 2020 the fcc funded the rural health care program that aims to make telemedicine services available to geographically remote patients. the combination of these dramatic regulatory shifts, in response to the suspension of most in-person elective clinical encounters has driven an impressive increase in telemedicine utilization. given the organizational density of most academic medical centers, rapid shifts of this magnitude are unusual. at our own institution, over the course of 1 week, the volume of telemedicine visits jumped from fewer than 100 encounters per day to well over 2200 per day (fig. 1) . predictability, the transition has led to various technological, logistical, and procedural challenges. after securing necessary internet bandwidth, healthcare organizations must decide which telemedicine platform to select. some electronic medical record (emr) platforms offer telemedicine modules available for rapid deployment, while users of other emrs must select from among third-party platforms. implementing a telemedicine strategy requires considerable education involving a variety of stakeholders including patients, physicians, schedulers, nurses, and billing specialists. sudden implementation of a telemedicine workflow is often associated with a temporary decrease in productivity and morale, as staff learns and integrates the new procedures. distribution of text-based tip sheets and video-based instructional modules, deploying technical support technicians, and nominating clinician champions can help defuse these initial frustrations and contribute to the success of a telemedicine rollout. a successful surgeondirected telemedicine tip sheet should include concise information regarding appropriate documentation and coding, and pearls for a successful video encounter (table 2 ). providers and/or patients who are less technologically inclined may prefer to avoid video visits and utilize telephone-based telemedicine. however, telephone visits typically convey less information than video visits and are reimbursed at a fraction of a comparative video telehealth visit. for example, the highest billing level for a new telephone encounter has a work relative value unit of 0.75 versus 3.17 for the comparable new video encounter (table 3) . 11 healthcare organizations implementing telemedicine should also verify the capacity to submit electronic prescriptions, including those for controlled substances. beyond the intended decrease in viral transmission, once implemented, a telemedicine platform has a variety of potential benefits for both patients and healthcare organizations. given the potential for equivalent quality of care, patients may prefer avoiding the inconvenience of travel, missing a day's wages, and enduring the stress of unfamiliar parking structures and buildings. for a significant proportion of patients, an in-person clinic appointment may require additional costs of transportation, meals, lodging, and child/elder care. these sacrifices can be particularly challenging for patients with disabilities. expending these resources can also be frustrating for patients who are told that their cancer is inoperable during an in-person surgical consultation, only to refer the patient to a separate medical oncology appointment on a different day. such conclusions can often be made by the surgeon based on review of clinical data without an in-person visit. in addition, patients may prefer that long-term routine surveillance visits, which typically involve review of imaging and laboratory values, may be performed remotely. 12 telemedicine encounters can also be attractive to healthcare organizations. telemedicine allows the possibility to expand traditional geographic catchment areas relative to the medical center/hospital; in fact, telemedicine can facilitate an international reach to patients across the world. in addition, a telemedicine platform can expand clinical services even when local physical structures are constrained. from this perspective, increasing telemedicine visits can improve the time interval between patient referral and the first clinical encounter. for many patients, prompt initial surgical consultation is an important marker of high-quality care and satisfies both patients and referring physicians. remote video visits may be particularly attractive to urban medical centers struggling with parking capacity and access to patient care facilities. increasing telemedicine volume can reduce congestion for the patients who require in-person encounters. telemedicine platforms are also being used to coordinate complex multidisciplinary care via a tumor board conference format among specialists that are geographically separated. the use of frequent, multi-disciplinary appointments can, in turn, lead to higher treatment compliance, increased satisfaction, and better outcomes. 13 fig. 1 telemedicine use in response to the covid-19 pandemic. in response to covid-19, the use of telemedicine at a single academic institution increased from less than 100 visits per day to more than 2200 over a period over 24 days while there has been considerable progress, important challenges remain with respect to how the telemedicine platform will be implemented in the post-covid-19 regulatory environment. to this point, the ability to complete a telehealth encounter is dependent upon a reliable data connection. a 2015 study from the pew research center reported, however, that 15% of households did not report having any type of internet access; in particular, african americans were 12% less likely to have high-speed broadband service than whites. 14 of note, race-based disparities in access to internet services have decreased over the last 15 years, yet discrepancies based on age and income level persist. specifically, only 54% of senior citizens reported internet use, whereas households with annual incomes less than $30,000 usage had internet utilization of 74% versus 97% among households with incomes greater than $75,000 per year. 15 in a separate study from 2014, the us department of education noted that older adults generally scored in the lower one-third for six proficiency measures related to problem solving in technology-rich environments. 16 comfort level when interacting with technology and general health literacy are important factors that must be considered in strategies to increase telehealth utilization post-covid19 . in addition to the provisions of the fcc's covid-19 telehealth program, the fcc has taken initial table 2 frequently asked questions about telemedicine visits. cpt current procedural terminology what are the keys to a high-quality telemedicine interaction? • dress professionally. • minimize ambient sounds. make sure the physical surroundings are appropriate. • keep the webcam directly in front of the surgeon's face, at eye level. when the surgeon speaks to the patient, the surgeon should focus the line of sight directly into the webcam lens, rather than focusing on the patient's screen image. • clearly identify yourself by full name, professional title, and institutional affiliation. verify the patient's full name and birth date as you begin the encounter. • speak clearly and pause frequently to address patient questions. • include all the information you would typically include for an in-person visit. • to facilitate accurate billing, indicate whether your telemedicine encounter was completed by phone or video. • since a detailed physical examination is generally not feasible for surgical video visits, most telemedicine visits will be coded using time-based billing. clearly state how many minutes the surgeon independently spent on the encounter, and what percentage of this time was spent counseling the patient regarding the diagnosis and treatment plan. the time spent should include the surgeon's review of clinical data (imaging, laboratory values, pathology, etc.), communicating with other providers, documenting the encounter, and placing new orders. • video visits are coded using standard evaluation and management codes for new and established patients (cpt 99201-99205 and 99211-99215, respectively) with the addition of the "gt" modifier. for all visits within the global surgical period, typically use cpt 99024 + gt modifier whether it is performed utilizing phone or video. can an attending bill for a telemedicine encounter if a resident performed the telemedicine encounter but the attending was present? • if a resident calls and speaks with the patient independently, the telemedicine encounter should not be charged. • the teaching physician must be present via video and listen to the key and critical portions of the encounter in order to bill for the service. a standard teaching physician statement is also required for documentation. • if the teaching physician participates in the visit and reiterates the information discussed by the resident, this also supports a billable service. a standard teaching physician statement is required for this encounter as well. are telemedicine visits permissible if the surgeon and patient are physically located in different states? • this is subject to individual state regulation. as part of the novel coronavirus response, many states liberalized their policies, but be sure to verify with individual state medical boards. steps to address disparities in access to broadband internet service. specifically, the fcc has granted 33 wireless internet service providers located in rural communities increased access to additional broadband spectrum. similar initiatives should focus on urban, inner city populations who are within range of wireless internet options, yet often do not have the economic means to pay for these services. in addition, next generation 5g high-speed wireless internet technology uses higher frequency signals that cannot travel as far as 4g signals, mandating closer placement of 5g antennas for a robust signal. as a result, access to 5g connections in rural communities will likely lag behind those in urban areas. software platforms that allow for multiple simultaneous users will also need to be adapted to provide real-time professional medical translation for patients and providers with language barriers. there has also been increased mainstream adoption of interconnected health devices such as smart watches, which can record continuous cardiac telemetry, as well as smart insulin pumps, which can record and transmit glucose levels. these smart devices will benefit from 5g data transfer rates that are anticipated to be about 100 times faster than current 4g technology. in march 2020, the hhs passed the twenty-first century cures act that aims to provide patients increased access to their health data. specifically, electronic health companies are mandated to maintain data security while removing barriers that previously limited the ability of smartphone applications to be used to access patient data. 17 the rule is anticipated to result in an increase in the number and availability of applications connecting patients to their electronic health information, including telemedicine platforms. surgeons will likely be called upon to integrate data from these and other such devices and apps into clinical recommendations. internationally, a form of population-level telemedicine via smartphones has already been implemented in efforts to limit sars-cov-2 transmission. for example, citizens in china, israel, iran, and great britain use a government phone application that tracks their location and alerts individual citizens when a close contact has contracted the novel coronavirus. 18 in some countries, use of this application is compulsory, but in other nations such as great britain it is voluntary. 19 there are no conclusive data to indicate whether this tracking strategy is effective in controlling the covid-19 pandemic. adoption of a similar strategy in the united states is unlikely due to individual privacy concerns. perhaps the greatest telemedicine advances in the next decade will be with respect to telesurgery. telesurgery denotes an operation in which the surgeon and patient are remotely and separately situated, often with the aid of an operating robot. improvements in data transfer speed and reduced signal latency associated with 5g will help facilitate telesurgery. latency, which is the perceived delay between surgeons input and the anticipated motion has to date been a shortcoming of telesurgery contributing to delayed reaction to intraoperative events. the increased performance of 5g data streams may also introduce an effective solution to the lack of haptic feedback in robotic surgery. 20 in a preliminary series of 12 patients undergoing robotic spinal telesurgery, as well as a case series of two patients undergoing remote robotic proctectomy, surgeons reported favorable outcomes using 5g data transmission. 21 while a surgeon may be able to perform a complex operation on a patient located hundreds of miles away, important logistical concerns remain. specifically, contingency plans regarding unanticipated conversions to an open approach necessitating proximate and immediate surgical expertise need to be considered. as telemedicine and telesurgery penetrate the mainstream, academic medical centers will also need to integrate these approaches into the trainee curriculum. for example, video platforms that allow for multiple, simultaneous video streams for residents to interact with patients under the live supervision of a remotely located teaching physician are emerging. the unprecedented shift to telemedicine is likely to have a durable effect on surgical specialties post-covid-19. prior to the novel coronavirus pandemic, the market penetration of real-time video visits was limited due to numerous regulatory restrictions. 6 , 22 while barriers such as reduced reimbursement and stringent hipaa regulations have been removed during covid-19, these changes are likely temporary. in order for telemedicine to remain a prominent part of the clinical enterprise, cms would need to permanently expand the improvements in medicare advantage coverage for all beneficiaries; private payers also need to adopt models for reimbursement of telemedicine services that closely approximate in-person visits. emerging evidence supports the benefit of telemedicine services for surgical patients. the covid-19 pandemic is an opportunity for healthcare organizations to embrace the crucial role telemedicine plays in the clinical mission. the coming decade is likely to usher in a proliferation of healthrelated connected devices and smartphone applications, along with the maturation of telesurgery due to improvements in 5g data transmission. in an effort to increase access to healthcare and expert surgical care, surgeons will need to embrace telemedicine technologies using data-driven guidelines for greater implementation into routine clinical practice. conflict of interest the authors declare that they have no conflict of interest. report to congress: e-health and telemedicine trends in telemedicine use in a large commercially insured population utilization of telemedicine among rural medicare beneficiaries telemedicine and telementoring in the surgical specialties: a narrative review. american journal of surgery current use of telemedicine for post-discharge surgical care: a systematic review the use of telemedicine in surgical care: a systematic review policy and technical changes to the medicare advantage, medicare prescription drug benefit, programs of all-inclusive care for the elderly (pace), medicaid fee-for-service, and medicaid managed care programs for years promoting telehealth for low-income consumers; covid-19 telehealth program notification of enforcement discretion for telehealth remote communications during the covid-19 nationwide public health emergency promoting telehealth for low-income consumers revisions to payment policies under the medicare physician fee schedule, quality payment program and other revisions to part b for cy 2020 patient preferences on the use of technology in cancer surveillance after curative surgery: a cross-sectional analysis the use of telemedicine for delivering healthcare to bariatric surgery patients: a literature review american americans and technology use: the pew research center sharper focus: results from the program for the international assessment of adult competencies (piaac) 2012/2014: first look (nces 2016-039rev): national center for education statistics 21st century cures act: interoperability, information blocking, and the onc health it certification program. in: services tdohah coronavirus spy apps: israel joins iran and china tracking citizens' smartphones to fight covid-19. forbes translating a surveillance tool into a virus tracker for democracies. the new york times a framework for predicting haptic feedback in needle insertion in 5g remote robotic surgery 5g-assisted telementored surgery. the british journal of surgery clinical assessment and management of general surgery patients via synchronous telehealth publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord-345809-tevi0sup authors: bidmead, elaine; marshall, alison title: covid-19 and the ‘new normal’: are remote video consultations here to stay? date: 2020-08-22 journal: br med bull doi: 10.1093/bmb/ldaa025 sha: doc_id: 345809 cord_uid: tevi0sup introduction: during the uk covid-19 lockdown, video consultations (telemedicine) were encouraged. the extent of usage, and to which concerns to earlier implementation were set aside, is unknown; this is worthy of exploration as data becomes available. sources of data: sources of data are as follows: published case studies, editorials, news articles and government guidance. areas of agreement: video can be clinically effective, especially where patients cannot attend due to illness or infection risk. patients are positive, and they can benefit from savings in time and money. adoption of telemedicine is hindered by a range of known barriers including clinician resistance due to technological problems, disrupted routines, increased workload, decreased work satisfaction and organizational readiness. areas of controversy: despite policy impetus and successful pilots, telemedicine has not been adopted at scale. growing points: increased use of telemedicine during the covid-19 crisis presents opportunities to obtain robust evidence of issues and create service transformation effectively. areas timely for developing research: examination of telemedicine use during the covid-19 crisis to ensure that the benefits and usage continue into the post-lockdown, ‘new normal’ world. over the previous decade, video conferencing has existed as a mature technology (e.g. facetime, skype, lync, webex) and used widely in both social and professional contexts. responding to this opportunity, many innovative individuals within the health professions undertook painstaking practice and service development work to devise clinical protocols for a range of remote consultation interventions, referred to here as telemedicine (see for example fetal telemedicine 1 ; telepsychiatry 2 ; teleswallowing 3 ). these individuals acted as champions, often seeking external funding and promoting their own work to management, colleagues and professional institutions. their work focused initially on designing and testing clinical validity and efficacy: could the patient receive (at least) the same standard of care over video as they would face to face? some work was often necessary with technology providers and internal support services to adapt the products being used. these innovators often assumed that if they could demonstrate clinically efficacy, managers and colleagues would immediately choose to implement their innovation. it was expected that the decision would be largely driven by financial factors. winning arguments would come from the ability to reduce hospital admissions through more timely intervention, the reduction of staff travel to service users and efficiencies to be gained through 'productionizing' interventions. rarely was the argument for reducing infection risk used, although it could have been. funding was duly made available to these clinical digital champions, often from external bodies such as national institute for health research or academic health science networks, for pilots and academic partners engaged to undertake the independent evaluation. however, despite a large body of work, progression from pilot to mainstream adoption proved surprisingly limited. [4] [5] [6] [7] [8] the reasons can be found in some of the independent evaluation studies and are discussed below; no new data were generated or analysed in support of this review. in late march 2020, the uk government imposed 'lockdown' throughout the uk, making it illegal for citizens to leave home unless they had specific, 'essential' reasons, in order to minimize the scale of covid-19 across the country. during this period, working from home was encouraged 'where possible.' with regards to healthcare, whereas governments in australia and the us had encouraged the use of technology for remote consultations, and backed this up with substantial funding, the uk government did not 9 -although the scottish government did accelerate funding for telemedicine. 9 fisk et al. 9 attribute this lack of promotion to an apparent 'general lack of developed services' in the uk. on march 17, 2020, nhs england directed nhs trusts, gp practices and other providers of nhs services to 'redirect staff and resources' in preparation for the expected rise in covid-19 cases. 10 this included the postponement of non-urgent elective surgeries and the urgent discharge of patients 'medically fit to leave.' brief mention was made to video consultation in this document, but only in relation to older and vulnerable people who were shielding, and the redeployment of vulnerable staff. a follow-up directive on march 19 laid bare the coming restrictions in access to healthcare, with face-to-face consultation being discouraged unless necessary, and remote consultation/virtual support being encouraged. 11 further, information governance regulations, often hitherto regarded as regulatory barriers, were relaxed. 12 healthcare staff members were permitted to use 'mobile messaging' and 'video conferencing tools such as skype, whatsapp, facetime,' as well as to use personal devices to support remote consultation 'where there is no practical alternative.' 12 consequently, the use of telemedicine was perceived as an appropriate response to lockdown and resulted in increased use globally. 22 although telemedicine use is reported to have increased in scotland, 9 how far it impacted in the rest of uk is yet to be determined. nevertheless, a number of questions arise, which are discussed in more detail as follows: (i) are the reasons for reluctance to use video in the past no longer valid? (ii) are the reasons temporarily invalid, during the crisis period, but will become important again once this is past? (iii) can we learn from both the previous concerns and the current usage to implement video consultations effectively in the longer term? the impact of the current crisis on the provision of non-covid-19 healthcare has been highlighted with many concerns (for example, affecting usage of emergency care 23 ; cancer survival rates, 24 and access to mental health support 25 ). telemedicine is perceived as a possible solution. telemedicine has already been used to communicate directly with patients in their own homes, 26 as well as for consultations with patients and/or clinicians in other settings, for example, between district general hospitals and tertiary centres 1 ; nursing home staff and allied health professionals 3 ; care homes and digital care hubs. 27 in these examples, telemedicine was seen as a way to increase access to healthcare for people living in remote/rural areas for whom limited access was the norm; this is now the new normal for most. it is worth noting that patients' views are largely positive, although there exists less systematic research into their experience. notwithstanding, patients can be motivated by convenience and cost savings, as telemedicine means their personal travel can be avoided. 1, 28 in the current context, patients will likely be motivated by the reduction of risk of infection and by some contact with the health service being better than no contact at all. the academic literature highlights known barriers and enablers to technological innovations in health settings. 5, 6 key among the barriers is resistance from clinical users. recurring concerns by health professionals, who have piloted the use of video consultations, are useful to guide the evaluation of current usage. the major concerns from our research are collated as follows 29 : (i) low confidence that the technology will work, or that support will be provided, (ii) dissonance with professional identity relating to issues of accountability and negative impacts on the staff-patient relationship-not comfortable with video distancing, missing out on body language cues, feeling of being deskilled, (iii) reduced job satisfaction (tiredness, eye strain, missing out on travel 'downtime' between consultations, (iv) fears of job losses, (v) concerns that patients are being offered 'second best' to reduce costs; (vi) concerns that some patients, particularly the elderly, will not be able to use the technology. greenhalgh et al. 30 identified four elements of clinician resistance to information and communication technology: resistance to 'the nature and justification for the policy' underpinning the innovation, resistance to the sociomaterial constraints of the technology, resistance to compromised professional practice and resistance to compromised professional relationships. resistance to policy relates to the underlying case for the implementation of technology. clinical staff members have often doubted the need for telemedicine and have struggled to comprehend its value to their service and/or practice. 4, 8, 9 it is important that user stakeholders understand why innovation is happening and what will be the 'relative advantages.' 31 the technology acceptance model 32, 33 identifies two main factors influencing the adoption of a technology or innovation: perceived usefulness and perceived ease of use. helping potential users to understand the usefulness of the innovation will help gain their acceptance. given the current covid-19 crisis, one would imagine clinical staff to be more inclined to see video as a solution and be more attuned to the 'relative advantages' and 'perceived usefulness' of remote consultation. nevertheless, one should not underestimate the importance of providing opportunities for 'sense making' wherein staff can develop shared understandings of purpose, the potential benefits and what is expected from them, which are necessarily absent in such a rapid rollout as we see in the current crisis. many authors recommend the use of clinical digital champions as facilitators of telehealth implementation. 4, 6 digital champions can legitimate an innovation by interpreting and disseminating evidence, and influencing stakeholders through enthusiastic promotion to colleagues, senior managers and service users. moreover, staff engagement is beneficial for gaining 'cognitive participation' or 'buy-in' 34 and fosters 'a sense of ownership.' 6 zanaboni and wootton 8 argue that adoption is 'significantly correlated with adopters' perceptions of the advantages'; telemedicine is successful and adopted 'when it is perceived as a benefit and as a solution to political and medical issues,' 8 which it surely must be at this time. during the pandemic, telemedicine is being used, but we do not know how it is perceived by staff users or whether they see it as a valuable tool for their clinical mission. moreover, we cannot tell whether this is seen as a long-term service transformation or whether clinical staff will revert to routine practice at the first opportunity. the sociomaterial constraints of the technology refer to the 'the material properties and limitations of the technology under conditions of expected use.' 30 the technology acceptance model refers instead to 'perceived ease of use.' 32, 33 technological problems are a known barrier to acceptance. 3, 4, 6, 29 the fact that rollout of new technology in the nhs has been plagued by technical problems is a major issue which cannot be underestimated and is still an issue now. 35 already stressed staff are extremely wary of technical unreliability and its ability to compromise their overloaded workflows, which are organized so that any delay can be critical. complex systems that are difficult to use can be problematic and have led users to avoid or reject such new ways of working. in the current climate, where there is not time for trialability, 30 it may be that staff members have no other option than to stick with it and to make it work. nonetheless, many authors highlight the importance of having easy-to-use, reliable equipment 4, 6, 8, 36 that can be adapted to the local context. 6 the availability of technical support is also recommended. 4, 6 another issue, relating to 'perceived ease of use' is the compatibility, or alignment, of the new service to existing practices, pathways and workflows. technological innovation can disrupt established routines, and a lack of fit between the innovation and normal practice can become a barrier to acceptance. 4-6 vuononvirta et al. 36 have highlighted the intransigent nature of routine practices due to habituation which 'has made them easy and fluent for health professionals.' consequently, for clinicians, telemedicine is 'almost always more time and trouble than practicing in an ordinary way' due to the 'additional effort and technical expertise required.' 8 compatibility also correlates with 'perceived usefulness,' and, subsequently, attitudes toward technological innovations; good alignment facilitates use. therefore, incorporating workflow analysis into system design is recommended. 6 where a lack of alignment is unavoidable then pathway redesign may be necessary. in normal times, rigorous planning for implementation would be recommended. 6 in the current situation, systems will have had to be adapted, rolled out and staff trained in a very short time, within an already stressful situation. this can only have been achieved through the significant diversion of resources and management priority. support from senior staff and strong leadership has been identified as a key enabler of innovation. 4 , 5 greenhalgh et al. 5 highlight the importance of an organization's readiness for innovation, pointing to factors such as good leadership and managerial relations; slack resources and the encouragement of risk-taking, as opposed to organizations that are under pressure due to limited resources, 'weak leadership and managerial relations' and an aversion to risk-taking. it may be that services that quickly transitioned to telemedicine resembled the former rather than the latter. however, the usefulness of the technology is at the forefront of the corporate mind, as video consultations may have proved to be critical to maintaining core services safely. furthermore, several studies have highlighted the altered staff-patient relationship caused by telemedicine; this is often viewed negatively. 3, 4, 36 many health professionals view face to face consultation as the exemplar of good care; any change to this is felt as threatening. undoubtedly, consultations requiring physical examination are unsuitable for telemedicine, yet many consultations involve only talking. during the lockdown, most face-to-face consultations were suspended meaning no consultations at all. notwithstanding, staff have voiced concerns about the impact of telemedicine on the staff-patient relationship, communications can be interrupted by problems with equipment which then inhibits conversation; staff miss face-to-face contact with patients and the satisfaction it brings. 3 , 4 evidence is still emerging, but it seems that the level of care has been reduced, particularly for the elderly and those with long-term conditions. 37 some of this could be due to the diminished efficacy of video consultations, or indeed to reluctance to use it, and this needs to be researched in due course. this brings us to the last question and the crux of this paper: how can we go from here to the successful implementation of video consultations for the longterm? the crisis has provided a golden opportunity for large scale usage to be researched and for the findings of earlier research to be revisited. some of the barriers may prove to be overstated. in the light of experience, professional users may find that the technology is more useful and easier to use than they had feared. however, some issues will not go away and will become glaringly obvious when studied at scale. there is no doubt, for instance, that working at home and sitting in front of a screen all day, alone, is more tiring than interacting with colleagues in a work environment. we have all experienced the eye strain, muscle ache, restlessness and inability to concentrate after long sessions. these concerns require creative approaches, as do the real concerns over job roles and ways to support digitally challenged users (staff members and patients). however, there is an opportunity to gather the evidence now and start the conversation. fisk et al. 9 argue that the 'covid-19 outbreak was a major "jolt" to the national health service, that had been and remains, in part, reluctant to embrace telehealth.' innovation should not be left to 'champions' who are prepared to defend and refine their ideas until they are grudgingly accepted. it should be the responsibility of senior management and all layers of staff, recognizing that the process involves building an evidence base and addressing problems in an open and transparent way. these concerns should still apply during the current crisis and in the longer term. however, what has radically changed in the new world is 'perceived usefulness.' health professionals-and perhaps more particularly, senior management-recognize that the service level can only be maintained safely by using video. where compromise is necessary-due to the patient's circumstances or the need for physical care-it places the health professional at greater risk of infection. suddenly there is a compelling reason to overcome all the issues and 'perceived usefulness' trumps 'perceived ease of use.' this is laudable and necessary during the crisis, but there is a real possibility that the use of video will be part of the 'new normal.' whilst this will be welcomed by patients, there needs to be an open discussion with professionals. research has shown that there has been much passive resistance to video consultations and technology enabled care, and that some of the objections can be mutually overcome if managers and staff members work together. for example, the lack of confidence in using the technology can be overcome by a greater investment in service design, training and safe experimentation by staff and service users. 29 the issue of job loss concern and dissonance with professional identity are both related to service transformation, in which new roles are emerging and older ones being discontinued. only by open and respectful discussion can this be done fairly: a process that has been almost impossible under the austerity ideology of the last 10 years. the covid-19 pandemic crisis has meant that video consultations are being rolled out globally. in the uk, whilst the scottish government accelerated its funding to support innovation, the uk government was slower to react on this front. 9 nhs england has encouraged health providers to use video consultation and guidelines have been rapidly written, but we do not know yet the extent of roll out. nevertheless, the efficacy and acceptability of telemedicine has been evidenced in many evaluations and so now is the ideal time to develop capability so that telemedicine becomes an integral part of health service delivery. whether telemedicine remains a significant part of service delivery in the future will depend on how useful it is perceived to be over the longer term and if there is a genuine benefit. service user and staff acceptance of fetal ultrasound telemedicine technology assisted psychiatryintroducing telepsychiatry into an emergency department service'. digital health and care congress teleswallowing": a case study of remote swallowing assessment factors affecting front line staff acceptance of telehealth technologies: a mixed-method systematic review beyond adoption: a new framework for theorizing and evaluating nonadoption, abandonment, and challenges to the scale-up, spread, and sustainability of health and care technologies factors that influence the implementation of e-health: a systematic review of systematic reviews (an update) a qualitative study of sustainability and vulnerability in australian telehealth services adoption of routine telemedicine in norwegian hospitals: progress over 5 years telehealth in the context of covid-19: changing perspectives in australia, the united kingdom and the united states important and urgent-next steps on nhs response to covid-19 publications approval reference: 001559 covid-19 prioritisation within community health services covid-19 information governance advice for staff working in health and care organisations covid-19: guide for rapid implementation of remote consultations telemedicine in the time of coronavirus covid-19 pandemic-is virtual urology clinic the answer to keeping the cancer pathway moving? managing patients with chronic pain during the covid-19 outbreak: considerations for the rapid introduction of remotely supported (ehealth) pain management services video consultations for covid-19 rapid implementation of inpatient telepalliative medicine consultations during covid-19 pandemic teleurology in the time of covid-19 pandemic: here to stay? future-proofing cardiac rehabilitation: transitioning services to telehealth during covid-19 digital mental health and covid-19: using technology today to accelerate the curve on access and quality tomorrow virtual health care in the era of covid-19 covid-19: a&e visits in england fall by 25% in week after lockdown thousands of lives could be lost to delays in cancer surgery during covid-19 pandemic mental-health-cha rity-mind-finds-that-nearly-a-quarter-of-people-havenot-been-able-to-access-mental-health-services-in-thelast-two-weeks renal telemedicine through video-as-a-service delivered to patients on home dialysis: a qualitative study on the renal care team members' experience airedale digital care hub systematic review of patient and caregivers' satisfaction with telehealth videoconferencing as a mode of service delivery in managing patients' health using telemedicine in practice and implications for workforce development rethinking 'resistance' to big it: a sociological study of why and when healthcare staff do not use nationally mandated information and communication technologies diffusion of innovations, 5th edn perceived usefulness, perceived ease of use, and user acceptance a theoretical extension of the technology acceptance model: four longitudinal field studies factors that promote or inhibit the implementation of e-health systems: an explanatory systematic review software problems thwart patient consultations with nhs specialists. the guardian the compatibility of telehealth with healthcare delivery understanding society covid-19 survey key: cord-333123-pglsgi2f authors: singh, jaspal; keer, nikky title: overview of telemedicine and sleep disorders date: 2020-07-02 journal: sleep med clin doi: 10.1016/j.jsmc.2020.05.005 sha: doc_id: 333123 cord_uid: pglsgi2f telemedicine is about more than simply using audio-visual technology to care for patients, but rather an opportunity to fundamentally improve patient access, quality, efficiencies, and experience. regarding sleep medicine, it has the potential to drive sleep medicine’s evolution. by enabling care across geographies and facilitating population-based management, sleep medicine is poised to take advantage of telemedicine capabilities. in this introductory chapter, we highlight issues related to sleep telemedicine, while providing a framework in which to approach this transformational journey thoughtfully. we thereby set the stage for the individual chapters in this edition of sleep medicine clinics. we are delighted to introduce this edition of sleep medicine clinics, which focuses on telemedicine and its applications, whereby multiple authors provide important and unique insights to the issues surrounding sleep telehealth as this field evolves. in this introduction, we provide a clinical, organizational, and philosophic context to the incorporation of sleep telehealth. to us and many others, telemedicine for sleep disorders is a natural fit, because: there is a large unmet patient need for sleep specialists that may be partially allayed by the expansion of telemedicine. diagnostic and treatment algorithms of several common disorders like obstructive sleep apnea are often data driven, enabling sound clinical decision making, potentially even in the absence of a physical examination. sleep clinicians generally rely less on discrete physical examination findings than many other specialists. telemedicine may minimize some of the traditional barriers that have hindered the growth of sleep medicine as a specialty. given these and other issues related to rapid technological adoption by society in general, sleep medicine seems poised to build on this platform of patient care delivery. the telemedicine industry is growing, and even before the coronavirus disease-2019 (covid-19) there is a clear need for the sleep medicine provider to consider telehealth use, and find means for incorporating, integrating, and expanding telehealth strategies. the technology behind telemedicine integration is often less of a consideration than strategic design of the telemedicine practice (workflow design, logistics, and communication). the telehealth industry's rapid and expansive growth, coupled with evolving legislation and reimbursement schemes, requires attention and consideration when defining the technology and applications. individual articles provide a more comprehensive examination of the various aspects of sleep telehealth adoption and integration. important questions related to telehealth still need to be answered, including what is the true impact of telehealth on quality, access, and efficiencies of sleep medicine? what is the impact of telehealth on individual patient and provider experiences? pandemic, the market was expected to hit $53.1 billion by 2026 in a recent report from acumen research and consulting. 1 fueled by faster data streaming options, better camera resolution, and enhanced software features, the technical aspects seem positioned optimally for telemedicine to succeed. in fact, since covid-19 and the widespread adoption of telemedicine to provide care while practicing social distancing, we expect those figures to skyrocket. 2 the frenetic pace at which primary care and specialties adopt telemedicine practices has been nothing short of breathtaking for telemedicine enthusiasts. it is also quite possible that the covid-19 pandemic and the medicare cares act have changed the face of telemedicine for the foreseeable future. so, if adequate technology is ubiquitous, why has telemedicine for sleep practices been so slow to evolve? it has been slowed down not only by previous issues of low reimbursement and slow adoption of technology, but also several key issues related to workflow disruption, behavioral and psychological issues, and of course disparities in access to technology. 3 as such, the array of services, user functionalities, and payment and workflow schemes have left many confused, and perhaps overwhelmed, by where to begin. there are many unique factors to health care regulation, many players and stakeholders, and a host of issues related to change management difficulties. thus, it has been difficult to identify clear paths to success as the pace of the technology, consumer demand, and regulatory and financial issues are continually evolving. such rapid and constant change are almost akin to playing a high-stakes game while one is actively learning the rules; moreover, the rules keep changing. with all these factors, it is no wonder many sleep medicine clinicians have been less keen to adopt and incorporate telehealth. sleep medicine has been exposed previously to large-scale disruption, because home sleep apnea testing was met by years of intense resistance. 4, 5 this change finally led to broader acceptance and integration into the daily practice of a sleep practitioner, benefitting a countless number of patients. many would suggest sleep medicine as a field benefitted from incorporation of new technology. in this vein, we would in fact argue that it is once again in the best interest of the field to accept this tidal wave of change by broad adoption and incorporation of telehealth into the sleep provider's clinical operations. we believe this has the potential to clearly benefit patients, sleep practices, and create much larger and broader impact through several potential mechanisms as discussed in this issue of sleep medicine clinics (fig. 1) . however, the logistics of telemedicine, including its nuances, need to be understood. importantly, one must also consider a patientcentered approach while maintaining fiscal, ethical, and legal responsibilities. as background, in 2015, the american academy of sleep medicine published its position paper for the use of telemedicine for the diagnosis and treatment of sleep disorders, 6 to seek more efficient and accessible ways to provide services beyond the traditional office model. the position paper noted that, at time of publication, the expansion of sleep telemedicine into all aspects of sleep disorder management was limited by technology resources and reimbursement and financial considerations, as well as a willingness of physicians, patients, and health care organizations to accept telemedicine as an alternative to in-office care. 6 in this edition of sleep medicine clinics, the editors have assembled a thoughtful group of experts who have a great deal of pragmatic experience in each of their areas, so that readers can learn other success factors (and some difficult lessons) in sleep telehealth use. because telemedicine is often referred to mean different models of care delivery, a quick recap of the definitions might be worth noting. the american telemedicine association cites 4 key models of telemedicine services: synchronous and asynchronous (store-and-forward) telemedicine patient encounters, remote patient monitoring (rpm), and mobile health (mhealth) smartphone applications. each of these receives a thorough examination in this edition, with pragmatic advice provided by each of the authors. for some basic definitions: synchronous telemedicine refers to the delivery of a live, interactive encounter in which patients and providers are separated by distance but interact in real-time using videoconferencing as the core technology. participants are separated by distance but interact synchronously with the provider performing interviews of the patient, and diagnostic and treatment options are addressed through live video interaction between the patient and the provider. asynchronous (store-and-forward) telemedicine is defined as a non-real-time, technology-assisted exchange of structured information between a patient and provider with the intent to diagnose, treat, and/or triage. for example, a sleep medicine history with certain diagnostic/therapeutic data are collected at the point of care and transmitted to the sleep medicine provider for review. in turn, the sleep medicine specialist provides clinical advice via a written or electronic report to the referring provider within a reasonable time frame to make clinical decisions. rpm refers to the use of digital devices to remotely collect physiologic data for interpretation and management of a patient under a specific treatment plan. for example, telemonitoring is routinely performed of positive airway pressure use; however, increasing rpm of physical activity, oximetry, or ambulatory blood pressure by the sleep clinician may also be considered. as such, this situation has to the potential to lead to personalized care, more rapid and frequent assessments, and perhaps even behavioral change. in addition, this technology may be used to do drive complex disease management to care for highrisk patients with a mix of cardiopulmonary and neuropsychiatric disorders. such applications have been shown to be successful in a broad range of disease states. mobile health applications, or mhealth, encompasses personal computer and smartphone applications that may be used to provide individuals with the behavioral and cognitive skills to manage a disease process. the application of sensors, mobile apps, and location tracking technology may not only enable simple behavioral changes, but also allow monitoring and intervention whenever and wherever acute and chronic medical conditions occur. arguably, rpm and mhealth models represent a heterogenous spectrum between asynchronous telemedicine and self-directed care mechanisms. however, these are worth mentioning now. importantly, the use of telehealth provides the opportunity therefore for responsive feedback from the patient and/or population, while setting the stage for more complex disease and population management schemes. it also creates interesting dilemmas as the lines become increasingly blurred between defining when a patient encounter begins and ends, which is why it is imperative to understand the technical, legal, regulatory, and financial environments in which one develops telehealth strategies. incorporation of sleep telehealth has the inherent potential to allow the limited number of specialists in the workforce to serve the broader population. the centers for disease control and prevention estimate that 50 to 70 million of the general adult population in the united states suffers from chronic disease related to sleep deficiency and sleep disorders. the repercussions of sleep deficiency include disease burden, lost productivity and accidents, and an array of social determinants overview of telemedicine and sleep disorders underlying health and health disparities. fortunately, the general public is more aware than ever before of the importance of healthy sleep. employers are placing a greater value on sleep and insurers, regulators, and legislators recognize the importance of diagnosing and treating sleep disorders. however, as of 2018, there are 6035 sleep medicine physicians board certified by the american board of medical specialties. 7 the reality is that this workforce is insufficient to meet the demands of the enormous population of patients who have a sleep disorder. by leveraging telemedicine capabilities, sleep physicians can access patients that who be in more rural or remote locations and increase access to subspecialties within sleep (eg, pediatric sleep experts, dental sleep experts), while allowing those practitioners to save time and costs associated with travel or distant clinics. importantly, telemedicine truly allows sleep providers to serve more as team leaders in the care of patients, allowing for potentially a greater population served. studies conducted within closed health care systems such as the veterans administration system 8 or kaiser permanente 9 have provided data on the value of telehealth components for evaluation and treatment, and how these components are delivered. telehealth use has led to dramatically reduced wait-times from referral to diagnosis and treatment of sleep-related breathing disorders as well as increased adherence to treatment, despite an increase in the volume of sleep consults and sleep studies performed. 8, 9 questions remain, however, about whether the workforce can adapt to these pressures. will telemedicine allow these providers to adopt, sustain, and grow larger panels of patients? will such providers be skilled and enabled to lead care teams through virtual access tools? will regulations and payment schemes limit successes in different markets of this approach? these are important questions that need to be addressed from the workforce perspective on the use of telemedicine. reimbursement has been and is one of the most significant barriers to the implementation of telehealth nationwide. encouragingly, state and federal legislation and regulation have been increasingly broadening access to telehealth services in recent years. in 2019, 48 state medicaid programs were reimbursing for synchronous video-based telehealth. additionally, 40 states and the district of columbia had adopted substantive policies to expand telehealth coverage and reimbursement. furthermore, the centers for medicare and medicaid services has shown a dedication to support these policies by continually expanding its fee schedule to reimburse newer forms of telehealth. for example, current procedural terminology codes to support rpm of physiologic values were added to the 2019 medicare physician fee schedule. even before the covid-19 pandemic, there had been rapid adoption, acceptance, and even demand of telehealth by both physicians and patients. a study of more than 29 billion private health care claim records found that national use of telehealth grew tremendously between 2014 and 2018. 10 in particular, the number of non-hospital-based provider-to-patient telehealth claims increased at a rate of an astonishing 1393%, much greater than other types of telehealth claims (fig. 2) . investment opportunities in telehealth have also been rapidly expanding. remarkably, digital health received nearly 1 in 10 venture dollars invested in the united states in 2019, totaling more than $7 billion. 11 additionally, digital health companies are proving outcomes and cost validation, increasing the likelihood of success when these ventures enter the public market. as of january 1, 2020, the combined market cap of the 9 digital health companies that entered the public market in 2019 is a staggering $17 billion. 11 there are countless applications currently on the market to provide an array of telehealth solutions, and likely more to come soon. importantly, in 2016 the american academy of sleep medicine even launched its own sleep telemedicine platform, sleeptm. this platform provides services ranging from synchronous telemedicine encounters for sleep disordered breathing, cognitive behavioral therapy for insomnia as well as data management and coordination of care services for durable medical equipment. with the dizzying pace of technological innovation, the us food and drug administration has enacted a digital health innovation action plan to provide regulatory framework for medical device software, mhealth, and other platforms. the goal is to provide timely patient access to high-quality, safe, and effective medical technology. regardless of telehealth strategy and application(s), the financial implications for payers, industry, investors, and the consumers will be scrutinized closely. as much as telemedicine offers a lot to be gained, concerns of costs, integration, and usability still will remain. moreover, the current reimbursement scheme by the centers for medicare and medicaid services is in response to the covid-19 pandemic, which if the reimbursement changes afterward, or the health care sector economy collapses, 12 then telemedicine may not be as easy to sustain in the current projections. much is evolving in this landscape as the financial sectors brace for a post-covid-19 world, and sleep telemedicine is not immune to the market forces. this issue of sleep medicine clinics offers a complete review of key principles related to sleep telemedicine. after the introduction, this edition begins with implementation of synchronous telemedicine, a staple for most sleep telemedicine provider's approach. therefore, understanding the practical aspects of the telemedicine or virtual visit is an imperative for the sleep professional. this is then followed by a thoughtful discussion of how one approaches the electronic health record, integration with data systems, and population management tools in sleep medicine. subsequent articles expand on the introduction of consumer sleep technologies and device wearables mentioned elsewhere in this issue, providing the reader with insight into the rapid advancements that many sleep clinicians see daily in their offices. after this overview, further detail is provided regarding how to manage certain populations with common sleep disorders such as obstructive sleep apnea and insomnia, with the respective authors providing tremendous insight and pragmatic information including managing those with complex inter-related disease states. this issue also addresses how to use telehealth to better integrate nonphysician providers, facilitate team-based care, and even what unique teaching and research opportunities are afforded using telemedicine. importantly, in-depth evaluations of regulatory, legal, and ethics issues as well as important principles related to coding, reimbursement, and financial considerations are highlighted. last, the integration of predictive analytics as the concluding article leads us into the many possibilities that telemedicine with all its uses and applications may allow. we are excited about this edition, particularly as each author is not only an accomplished leader, but also a skilled clinician. as such, each author has tried (and failed) at certain aspects of telemedicine care delivery, but each wants the next person to be successful in advancing the field as well as the care of any patient with a sleep disorder. telemedicine is growing rapidly in all aspects of medicine, and sleep medicine seems well-poised to adapt to this transformation of health care delivery. that said, there are numerous issues related to understanding the technologies, the interface, the workflow and the patient and provider experience. last, providing value, and remaining fiscally, legally, and ethically responsible are important considerations with the sleep telemedicine. therefore, in this issue of sleep medicine clinics, a collection of articles has been assembled that address where our field currently is with respect to telemedicine and telehealth principles for many sleep disorders. it is our opinion that sleep telehealth will be synonymous and integrated with bedside care of the patient with sleep disorders, and that the time is now to incorporate telemedicine principles into one's sleep medicine practice. but there remain questions as to how and to what degree sleep telemedicine will affect the quality, access, and efficiencies of the care of the sleep patient, and to what lessons the sleep medicine field will learn and share along this journey. telehealth market to hit $53.1 billion by 2026. insurance business america web site virtually perfect? telemedicine for covid-19 the use of telemedicine by physicians: still the exception rather than the rule pediatric home sleep apnea testing: slowly getting there! portable monitoring for the diagnosis of obstructive sleep apnea american academy of sleep medicine (aasm) position paper for the use of telemedicine for the diagnosis and treatment of sleep disorders the national center on sleep disorders research-progress and promise national expansion of sleep telemedicine for veterans: the telesleep program effect of telemedicine education and telemonitoring on continuous positive airway pressure adherence. the tele-osa randomized trial multilayered analysis of telehealth digital health celebrated six ipos as venture investment edged off record highs. rock health covid-19 and the upcoming financial crisis in health care key: cord-323980-rcyjthze authors: willems, laurent m.; balcik, yunus; noda, anna h.; siebenbrodt, kai; leimeister, sina; mccoy, jeannie; kienitz, ricardo; kiyose, makoto; reinecke, raphael; schäfer, jan-hendrik; zöllner, johann philipp; bauer, sebastian; rosenow, felix; strzelczyk, adam title: sars-cov-2-related rapid reorganization of an epilepsy outpatient clinic from personal appointments to telemedicine services: a german single-center experience date: 2020-10-06 journal: epilepsy behav doi: 10.1016/j.yebeh.2020.107483 sha: doc_id: 323980 cord_uid: rcyjthze introduction: when the sars-cov-2 pandemic reached europe in 2020, a german governmental order forced clinics to immediately suspend elective care, causing a problem for patients with chronic illnesses such as epilepsy. here, we report the experience of one clinic that converted its outpatient care from personal appointments to telemedicine services. methods: documentations of telephone contacts and telemedicine consultations at the epilepsy center frankfurt rhine-main were recorded in detail between march and may 2020 and analyzed for acceptance, feasibility, and satisfaction of the conversion from personal to telemedicine appointments from both patients' and medical professionals' perspectives. results: telephone contacts for 272 patients (mean age: 38.7 years, range: 17–79 years, 55.5% female) were analyzed. patient-rated medical needs were either very urgent (6.6%, n = 18), urgent (23.5%, n = 64), less urgent (29.8%, n = 81), or nonurgent (39.3%, n = 107). outpatient service cancelations resulted in a lack of understanding (9.6%, n = 26) or anger and aggression (2.9%, n = 8) in a minority of patients, while 88.6% (n = 241) reacted with understanding, or relief (3.3%, n = 9). telemedicine consultations rather than a postponed face-to-face visit were requested by 109 patients (40.1%), and these requests were significantly associated with subjective threat by sars-cov-2 (p = 0.004), urgent or very urgent medical needs (p = 0.004), and female gender (p = 0.024). telemedicine satisfaction by patients and physicians was high. overall, 9.2% (n = 10) of patients reported general supply problems due to sars-cov-2, and 28.4% (n = 31) reported epilepsy-specific problems, most frequently related to prescriptions, or supply problems for antiseizure drugs (asds; 22.9%, n = 25). conclusion: understanding and acceptance of elective ambulatory visit cancelations and the conversion to telemedicine consultations was high during the coronavirus disease 2019 (covid-19) lockdown. patients who engaged in telemedicine consultations were highly satisfied, supporting the feasibility and potential of telemedicine during the covid-19 pandemic and beyond. sars-cov-2-related rapid reorganization of an epilepsy outpatient clinic from personal appointments to telemedicine services: a german single-center experience 1 during the rapid pandemic spread from its assumed origin in wuhan, china around the world, the new severe acute respiratory syndrome coronavirus 2 (sars-cov-2) and its clinical manifestation as coronavirus disease 2019 (covid19) reached germany in the first quarter of 2020 [1, 2] . at that time, the known number of infected patients worldwide was in the hundreds of thousands, a high percentage of which had severe courses of disease, with many patients hospitalized and deceased in china and italy [3] . on march 16, 2020 , the german ministry of health, and the health authorities of the 16 german states, released an order obliging all hospitals and clinics to shut down their elective ambulatory and inpatient care services immediately to prepare for the anticipated increased need for emergency care, isolation, and intensive care capacity [4] ; the time course of the pandemic in hessen is shown in fig. 1 . the german healthcare system is based on a broad supply of general practitioners as well as on specialist medical practitioners, e.g., neurologists in private practice [5, 6] . the third level of outpatient medical care is provided by specialized hospital outpatient clinics, e.g., specialized epilepsy centers, serving as a main supplier for severely ill patients. based on the extremely subdivided and specialized medical care system in germany, many patients who relied on additional care by specialized hospital outpatient clinics were greatly affected by the government's order. as a direct consequence of the statutory decree, ambulatory care options especially for patients with chronic illness decreased dramatically. epilepsy is one of the most frequent chronic neurological diseases, characterized by paroxysmal and mostly unpredictable seizures, affecting more than 700,000 patients of every age in germany with a prevalence between 0.6% and 0.8% [5, 7, 8] . in spite of excellent medical treatment, approximately one-third of these patients have refractory disease and are therefore often seen in outpatient departments at specialized epilepsy centers or hospitals on a regular basis [9, 10] . patients with high seizure frequencies, frequent generalized tonic-clonic seizures, those participating in ongoing pharmacological studies, those with therapeutic neuromodulation devices (e.g., vagal nerve stimulation (vns)), and those with potentially surgically treatable focal epilepsy continued to rely on specialized epilepsy care, which has been shown to be associated with a reduction in mortality within this cohort [11, 12] . at the onset of the covid-19 pandemic, the influence on patients with epilepsy was unknown, and a recent study points toward a higher cumulative incidence in patients with active epilepsy and increased fatality in patients with hypertension and epilepsy [13] . to maintain at least a minimal version of specialized medical care for these often severely affected patients, many specialized departments in germany, and all over the world, tried to rapidly convert face-toface contacts during personal clinic appointments to telemedicine consultations by telephone or video-telephone [14, 15] . evaluation of theses fundamental changes in outpatient medical care is indispensable in measuring the performance and flexibility of medical systems on the one hand as well as improving patient care in potentially upcoming pandemics or crisis, on the other. the aim of this study was to analyze the acceptance, feasibility, and satisfaction of the sars-cov-2-related conversion from face-to-face to telemedicine appointments from the perspectives of both patients and medical professionals. in addition, different sociodemographic, disease-specific, and sars-cov-2-associated aspects were assessed regarding acceptance of telemedicine services. the epilepsy center frankfurt rhine-main at the university hospital frankfurt (germany) is a tertiary care center for patients with epilepsy of all ages, performs presurgical evaluations for drug-refractory epilepsies, and includes a large epilepsy outpatient clinic with about 2500 patient-contacts per year [11] . the university hospital frankfurt provides inpatient care for over 50,000 patients, and ambulatory care for over 450,000 patients, annually. on march 16, 2020, a governmental decree [4] against the spread of sars-cov-2 resulted in the cessation of elective outpatient treatments with the consequence that all outpatient visits had to be canceled. telemedicine consultations in the sense of a telephone contact were offered to all patients with canceled personal appointments. the option of contacts via video telephony or internet-based video chats was not possible due to the lack of lead time and german data protection guidelines. patients who accepted a telemedicine consultation were contacted by telephone on the day of their original appointment at a prearranged time by an experienced doctor's receptionists. patients with life-threatening conditions, or those requiring immediate medical care or advice, were contacted rapidly or seen in the emergency department while meeting strict local hygienic requirements due to sars-cov-2, and were not included in this study. all telephone-contact appointments, as well as later telemedicine consultations, were documented by detailed protocol from march 17, 2020 [4] until may 29, 2020 during the lockdown of the outpatient department. all telemedicine consultations were performed by experienced residents or specialists from the epilepsy center frankfurt rhine-maine with a supervision from a senior physician being available at all times. documentation focused on acceptance, feasibility, and satisfaction of the rapid conversion from faceto-face to telemedicine appointments from both patients' and medical professionals' perspectives, and on sars-cov-2-related aspects. data regarding sociodemographic and epilepsy characteristics were retrieved from patient files for a retrospective exploratory analysis that was approved by the local ethics committee of the goethe-university frankfurt (ref. . strengthening the reporting of observational studies in epidemiology (strobe) guidelines and reporting of studies conducted using observational routinelycollected data (record) guidelines were closely followed to improve the study design and reporting [16, 17] . seizure and epilepsy [18] [19] [20] and the integrated epilepsy classification published in 2020 [21] . patients' acceptance, urgency of the appointment, satisfaction, reaction, and subjective thread for sars-cov-2 were accessed using an anchored scale with 4-5 items. physicians' satisfaction and assessment of urgency was directly accessed after the phone call. data collection was performed using microsoft excel version 16 (microsoft corp., albuquerque, us) using a double-entry procedure to minimize entry errors. data analysis was performed using ibm spss statistics version 24 (ibm corp., armonk, us). for descriptive categorical variables, percentages and frequencies were used; for descriptive cardinal variables, means and standard deviations (sds) or medians and ranges were used, as appropriate. all numbers, except p-values, were rounded to the first decimal place. statistical comparisons were conducted using pearson's chi-squared test. in cases with fewer than 60 subjects, pearson's chi-squared test with a yates correction was performed. p-values < 0.05 were considered significant. corrections for multiple testing was performed using the wellestablished benjamini-hochberg procedure based on falsediscovery rates [22] . a total of 272 patients were enrolled in this study, i.e., all patients that had an already scheduled outpatient visit between march 17, 2020 and may 29, 2020 that did not require immediate care (2 patients were excluded and immediately seen at the er). the mean age was 38.7 years (sd ± 14.5 years, median: 36.0 years, range: 17-79 years), gender distribution was 55.5% female (n = 151) and 44.5% male (n = 121) among participants ( table 1 ). the geographical distribution of patients and distribution of confirmed covid-19 cases is shown in fig. 2 . most patients had focal epilepsy (63.4%, n = 174), followed by patients with unknown (19.1%, n = 52), generalized (16.2%, n = 44), or combined epilepsy (0.7%, n = 2). regarding seizure types, most patients reported only focal seizures with or without impaired awareness (22.1%, n = 60), followed by focal to bilateral convulsive seizures (58.8%, n = 160), only generalized convulsive seizures (16.5%, n = 45), and unknown or other seizure types (19.1%, n = 52). overall, 76.1% of the enrolled subjects had active epilepsy with ongoing seizures during the previous 12 months, while 19.5% of the patients had epilepsy in remission, with complete seizure freedom for more than 12 months. in 4.4% (n = 12) of the study population, there were insufficient data available for recent seizure frequency. overall, 272 initial phone calls were performed to cancel personal appointments and to schedule telemedicine services. most patients (88.6%, n = 241) reacted with understanding and 3.3% (n = 9) with relief to cancelations of their outpatient appointments. only a minority (9.6%, n = 26) showed lack of understanding, and 2.9% (n = 8) reacted with anger or aggression (fig. 3a) . asked for the urgency of their disease-specific concerns, patients estimated appointment priorities as very urgent (6.6%, n = 18), urgent (23.5%, n = 64), less urgent (29.9%, n = 81), and not urgent (39.3%, n = 107). a total number of 109 patients (40.1%) requested telemedicine consultations, while 61.4% (n = 167) of subjects preferred to postpone visits, even if exact future rescheduling was unknown. one patient (0.4%) insisted on an urgent appointment because of an increased seizure frequency and seizure clusters, but failed to appear on the arranged day. the patient was seen later at the emergency department, electroencephalography (eeg) was performed and antiseizure drugs (asds) changed. he was discharged at the same day a total of 109 telemedicine appointments were analyzed ( table 2 ). the geographical origins of patients are provided in the supplementary table 1 . the most frequent reasons for seeking medical advice were general disease-specific questions and aspects (57.8%, n = 63) followed by concerns about side effects of asds (31.2%, n = 34), ongoing or planned changes in asd regimens (29.4%, n = 32), increased seizure frequency (14.7%, n = 16), discussions of diagnostic findings and recommendations (14.7%, n = 16), asd management during a planned, new or known pregnancy (each 9.2%, n = 10 each), and questions about epilepsy-specific driving restrictions (6.4%, n = 7). according to physicians' notes, the following issues were addressed in detail during telemedicine consultations: changes or maintenance of asd regimens (82.6%, n = 90), general disease-specific questions and aspects (72.5%, n = 79), sars-cov-2-associated questions (40.4%, n = 44), seizure frequency (35.8%, n = 39), side effects of asds (34.9%, n = 38), asd prescriptions (33.0%, n = 36), social aspects and supportive services or further diagnostic/therapeutic steps (each 30.3%, n = 33 each), the need for a written change in medication regime (25.7%, n = 28), work or employment issues (11.0%, n = 12), epilepsy-specific driving restrictions (9.2%, n = 10), and finally, the need for medical certificates (4.6%, n = 5). information on disease-specific and general sars-cov-2-related supply problems for patients with epilepsy are provided in supplementary table 2 . most participating patients rated telemedicine appointments as either completely satisfying (38.5%, n = 42) or satisfying (56.9%, n = 62), with three patients less satisfied (2.8%), and one unsatisfied patient (0.9%) (fig. 3b) . the conversion from face-to-face appointments to telemedicine appointments was rated as not being a disadvantage for current treatment in 87.2% (n = 95) of subjects, but in 12.8% (n = 14), it was rated as a disadvantage (fig. 3c) . other disadvantages were the postponements of diagnostics or therapies (5.5%, n = 5), limited possibilities for interpretation of asd side effects or other symptoms (5.5%, n = 5), language barrier without gesturecompensated communication (0.9%, n = 1), and increased uncertainty due to lack of face-to-face contact (0.9%, n = 1). from the perspective of counseling physicians, 46.8% (n = 51) of appointments were completely satisfying, 45.0% (n = 49) were satisfying, and 5.5% (n = 6) were less satisfying. no telemedicine appointment was rated as unsatisfying (fig. 3b) . discrepancies between patients' and physicians' rating of urgency for the appointment were visualized using a sankey diagram (fig. 3d) . there was no significant difference in urgency ratings between patients' and physicians' view (χ 2 = 0.0539, p = 0.8165). in cases of discrepancies, physicians mostly rated the urgency for the appointment lower than the patients themselves. univariate analyses of factors associated with the request of telemedicine consultation rather than a postponed face-to-face visit showed significant associations to (table 3) : subjectively high-hazard estimations of potential sars-cov-2 threats (χ 2 = 14.103, p = 0.004); subjectively urgent or very urgent medical needs (χ 2 = 96.783, p = 0.004); and female gender (χ 2 = 7.067, p = 0.024). there were no significant associations regarding age, drug-refractory course, epilepsy type, seizure semiology, and living environment (urban vs. rural) (all p > 0.05). the sars-cov-2, and its clinical manifestation as covid-19, currently are in the limelight of scientific and popular media around the world. the sars-cov-2 and the consequent restrictions on private and business life have determined everyday life in ways never before ⁎ p-values after two-tailed pearson's chi-squared and post hoc correction on difference between the expected frequencies and the observed frequencies of the mentioned aspect within the cohort, corrected for multiple testing after benjamini-hochberg (bold figures represent significant findings). imaginable, in addition to controversial discussions of direct and indirect effects of covid-19 on the central nervous system, especially on seizures and epilepsy [23] [24] [25] . physicians are encouraged to share case information, continue investigations, and provide known facts about covid-19 to patients with epilepsy and their families [26] . the sars-cov-2 has led to additional supply problems for patients with chronic diseases, such as epilepsy. in germany, a governmental order forced all clinics to immediately suspend elective care on march 16, 2020 to allow hospitals to focus on preparing and expanding their emergency and intensive care capacities [4] . as shown in the sars outbreak in 2003, pandemic effects on a healthcare system can have devastating effects on patients with epilepsy, mainly due to decreased ambulatory medical supply leading to asd withdrawals and increased seizure frequencies [27] . in comparison, a recent consensus paper on covid-19 recommended the reduction of hospital visits for patients with epilepsy to an absolute minimum to decrease the probability of sars-cov-2 transmission at possibly "contaminated" medical sites. physicians were further urged to provide their patients with emergency-care plans, adequate asd supplies, and detailed individualized information on lifestyle issues and diseasespecific information [26, 28] . to allow for individualized and ongoing ambulatory care despite the sars-cov-2 pandemic, telehealth and other telemedical services were seen as having the potential to close these ambulatory supply gaps [28] , but their limitations in this context have also been highlighted and discussed [29, 30] . to the best of our knowledge, here, we present the first data on the feasibility, acceptance, and satisfaction of a sars-cov-2-related conversion from face-to-face ambulatory care visits to telemedicine services for specialized epilepsy care. in this cohort, a large proportion (40.1%) of patients opted for telemedicine consultations rather than a postponed face-to-face visit after their planned onsite appointments had been canceled. the request of a telemedicine visit was significantly associated with medical-need urgency and a high sars-cov-2 subjective threat level, in keeping with other reports highlighting personal needs and other intrinsic motivational aspects (such as fear) as important factors for telemedicine acceptance [31, 32] . patients with a nonurgent appointment priority mainly opted for shifting their appointment to a later date. especially during pandemics, decisions to avoid medical sites are understandable, as reflected by the 3.3% of subjects who reported relief that their initial appointments were canceled. moreover, the request of telemedicine consultations was significantly associated with being female, matching previous study results on the use of telemedicine and mobile health [33] [34] [35] . exactly why male patients are more hesitant to accept telemedicine and mobile health has not yet been determined, but a general reluctance by male patients to use medical services and medicine [36] could be fundamental, and requires further research to better understand this patient group. as previously reported, patient satisfaction with telemedicine consultations was high (only 3.8% of subjects being less or unsatisfied) [37] . most of the reported disadvantages were related to limited interpretations of adverse events or other symptoms, and postponements of diagnostic or therapeutic measures (such as eeg recordings or vns adjustments) for technical reasons, and increased uncertainty due to missing face-to-face contact. similar to patient findings, physician satisfaction among the mostly ehealth-naïve physicians in our department was also high, reporting less satisfying results in only 5.5% of cases, and mirroring the high rate of general acceptance of telemedicine in healthcare professionals [38] . a disadvantage remains, however, that the services are not appropriately remunerated and reimbursed by the statutory health insurance [39] , so that such a telemedicine service can only be offered for a limited time without endangering the funding of the department. another important aspect of this study was to record and analyze sars-cov-2 associated supply problems in patients with epilepsy based on experiences with the sars pandemic in 2003 [27] . remarkably, the sars-cov-2 pandemic led to supply problems for 22.9% of the cohort who reported asd undersupply, and 5.5% of the cohort who reported a shortage of primary outpatient medical care. these results are in line with another study that discussed medical support problems for patients with parkinson's disease and other movement disorders [40] . for the usa, a similar public healthcare problem has been reported, especially for underserved and homeless people, during the covid-19 pandemic [41] . moreover, 9.2% of subjects reported general supply problems with food and sanitary products, which seems high for a industrialized country like germany that usually has an unrestricted food and consumables supply. a study from china analyzing online research behavior during the covid-19 pandemic suggested that food supply problems were also present in that country, based on 29.4% of all online queries being in the "food and drinks" category [42] . patients with epilepsy may be a highly vulnerable group for such supply problems, given the driving restrictions applied to patients with ongoing seizures [43] . based on its single-center design, this study suffers from several methodical limitations that may influence its generalizability, especially the individual characteristics of clinics within the extremely specialized german ambulatory healthcare system, and the broad availability of unrestricted healthcare services in this country. moreover, because of the short lead time of the study, no specific outcome measures or comprehensive detection for confounders for the acceptance and feasibility could be implemented [44] . in addition, the lack of alternatives to the offered telemedicine pandemic services during the covid-19 could have an influence on the reported acceptance and satisfaction. however, the similarity of some of our findings with other studies conducted before or during the sars-cov-2 pandemic allow for basic international comparisons and extrapolations of the results. to minimize potential biases due to the study design, strobe and record guidelines were closely followed [16, 17] . general understanding and acceptance of cancelations of elective face-to-face ambulatory visits and of the option to have telemedicine consultations during the sars-cov-2 pandemic in germany was high, especially in patients with very urgent or urgent appointment priority. patients with a nonurgent appointment priority mainly opted for shifting their appointment to a later date. patients who engaged in telemedicine consultations were highly satisfied, supporting the feasibility and potential for telemedicine during the covid-19 pandemic, and beyond. male sex appears to be a risk factor for underutilization of telemedicine services. this barrier should be addressed when future telemedicine services for patients with epilepsy are planned. moreover, patients with epilepsy seem to suffer from medical and general supply problems, which should be addressed in further studies to improve ambulatory care and medical supply chains for future pandemics or other crises. we confirm that we have read the journal's position on issues involved in ethical publication and affirm that this report is consistent with those guidelines. none of the authors reports conflicts of interest related to this manuscript. transmission of 2019-ncov infection from an asymptomatic contact in germany number of daily recorded coronavirus (covid-19) cases in germany since similarity in case fatality rates (cfr) of covid-19/sars-cov-2 in italy and china in: hessen, editor. fifth regulation on the control of corona virus (fünfte verordnung zur bekämpfung des corona-virus) guideline conform initial monotherapy increases in patients with focal epilepsy: a population-based study on german health insurance data neurologist adherence to clinical practice guidelines and costs in patients with newly diagnosed and chronic epilepsy in germany kapitel 4 -gesundheit: statistisches bundesamt (destatis) prevalence, utilization, and costs of antiepileptic drugs for epilepsy in germany-a nationwide population-based study in children and adults definition of drug resistant epilepsy: consensus proposal by the ad hoc task force of the ilae commission on therapeutic strategies definition of refractory epilepsy: defining the indefinable? lancet neurol revised version of quality guidelines for presurgical epilepsy evaluation and surgical epilepsy therapy issued by the austrian, german, and swiss working group on presurgical epilepsy diagnosis and operative epilepsy treatment association of levels of specialized care with risk of premature mortality in patients with epilepsy incidence and case fatality rate of covid-19 in patients with active epilepsy global telemedicine implementation and integration within health systems to fight the covid-19 pandemic: a call to action virtually perfect? telemedicine for covid-19 strengthening the reporting of observational studies in epidemiology (strobe) statement: guidelines for reporting observational studies the reporting of studies conducted using observational routinely-collected health data (record) statement operational classification of seizure types by the international league against epilepsy: position paper of the ilae commission for classification and terminology instruction manual for the ilae 2017 operational classification of seizure types ilae classification of the epilepsies: position paper of the ilae commission for classification and terminology could the 2017 ilae and the four-dimensional epilepsy classifications be merged to a new "integrated epilepsy classification controlling the false discovery rate: a practical and powerful approach to multiple testing central nervous system manifestations of covid-19: a systematic review new onset acute symptomatic seizure and risk factors in coronavirus disease 2019: a retrospective multicenter study focal status epilepticus as unique clinical feature of covid-19: a case report epilepsy and covid-19: associations and important considerations. epilepsy behav the impact of sars on epilepsy: the experience of drug withdrawal in epileptic patients keeping people with epilepsy safe during the covid-19 pandemic telemedicine and the challenge of epilepsy management at the time of covid-19 pandemic interpreting covid-19 and virtual care trends: cohort study theories predicting end-user acceptance of telemedicine use: systematic review investigating acceptance of telemedicine services through an extended technology acceptance model (tam) factors determining patients' choice between mobile health and telemedicine: predictive analytics assessment factors influencing the acceptance of telemedicine for diabetes management gender similarities and differences for e-health behaviors among u.s. adults patient medication adherence: measures in daily practice telemedicine: a primer telemedicine vs office visits in a movement disorders clinic: comparative satisfaction of physicians and patients tele-eeg: current applications, challenges, and technical solutions impact of the covid-19 pandemic on parkinson's disease and movement disorders covid-19: a potential public health problem for homeless populations corona virus (covid-19) "infodemic" and emerging issues through a data lens: the case of china noncompliance of patients with driving restrictions due to uncontrolled epilepsy psychometric assessment of three newly developed implementation outcome measures. implement sci this study analysis was supported by the state of hessen with a loewe-grant to the cepter consortium (https://www.uni-frankfurt. de/67689811).the establishment of telemedicine services for patients with epilepsy in hessen was supported under the program "e-health-initiative hessen" by the hessian ministry for social affairs and integration (https://soziales.hessen.de/) and hessian ministry of higher education, research and the arts (https://wissenschaft.hessen.de/) with a grant to the goethe-university and university hospital frankfurt (project title: establishment and health economic evaluation of telemedical epilepsy care in hessen; project duration: 2017-2021).we are grateful to our patients, colleagues, and hospital staff for assistance in conducting this analysis during the covid-19 pandemic. supplementary data to this article can be found online at https://doi. org/10.1016/j.yebeh.2020.107483. key: cord-343205-zjw4fbfd authors: bhaskar, sonu; bradley, sian; chattu, vijay kumar; adisesh, anil; nurtazina, alma; kyrykbayeva, saltanat; sakhamuri, sateesh; moguilner, sebastian; pandya, shawna; schroeder, starr; banach, maciej; ray, daniel title: telemedicine as the new outpatient clinic gone digital: position paper from the pandemic health system resilience program (reprogram) international consortium (part 2) date: 2020-09-07 journal: front public health doi: 10.3389/fpubh.2020.00410 sha: doc_id: 343205 cord_uid: zjw4fbfd technology has acted as a great enabler of patient continuity through remote consultation, ongoing monitoring, and patient education using telephone and videoconferencing in the coronavirus disease 2019 (covid-19) era. the devastating impact of covid-19 is bound to prevail beyond its current reign. the vulnerable sections of our community, including the elderly, those from lower socioeconomic backgrounds, those with multiple comorbidities, and immunocompromised patients, endure a relatively higher burden of a pandemic such as covid-19. the rapid adoption of different technologies across countries, driven by the need to provide continued medical care in the era of social distancing, has catalyzed the penetration of telemedicine. limiting the exposure of patients, healthcare workers, and systems is critical in controlling the viral spread. telemedicine offers an opportunity to improve health systems delivery, access, and efficiency. this article critically examines the current telemedicine landscape and challenges in its adoption, toward remote/tele-delivery of care, across various medical specialties. the current consortium provides a roadmap and/or framework, along with recommendations, for telemedicine uptake and implementation in clinical practice during and beyond covid-19. coronavirus disease 2019 has challenged the status quo of how we approach, deliver, and receive modern medicine (1) (2) (3) (4) . according to the american telemedicine association, telemedicine is defined as "the remote delivery of healthcare services and clinical information using telecommunications technology" (5) . it allows for patient care while minimizing the need for physical interaction, thus reducing infection transmission and healthcare facility burden. it can be utilized for ongoing management of chronic conditions, medication compliance, physician-topatient consultation, and other remote services (3, 4) . this can be leveraged to benefit broader populations through telehealth platforms and assisted technologies such as the internet of things (iot). telemedicine and digital technologies demonstrate exceptional potential in improving access and delivery in remote settings. there is also an opportunity to exploit the power of artificial intelligence (ai) algorithms to design a better pandemic preparedness and response plan (6) . health systems have had to adapt to address emerging needs quickly, and many medical subspecialties have transitioned from in-person outpatient care to remote tele-or e-health. broadly, telehealth technologies can be deployed for targeted purposes relevant to a pandemic (7) . remote assessment of patients could be undertaken, circumventing visits to outpatient clinics or primary care providers. patient continuity for those with chronic diseases is essential during a pandemic (3, 4) . such patients are also at high risk of infection and poor outcomes, including mortality, among covid-19-positive patients (3) . notably, telemedicine also limits infection exposure to healthcare staff, can provide rapid access to subspecialists who are not immediately available in person, and allows for multidisciplinary team discussions. this is crucial in pandemic settings, as the safety of healthcare professionals is essential to ensure the sustainability of health systems to cater to emergent cases and maintain ongoing care. patients with flu-like symptoms can be triaged, and telemonitoring using video surveillance could be considered for patients who are homebound such as the elderly or frail. telemedicine can increase access for certain populations who are challenged during limited healthcare facility visitation, stay-home orders, and quarantine, such as single parents, immunocompromised patients, and patients who rely on the assistance of others for transportation. monitoring of patients along with remote delivery of home-based exercise, physiotherapy, psychological counseling, social work consultations, and speech and language interventions could be undertaken through telemedicine. our previous work analyzed the status and deployment of telemedicine during covid-19 across the geographical divide (bhaskar et al., under review) . in this article, we analyze the uptake of telemedicine across various medical subspecialties and organizational settings with a focus on the current covid-19 pandemic and propose an operational roadmap for further integration of telemedicine or tele-technologies across health organizations. as hospital systems become strained by the surge of covid-19 patients, methods to improve the efficiency of emergency departments (eds) are required, while maintaining standards of patient care. telemedicine supplies a potential avenue for triage of critical cases. remote and ambulatory monitoring of patients can allow for remote triage and assessment of emergencies such as acute myocardial infarction (mi), allowing patients to bypass the ed (8) . automated forward triage systems that use algorithms to categorize patients into risk groups could also be utilized, as ed physicians experience considerable time pressure. current examples include the multi sources healthcare architecture (mhsa) algorithm and the electronic modified early warning scorecard (9) . telemedicine has also been used to triage, expedite, and streamline the local covid-19 screening process, thereby reducing the strain on healthcare facilities and practitioner exposure. the new york presbyterian hospital, a world leader in digital health innovation, has demonstrated an effective method to reduce the burden of milder presentations (10) . they established an ed-based telehealth express care service, in which after presentation and triage at the ed, patients with milder cases are taken into a private room for a teleconsultation with a physician. prescriptions and patient instructions are then printed to the room, and the patient is discharged. this dramatically reduces ed waiting times and allows the hospital to deal with everincreasing ed presentation numbers (10) . as patients become anxious about ed infection risk, systems such as these are required, and patients need to be able to effortlessly contact eds to query whether their symptoms require a presentation. cardiology is one of the first specialties in which comprehensive telemedicine systems have been implemented. monitoring of heart rhythm in patients with implanted or real-time wearable devices has allowed ecg with holter monitoring, echocardiography records, and virtual auscultation. an emerging body of evidence suggesting cardiac involvement in covid-19 patients has concerned cardiologists (3, 11) . this includes cardiovascular complications such as cardiac injury, heart failure, myocarditis, pericarditis, vasculitis, and arrhythmias (12) (13) (14) . patients with pre-existing cardiovascular conditions who contract covid-19 also experience inordinately poor outcomes, including a 5-to 10-fold rise in mortality (15) . due to the covid-19 pandemic, the american college of cardiology urgently updated its guidance on "telehealth: rapid implementation for your cardiology clinic, " in which it encouraged remote monitoring and virtual visits of patients with cardiac problems (16) . the development of prognostic models based on the recently launched new european register capacity-covid will help to understand the role of underlying cardiovascular disease (cvd) in patients with covid-19 (17) . virtual options can significantly increase efficiency compared to in-person doctor appointments (18) . notably, non-invasive telemonitoring in patients with heart failure reduces allcause mortality and number of hospitalizations, as well as improves the quality of life (19) . in february 2020, the italian society of cardiology published data on the implementation of telemedicine in cvd patients and reported crucial involvement of telemedicine in the prehospital triage for st-elevated myocardial infarction (stemi) cases and remote monitoring by primary care physicians (20) . an american heart association (aha) statement emphasized the role of telemedicine in pediatric cardiology through advanced video technologies like tele-echocardiography, fetal echocardiography in prenatal diagnosis, screening for congenital heart diseases, and confirmatory echo tests, external rhythm monitoring, catheterization laboratory, and personal tele-electrophysiology (21) . due to their comorbidity risk, efforts to prevent covid-19 infection in cvd patients should be undertaken seriously by reducing hospital admission and outpatient visits (3) . treatment adherence is one of the significant issues in the long-term management of cvds (22) . the utilization of mobile phones through mobile health (mhealth) can be one of the reliable potential solutions in this area through measures such as electronic pillboxes and text reminders (22) . the unique advantage of portable devices and smartphones is the ability to reach most patients and caregivers. the widespread use of mobile technologies makes medical support more effective, faster, safer, and less expensive in both outpatient and inpatient settings (23) . mhealth can play an increasingly important role in cardiac care, extensively applied in triage, interventions, management, patient education, and rehabilitation. telehealth solutions are critical now, as we aim to minimize patients at high and very high cardiovascular risk being hospitalized and provide ongoing support to cvd patients during the covid-19 pandemic. in poland, some other systems have been tested in heart failure patients (24, 25) , including e-oximeter, allowing for monitoring of heart rhythm and blood saturation, which might help to decide whether those quarantined should be hospitalized during covid-19. telemedicine allows for prompt assessment of potential emergent neurological cases and can aid those with hospital access issues and those requiring fast acute assessment (2, 4) . acute stroke outcomes are vastly impacted by the speed at which treatment is given, whether it be through tissue plasminogen activator (tpa), endovascular clot retrieval (evt), or antihypertensives. during times of physician shortages, as doctors become re-purposed for covid-19 purposes, rapid approaches to acute stroke management are needed (2) . reperfusion treatment viability through computed tomography (ct) can be assessed remotely, allowing reperfusion treatment using tpa and/or evt to be efficiently undertaken. furthermore, telemedicine can be utilized to determine which patients require an urgent transfer from non-evt-capable hospitals to evtcapable hospitals (26) . a program developed in germany known as transit-stroke, in which rural hospitals established a telemedicine network, saw an improvement in patient outcomes as neurological assessment was made faster, treatments were issued within the required timeframe, and 24 h neurologist access was enabled (27) . similarly, successful programs have been undertaken worldwide, such as telestroke programs in hawaii and south california (28) . there is also evidence to suggest that patients who receive acute stroke assessment through telemedicine do not perceive decreased physician empathy compared to those who receive physical consultation (29) . this somewhat relieves concerns about impaired patientphysician connection through telemedicine. while telemedicine decreases the time it takes to analyze head cts, more work is needed to ensure that this benefit applies equally across different telestroke programs (30). mobile stroke units (msus) go beyond this to provide ct scanners and stroke personnel within an ambulance vehicle. such programs exist in locations such as melbourne (australia), various states in the us, and hamburg and berlin (germany), among others (31). msus improve acute ischemic stroke outcomes by reducing the time to reperfusion; however, further development is needed in the treatment of hemorrhagic stroke. telemedicine could also allow ct assessment of mild traumatic brain injuries (such as concussions). this can help to determine if the patient requires transfer to a major hospital or can be treated locally and will also allow for post-concussion checkups (32) . vulnerable patients who require respiratory management and/or critical care are at increased covid-19 risk due to their impaired state and require effective management with the aid of technology (33) . in 2019, the society of critical care medicine (sccm) tele-icu committee in the united states published an update on developments in telehealth critical care (tcc) (34) . they described three emerging trends in tcc: hub-andspoke structure in which a central hub provides remote technical support, administrative support, and integration to a network of hospitals; decentralized structures in which consultations and patient reviews will be made on a case-by-case and request basis between two sites; and a hybrid structure in which a centralized structure exists but direct contact between spokes can be made for, e.g., specialist consultations. barriers to tcc included cost and reimbursement issues, lack of responsibility for individual hospitals, and legislative issues (34) . a 2012 systematic review and meta-analysis of telemedicine in the us intensive care unit (icu) setting demonstrated decreased mortality and length of hospital stay with telemedicine incorporation (35) . however, a statistical difference between an active model or high-intensity passive model, in which continuous patient telemonitoring is conducted, and a lowintensity passive model, in which only teleconsultation with an intensivist is conducted, was not ascertained and is an area for further research (35) . patients with respiratory issues are at higher risk of covid-19 severe infections due to issues such as ventilator reliance and decreased cough function (33) . this includes patients with chronic respiratory conditions such as chronic obstructive pulmonary disease (copd), bronchial asthma, interstitial lung diseases, as well as chronic neurological conditions such as neuromuscular diseases (33, 36) . telemedicine aids respiratory patients through data collection, such as monitoring of vitals and ventilator status, and by transmitting these data for constant monitoring. in the case of under-resourced or under-developed critical care units in low and middle-income countries (lmics) (bhaskar et al., under review) , frequent international tele-education can serve to upskill doctors and spread critical care knowledge, such as ventilator management (37) . patients with non-acute diseases require ongoing support and cannot be neglected during covid-19 times (1, 3, 4, 33) . studies have shown that telemedicine can lead to similar outcomes as face-to-face delivery of care in the management of patients with heart failure, hypertension, and diabetes (38, 39) . ongoing monitoring of these patients is required to prevent acute manifestations, hospitalization, or disease progression (3, 4) . the differences within medical subspecialties and individual patients need to be considered, rather than broadly implementing uniform telemedicine approaches across all departments. for example, infectious disease cases can be complicated and require careful consideration of patient history and investigation findings. in these cases, asynchronous consultations, in which the physician reviews data before supplying patient recommendations, will be helpful (40) . in other fields such as neurology, cardiology, and endocrinology, realtime, interactive consultations might be more applicable (3, 4) . patients with neuromuscular issues are particularly at risk due to covid-19 (4). patients with motor neuron disease (mnd)/amyotrophic lateral sclerosis (als) are among those who experience considerable disability and will require multidisciplinary telehealth (4). types of telehealth include teleadvice, teleconsultation, tele-prescription, videoconferencing, home-based self-monitoring, and remote non-invasiveventilation (niv) monitoring. videoconferencing involves consultation with a health professional, home-based selfmonitoring involves taking one's own measurements and submitting them to a physician, and remote niv monitoring involves remote monitoring of the patient's niv data (41) . the use of telehealth with als patients has been shown to be associated with positive benefits such as reasonable adoption rates, personalized data, and efficient consultations (42) . other movement disorders such as parkinson's disease (pd) also require ongoing multidisciplinary care (43) . established programs such as the ontario telemedicine network, the parkinsonnet infrastructure in the netherlands, and that of kaiser permanente in the us all display the ability to integrate telehealth into pd patient care (44) . areas for growth include the reimbursement of nursing homes that utilize telemedicine, acceptance by patients and physicians, and reimbursement of at-home telemedicine programs (44) . furthermore, global partnerships can increase international telehealth integration. for example, the international parkinson and movement disorders society africa section, established in the usa, launched a 5-year program to deliver specialist care to disadvantaged areas in africa using whatsapp tm . diagnosis of pd could also be aided by telehealth, with the unified parkinson's disease rating scale (updrs) and montreal cognitive assessment (moca) for pd both being able to be performed remotely (45) . such tele-tools have also been recently proposed in the times of covid-19 for familial hypercholesterolemia patients, who require continuous monitoring of their health due to lifelong high levels of cholesterol and increased cvd risk (46) . in migraine and headache patients, telemedicine could be used to assess new headache profiles for possible covid-19 symptomology or standard outpatient consultations (4, 47) . cancer patients are another group at risk of covid-19 infection due to their immunosuppressed states, which could have fatal outcomes subsequent to infection (48) (49) (50) (51) (52) . oncologists would use telemedicine for ongoing monitoring and compliance with cancer patients (49, 51). this could be useful in monitoring adverse reactions to ongoing chemo-or radiotherapy, as well as to identify patients who might be at high risk of emergent medical attention, such as those at risk of venous thromboembolism. cancer patients could also be offered multidisciplinary care, including psychological interventions, physiotherapy, and specialized interventions such as mindfulness training, to improve the overall quality of life (49). overall, telemedicine offers opportunities for cancer patients to access specialist care in the comfort of their homes. approaches to the use of telemedicine and mobile technologies in increasing access to novel drugs or interventions through clinical trials should be expeditiously pursued. telemedicine could also be used in palliative care and end-of-life planning involving patients' carers, family, and multidisciplinary care team (53) . teledermatology is another promising perspective in the diagnosis and monitoring of skin lesions, including cancer (54) . non-acute ophthalmological telemedicine has been implemented for retinal scans relating to diabetic retinopathy, retinopathy of prematurity, and other non-acute retinal monitoring (55) . fundus scanning and optical coherence tomography imaging are being sent to remote trained healthcare practitioners (hcps) for evaluation and additionally are being evaluated by ai analysis using deep learning. these non-acute services are also being utilized locally by emergency and urgent care services to a certain extent (55) . chronic patients must adhere to medications during this time and should not stop treatment regimens without consulting their physician (3, 4) . patients taking immunosuppressants, steroids, or pain medications may be concerned about their covid-19 risk, and contact with their physicians needs to be ensured. adherence to medications can be monitored through mhealth and telehealth means (56) . such examples include digital adherence technologies (dats) or electronic directly observed therapy (edot) for patients with tuberculosis (56) . measures include ingestible sensors, video observation, digital pillboxes, and smartphone applications and have been trialed in china, india, belarus, and the us (56, 57). the european respiratory society (ers) task force has described the implementation of remote home mechanical ventilation and physical therapy for patients with chronic respiratory disorders (58) . the emphasis is on promoting common standards of clinical criteria as well as analyzing the cost/benefit ratio and evaluating reimbursing rules to implement in different countries (58) . tele diagnosis uses patient data to aid remote diagnosis and can be utilized to identify those with bulbar and respiratory weakness. telemedicine strategies such as electronic inhalers, chipped nebulizers, self-monitoring through apps, and text reminders increase medicine compliance in patients with asthma, copd, and cystic fibrosis (cf) (59) . furthermore, the diagnosis of copd through telemedicine means such as spirometry tracing and teleconsultation provides an opportunity to utilize technology to increase patient care. further studies are needed to stratify which patients, in terms of severity, will be best suited to a telemedicine management approach. another area of potential growth is in using ai algorithms to determine developing copd exacerbations (60) . telemedicine for asthmatics tends to be more focused on treatment compliance and self-monitoring and can be useful in helping patients learn more about their disease, such as recognizing patterns of asthma triggers (61) . other barriers to care include the risk that patient data may be manipulated, networks potentially becoming compromised, and inconclusive data on the benefit of telehealth on specific diseases such as copd (62) . obstructive sleep apnea (osa) is one such disease in which remote monitoring can be utilized to prevent patients from having to spend time in a sleep clinic or respiratory clinic (63) . home polysomnography devices can be used to track patients' breathing and oxygen levels; however, further work is needed to lower the rate of false negatives to the level of in-person sleep clinics (63) . a 2018 prospective study of 780 patients used a portable spirometer, with bluetooth capabilities and connected to a mobile phone application, to trace results and connect the patient to a physician for analysis (64) . this allowed the patient's breathing difficulties to be assessed and categorized as asthma, copd, or normal breathing function (64) . this study shows promising results for remote diagnosis of chronic breathing conditions; however, it does not preclude the need for future testing in some more complicated cases. other smartphone applications have utilized microphones and questionnaires to analyze and detect breathing difficulties associated with other pulmonary conditions such as coughs and lung cancer (65) . covid-19 could impose severe stress on sleep clinics and may limit in-laboratory polysomnography sleep studies for osa assessments and diagnosis. home-based telepolysomnography for osa assessment could be explored so that the delayed diagnosis and the associated impact on patients could be minimized. patients with osa often require continuous positive airway pressure (cpap) while sleeping to improve symptoms and achieve proper rest (66) . in order to see sustained results, patients need to use cpap for at least 4 h at night, combined with lifestyle changes such as weight reduction and smoking cessation (66) . low adherence to cpap remains a continuous problem for osa patients due to lack of motivation, discomfort, loud noise, and claustrophobia (67) . telehealth provides an opportunity to increase cpap adherence by monitoring device output data and patient self-tracking of lifestyle factors. when usage falls, the patient can be contacted to discuss their reasons for low adherence and to motivate them to continue use (68) . telemedicine could be used to monitor bulbar function in patients with a compromised bulbar function such as als (4, 69) . the rapid decline in bulbar function could be captured using technologies that are useful in delivering specialist multidisciplinary care (69) . other diseases in which bulbar function may be impaired include myasthenia gravis, spinalbulbar muscular dystrophy, and riboflavin transporter deficiency (4, (70) (71) (72) . telemedicine can aid with rehabilitation following acute incidents such as stroke and traumatic brain injury (tbi) (2, 4), as well as chronic conditions that require ongoing rehabilitation efforts such as copd, cvd, diabetes, and obesity (3). stroke telerehabilitation programs involving consultations, exercises, games, and therapy aspects have shown positive outcomes such as improving patients' functional abilities and mental health (4) . other benefits include increasing patient motivation and ease due to being in a home setting (73) . it is important that patients receive enough support in areas such as technical setup and troubleshooting. the telerehabilitation in heart failure patients (telereh-hf) trial in poland demonstrated that a 9-week hybrid comprehensive telerehabilitation (hctr) program consisting of remote monitoring of training at patients' homes was well-tolerated (24, 25) . however, the positive effects of the intervention didn't translate into improvement in clinical outcomes over a follow-up period of 12-24 months in comparison to standard care (24) . a 2018 systematic review similarly found that telerehabilitation allowed for equal or more significant patient outcomes than center-based rehabilitation programs in stroke (74) . furthermore, wearable devices can be used in the rehabilitation of various neurological diseases such as stroke, pd, multiple sclerosis, and tbi. inactivity is associated with various comorbidities and is often a result of chronic neurological disease or acute accident recovery. remote monitoring through wearable devices can track activity, gait, and any falls throughout rehabilitation (75) . tbi can result in cognitive issues such as sleep disturbance, photophobia, memory, and behavioral changes (76) . it is crucial that patients are not discharged without a follow-up plan. a neuropsychological test battery in the few years following moderate-to-severe brain injury and inpatient rehabilitation is vital to assess any cognitive decline and plateau. during covid-19 times, it is necessary to move outpatient testing of this sort to remote delivery, wherever feasible and while maintaining efficacy. the brief test of adult cognition (btact) has been shown to be effective over the telephone in patients with tbi to assess cognitive state (77) . remote monitoring of physical activity by physiotherapists and patient consultation with neurologists can also be achieved through telemedicine. however, clear guidelines for rehabilitation management and evidence of efficacy through different delivery systems are lacking (78) . pulmonary rehabilitation is essential for patients with chronic respiratory issues such as copd and can be achieved through telehealth measures such as monitoring, consultation, and education (79) . this is important in copd, as potential exacerbations need to be monitored, and lower levels of rehabilitation access are associated with increased rates of hospitalization (79) . additionally, personal movement tracking devices involving accelerometers are helpful in tracking patient exercise, which is an essential area of pulmonary rehabilitation (80) . telehealth rehabilitation still faces major hurdles, however, such as cost-effectiveness, patient training, and the lack of regulatory frameworks surrounding personal health devices (80) . according to the who, about 40 million people annually need palliative care, and only 14% of them receive it (81) . the importance of primary healthcare in palliative care was highlighted by the first who global resolution on palliative care in 2014. the project echo (extension for community healthcare outcomes), as one of the examples, shows the potential of telemedicine in the training of patients, their family members, and medical workers in palliative care (82, 83) . the training of palliative care via telemedicine/telehealth for outpatients in primary care will increase the coverage and quality of both care and life for these patients. telehealth, including mobile applications, plays a role in making patients more adherent to both pharmacological and non-pharmacological therapies; in remote monitoring of clinical parameters such as cardiovascular and respiratory system function; as well as in monitoring of diet and physical activity. given the overload of respiratory diseases and the flu-like presentations in routine practice, telemedicine offers an alternative that is particularly relevant in the covid-19 era. mental health support to frontline health workers, patients, and carers will be crucial, as long isolation, lack of social interaction, as well as anxiety over one's own and others' health will take a toll on well-being (2) (3) (4) 84) . psychotherapy, psychiatry, and counseling are easily converted to a teleconference format through platforms (such as-but not limited to-zoom tm and skype tm ) and should be utilized by frontline health workers, patients, and carers where necessary (85) . anecdotal evidence also suggests that patients experiencing paranoid, anxiety, or post-traumatic stress disorders, who may be particularly affected by the covid-19 climate (84), may feel more comfortable undergoing telepsychiatry over in-person psychiatry. online delivery will further help to resolve issues such as lack of access to practitioners in rural settings and cultural and linguistic barriers (86) . furthermore, psychoeducation and mental well-being advice can be leveraged through smartphone apps and digital outreach programs (87) . these services will become increasingly crucial in the pandemic setting, as physical isolation and frontline work pose both access issues and mental health stressors. the ethics of such teleservices needs to be ensured, with patient confidentiality, referral and billing practices, and physician eligibility being upheld (88) . psychiatrists, psychotherapists, and psychologists need to ensure that they are maintaining their own mental health during this time, with programs such as professional supervision being of help (4). in 2018, nearly one-fifth of the european population was aged over 65 years old (89) . an aging population has put significant pressure on public spending; therefore, telemedicine can improve the scale and efficiency of delivery and ongoing management of elderly patients. elderly patients with mild cognitive impairment or dementia who might be at high risk of an acute condition should be identified using mobile technologies and telemedicine, and telemedicine solutions for the elderly should be easy to use and possibly automatic (4). this would avoid unnecessary burdens to public health facilities. telemedicine can also be used to act as an interface of the local nursing care staff, carers, and patients with medical specialists. elderly patients will benefit from remote allied health delivery. patients who have had a recent surgery could be monitored at home or in nursing care facilities, preventing extended hospital stays. elderly patients with diagnosed mental health conditions could also benefit from telemedicine. however, self-efficacy and digital literacy presumably have a significant impact on the uptake of telehealth among the elderly (90) . recent data from the us confirm that the most vulnerable age group for covid-19 is people over 65 years old, and the highest mortality is observed in those aged 85 and older (91) . in ontario, canada (as well as in italy and the us), 54% of deaths related to covid-19 occurred in retirement homes and long-term care (92, 93) . strict zero-visitation policies have had debilitating effects for some elderly patients, particularly those with dementia (4). telemedicine has been utilized to connect family members with these patients to prevent further decline in mental status and provide comfort. this is useful, as family members have voiced concerns that physically distanced visits such as through windows may further confuse their loved ones. telehealth allows continual monitoring of vitals, physical examination, ongoing clinical management, and communication with patients. in elderly patients with limited accessibility, telemedicine could provide an alternative, easy-to-access service. elderly patients often suffer from social isolation, and telehealth can bring a sense of community. furthermore, by using ai, falls can be detected among elderly patients (94) . ai can provide personalized medicine solutions to help identify patients at risk of harm. primary healthcare physicians and nursing homes should watch for signs of depression in the elderly, particularly as it has been shown that telemedicine is competent in managing depressive symptoms in the elderly (95) . telemedicine can be useful in delivering interventions in congregate settings (96, 97) . challenges in congregate settings include high population density, limited mobility, built environment issues, and limited access to health. this can make the prevention and management of covid-19 onerous while preserving human rights and ethical issues. some of the potential target populations include refugees and migrants (96) , those living in incarceration, orphanages, old-age homes, or childcare centers; and schools. these populations are especially vulnerable to infection such as covid-19, where an outbreak can have facility-wide implications and adverse health consequences and fatality. a simulation study on the possible impact of covid-19 outbreak in a bangladeshi refugee camp found a dire need for dramatic increases in healthcare capacity and infrastructure (97) . existing approaches to control an outbreak, should it occur, would not be practically feasible, necessitating innovative solutions as well as novel and untested strategies in humanitarian settings (97) . telepsychiatry to monitor and deliver interventions in congregate settings, especially among refugee populations living in resource-constrained areas (98, 99) , could be an alternative when traditional therapy is not possible. telepsychiatry programs for congregate settings should be developed, and further studies are needed to evaluate their long-term impact on patient monitoring and care (99, 100) . telemedicine systems are not novel concepts and have been used to good effect for programs such as forward triage in eds, critical care monitoring, and physician communication. existing systems will need to be reallocated, and innovations will be pushed through in order to provide care across all medical fields and to reduce hospital burden. this needs to be achieved within the constraints of funding, legislation, and supply-chain barriers. temporary government funding will be necessary to roll out telemedicine to both rural and urban settings, as well as relaxations to legislation that allow practitioner reimbursement of telemedicine services (101) . a study by sayani et al., addressing the cost and time barriers in chronic disease management through telemedicine in lmics, found telemedicine to be economically beneficial not only by reducing the socioeconomic barriers to cost and access but also by increasing the uptake of services (102) . another systematic review of studies conducted on costs of home-based telemedicine programs from 2000 to 2017 found that home telemedicine programs reduced care costs, although detailed cost data were either incomplete or not presented in detail (103) . the data on the cost-effectiveness of telemedicine solutions in different medical areas remains inconsistent and confounded by many variables, including the type of disease and "digital maturity" of healthcare systems. however, in critical situations such as the covid-19 pandemic, telemedicine is proven necessary, and costing, billing, and reimbursement solutions are needed. there are variations in reimbursement policies across regions and healthcare systems. one of the major barriers has been harmonizing a standard reimbursement policy that is acceptable to all stakeholders and sustainable. we recommend that an integrated framework involving public and private parties could help develop a less complicated and streamlined reimbursement structure. notably, the adoption of a "flip the switch" health insurance strategy in north carolina to reimburse telehealth visits "at parity" with conventional office visits for all healthcare providers and specialists is timely and essential. in the long term, the impact of these strategies on healthcare quality and healthcare costs needs further study. healthcare providers must lead the way here in the covid-19 crisis to explore innovative approaches such as b2b monitoring. certain limitations may act as roadblocks in the uptake, implementation, and scale-up of telemedicine and supporting technologies. considerable training is required to ensure patients can familiarize themselves with video teleconsultations and the use of supportive technologies. physicians also need targeted technical, clinical, and communication training based on their subspecialty needs. issues of limited access to broadband and internet facilities are an area that particularly limits the deployment of telemedicine in remote areas and under-resourced settings. telehealth requires reliable broadband access, which is not always acceptable both for clinics in rural areas and for patients living in such areas. when using telemedicine technology, legal restrictions and a lack of clarity as to what is permitted are possible, and these restrictions force telemedicine providers to proceed with caution. some conditions are not considered in the legislation of health systems. it is still not entirely clear whether virtual consultations and video surveillance will be fully paid in hospitals or will be evaluated as shorter visits so that the rates will be lowered. physician licensing and stability of the telemedicine infrastructures are issues of relevance in under-resourced settings. several critical medical procedures cannot be replaced by telemedicine, nor can it be offered to everyone, and there are many excluded groups of patients, including those with deficiencies (e.g., deaf and blind patients) and elderly patients. the effectiveness of telemedicine relies on the possibilities of the implementation of these tools in the given hospital/healthcare system, preparations/training of physicians/nurses, and awareness of the patients. figure 1 | text, audio, or video means. effective telemedicine has several requirements, including culturally appropriate and available infrastructure; regulatory oversight and privacy compliance such as through the health insurance portability and accountability act of 1996 (hipaa); integration of technologies with existing data such as electronic health records (ehrs), apps, and monitoring devices; and insurance coverage such as medicare or private-payer schemes. credentialing on both sides is essential. the consultation should start with verification of the patient's identity through name, age, phone number, date of birth, and address. the physician should then clearly specify that this is a telemedicine consult and that no audio or video of the communication will be recorded. it is imperative that health record information is protected. the physician should then clearly and explicitly ask for consent, whether that be verbal, text, or video. at the start of the consultation, the physician should assess if acute care is required and make a cursory determination if telemedicine consultation is sufficient. if necessary, the physician should supply an immediate referral or advise the patient to seek immediate medical attention. during a typical consultation, the patient will be evaluated; and specific diagnostics and treatment would be recommended based on the assessment of the healthcare provider; and follow-up could be scheduled either in person or virtually. the physician should go through records, clinical history, and investigations including pathology and diagnostic reports, and obtain any additional information that the patient can provide. a general, non-specialist examination should be obtained, and any vital signs that the patient has the means to measure should be gathered. beyond this, when introducing technologies and measures to overcome gaps in the healthcare system, it is essential not to simply ask, "where are the gaps, " but also to define the standards and ideals of care and continually iterate toward these ideals. as mentioned before, telemedical consultations do not approach the same level of fidelity that an in-person physical exam yields, between physical exams, body language, vocal intonations, and odors. as such, the fidelity of the technology involved with telemedical consults must continually iterate to reach the same level of fidelity and information that an inperson visit might yield. in this vein, virtual and augmented reality technologies, while evolving, hold promise for the future of telemedicine, particularly in envisioning a future in which high-fidelity physician and patient "avatars" may meet in a virtual space for a telemedical consult, replicating aspects of an inperson visit through immersive technologies. covid-19 has expedited the uptake of telemedicine across various specialties. the rapid move by various bodies, associations, and providers to use telemedicine in maintaining patient continuity while limiting covid-19 risks of exposure to patients and healthcare workers will have a long-term impact well-beyond the current pandemic. teleconsultation needs are varied across specialties, and therefore, specialty-specific guidelines and recommendations need to be developed. a scoping list of various telemedicine studies across medical subspecialties (telemedicine vs. standard care) has been provided in table 1 . a comprehensive workflow that critically profiles various telemedicine enablers has been proposed in figure 1 , and recommendations to improve various factors are listed in table 2 . the proposed workflow (figure 1 ) provides a practical telemedicine framework cognizant of relevant requirements and considerations, and a step-by-step pathway to streamlined telemedicine delivery. this could be used as a template (for further customization or adaptation) by individual medical subspecialties. current challenges and recommendations to improve telemedicine include (130) : (i) infrastructure capacity [formation and expansion of dedicated telemedicine units and workforce; cloud-based infrastructure to support telemedicine associated bandwidth traffic; liability, maintenance, and safety of telemedicine platforms; ongoing and regular maintenance and servicing of telemedicine hardware and software; awareness, education, and training to build confidence about telemedicine use among providers and consumers; compulsory telemedicine modules for medical students and continued professional development (cpd) workshops/courses for healthcare providers and medical informaticians/technologists; targeted courses aimed at re-skilling clinicians]; (ii) integration with existing data (standardized patient-specific information and consent form with telemedicine opt-in/out option); (iii) regulatory oversight issues (setup of telemedicine regulatory authority; accreditation/licensing of providers using telemedicine; guidelines for telemedicine use in inter-state and -nation settings; standardization of telemedicine related technologies and services with regulatory oversight, audit, and reporting; appropriate measures and oversight to protect privacy, security, and confidentiality of patient data; legal frameworks for telemedicine-specific information storage, sharing, and access); and (iv) insurance/payers (guidelines for telemedicine insurance; streamlined payment facilities for making and receiving payments; bundled services payments and insurance coverage). another important and emerging area is the use of text messaging [short message service (sms) or multimedia message service (mms)] as a model for service delivery (131) (132) (133) (134) (135) (136) . text messaging has proven efficacious in diabetes self-management, smoking cessation, weight loss, physical activity, and adherence to medication regimens [such as in human immunodeficiency virus infection and acquired immune deficiency syndrome (hiv/aids) patients who are on antiretroviral therapy] (132) . a systematic review on text messaging interventions identified the following issues: identification of intervention characteristics, ensuring intervention effects last over a longer duration of time, and cost-effectiveness of these interventions (132) . issues of privacy and security are also poignant in this context. nevertheless, text messaging offers potential benefit as a public health intervention toward chronic disease management (133) (134) (135) (136) , medication adherence, and secondary prevention (134) . perceptions and experiences/satisfaction, regarding telemedicine services, of the patients and providers is important in improving telemedicine implementation, delivery, and impact (137) (138) (139) (140) (141) . a systematic review on patient satisfaction with telemedicine highlighted methodological deficiencies in published studies (137) . a study on patient and clinician experience with telemedicine found that virtual video visits may provide effective follow-up and increased convenience in comparison to routine in-person visits (139) . another study found a perception of patients with type 2 diabetes that telemedicine can improve their access to care (140) . further studies focusing on communication issues and the quality of interpersonal relationships during telemedicine consultations and how these factors affect healthcare delivery using this medium are required (137, 141) . some specialist examinations, including neurologist consultation, can also be conducted. the american academy of neurology has issued guidelines for telemedicine consultation (142) . physicians can assess mental status; any visual, auditory, or cognitive deficits; comprehensive speech; cranial nerves; apparent tremors; and gait. motor examinations can also be conducted with the aid of a caregiver in order to help ascertain strength, tone, reflexes, dermatome sensation, and cerebellar function. in such a case, consent must be gained from both the patient and the assistor. special considerations may apply for pediatric patients or adults with intellectual disabilities. based on the severity of symptoms, the patient may require a management plan, including specific treatment, health education, and counseling if necessary. patients can be prescribed ongoing prescriptions, specific medications, or add-on medication to optimize regimes, given that there is no ambiguity about diagnosis and the medications are not dangerous. if there is any ambiguity about diagnosis, this must be recognized as a limitation of this mode of telemedicine, and documentation must be made. further tests should be done or referred for in-person consultation if necessary. it should be noted that detailed examination of tone, strength, and reflexes; comprehensive eye examinations; and examinations that require specific maneuvers such as vestibular examinations should be avoided, as examination findings won't be accurate. these recommendations will also need to be adjusted according to individual state or federal legislation. the future of telemedicine beyond the current covid-19 pandemic will depend on how we address existing challenges, building resilient health systems (2) (3) (4) . further randomized controlled trials to evaluate the long-term effects of telemedicine-based interventions in various patient populations should be planned. telemedicine will play a major role as a "safety net" during the pandemic. the covid-19 pandemic is causing an unprecedented public health crisis impacting healthcare systems, healthcare workers, and communities. the covid-19 pandemic health system resilience program (reprogram) consortium is formed to champion the safety of healthcare workers, policy development, and advocacy for global pandemic preparedness and action. sbh devised the project, the main conceptual ideas, including the proposal for a new telemedicine workflow, the proof outline, and coordinated the writing and editing of the manuscript. sbh and sbr wrote the first draft of the manuscript. sbh encouraged sbr to investigate and supervised the findings of this work. all authors discussed the results and recommendations and contributed to the final manuscript. we would like to acknowledge the reprogram consortium members, who have worked tirelessly over the last days in contributing to various guidelines, recommendations, policy briefs, and ongoing discussions during these unprecedented and challenging times despite the incredibly short timeframe. we would like to dedicate this work to our healthcare workers who have died due to covid-19 while serving patients at the frontline and to those who continue to serve during these challenging times despite the lack of personal protective equipment. coronavirus disease 2019 (covid-19): protecting hospitals from the invisible acute neurological care in the covid-19 era: the pandemic health system resilience program (reprogram) consortium pathway key strategies for clinical management and improvement of healthcare services for cardiovascular disease and diabetes patients in the coronavirus (covid-19) settings: recommendations from the reprogram consortium chronic neurology in covid-19 era: clinical considerations and recommendations from the reprogram consortium artificial intelligence for good global summit telemedicine during covid-19: benefits, limitations, burdens, adaptation. healthcare it news ambulatory arrhythmia monitoring medical emergency triage and patient prioritisation in a telemedicine environment: a systematic review telemedicine and its transformation of emergency care: a case study of one of the largest us integrated healthcare delivery systems the variety of cardiovascular presentations of covid-19 association of cardiac injury with mortality in hospitalized patients with covid-19 in wuhan, china cardiac involvement in a patient with coronavirus disease 2019 (covid-19) cardiovascular implications of fatal outcomes of patients with coronavirus disease 2019 (covid-19) association of coronavirus disease 2019 (covid-19) with myocardial injury and mortality telehealth: rapid implementation for your cardiology clinic capacity-covid: a european registry to determine the role of cardiovascular disease in the covid-19 pandemic telemedicine helps cardiologists extend their reach structured telephone support or non-invasive telemonitoring for patients with heart failure disease: a report from the working group on telecardiology and informatics telemedicine in pediatric cardiology: a scientific statement from the american heart association the role of mhealth for improving medication adherence in patients with cardiovascular disease: a systematic review mobile health applications in cardiac care effects of a 9-week hybrid comprehensive telerehabilitation program on long-term outcomes in patients with heart failure: the telerehabilitation in heart failure patients (telereh-hf) randomized clinical trial hybrid comprehensive telerehabilitation in heart failure patients (telereh-hf): a randomized, multicenter, prospective, open-label, parallel group controlled trial-study design and description of the intervention endovascular therapy for anterior circulation large vessel occlusion in telestroke two years' experience of implementing a comprehensive telemedical stroke network comprising in mainly rural region: the transregional network for stroke intervention with telemedicine (transit-stroke) impact of statewide telestroke network on acute stroke treatment in hawai'i patient perception of physician empathy in stroke telemedicine concussion and mild-traumatic brain injury in rural settings: epidemiology and specific health care considerations the stanford hall consensus statement for post-covid-19 rehabilitation tele-critical care: an update from the society of critical care medicine tele-icu committee the effect of telemedicine in critically ill patients: systematic review and meta-analysis tele-medicine in respiratory diseases telemedicine in chronic obstructive pulmonary disease interactive telemedicine: effects on professional practice and health care outcomes lipid-lowering therapy and reninangiotensin-aldosterone system inhibitors in the era of the covid-19 pandemic association of a remotely offered infectious diseases econsult service with improved clinical outcomes the current use of telehealth in als care and the barriers to and facilitators of implementation: a systematic review telehealth as part of specialized als care: feasibility and user experiences with "als home-monitoring and coaching covid-19 is catalyzing the adoption of teleneurology the past, present, and future of telemedicine for parkinson's disease telehealth increases access to palliative care for people with parkinson's disease and related disorders brief recommendations on the management of adult patients with familial hypercholesterolemia during the covid-19 pandemic migraine care in the era of covid-19: clinical pearls and plea to insurers covid-19 in the cancer patient managing haematology and oncology patients during the covid-19 pandemic: interim consensus guidance risk of covid-19 for patients with cancer cancer care during the spread of coronavirus disease 2019 (covid-19) in italy: young oncologists' perspective cancer patients in sars-cov-2 infection: a nationwide analysis in china telemedicine in cancer care teledermatology for diagnosing skin cancer in adults retinal telemedicine digital adherence technologies for the management of tuberculosis therapy: mapping the landscape and research priorities a national survey on the use of electronic directly observed therapy for treatment of tuberculosis tele-monitoring of ventilator-dependent patients: a european respiratory society statement impact of weekly case-based tele-education on quality of care in a limited resource medical intensive care unit digital technologies and adherence in respiratory diseases: the road ahead how will telemedicine change clinical practice in chronic obstructive pulmonary disease? the role of tele-medicine in patients with respiratory diseases telemedicine in the diagnosis and treatment of sleep apnoea a telehealth system for automated diagnosis of asthma and chronical obstructive pulmonary disease smartphone sensors for health monitoring and diagnosis does remote monitoring change osa management and cpap adherence? respirology management of continuous positive airway pressure treatment compliance using telemonitoring in obstructive sleep apnoea a telehealth program for cpap adherence reduces labor and yields similar adherence and efficacy when compared to standard of care process evaluation and exploration of telehealth in motor neuron disease in a uk specialist centre life-threatening misdiagnosis of bulbar onset myasthenia gravis as a motor neuron disease: how much can one rely on exaggerated deep tendon reflexes natural history of spinal-bulbar muscular atrophy clinical presentation and outcome of riboflavin transporter deficiency: mini review after five years of experience a qualitative study on user acceptance of a home-based stroke telerehabilitation system tele-rehabilitation after stroke: an updated systematic review of the literature remote physical activity monitoring in neurological disease: a systematic review evaluation and treatment of mild traumatic brain injury through the implementation of clinical video telehealth: provider perspectives from the veterans health administration the feasibility of telephone-administered cognitive testing in individuals 1 and 2 years after inpatient rehabilitation for traumatic brain injury remote supervision of rehabilitation interventions for survivors of moderate or severe traumatic brain injury: a scoping review telehealth pulmonary rehabilitation: a review of the literature and an example of a nationwide initiative to improve the accessibility of pulmonary rehabilitation delivering telemedicine interventions in chronic respiratory disease noncommunicable diseases and their risk factors telementoring primary care clinicians to improve geriatric mental health care supporting and improving community health services-a prospective evaluation of echo technology in community palliative care nursing teams psychological aspects of the covid-19 pandemic telepsychiatry today telepsychiatry integration of mental health services into rural primary care settings review of use and integration of mobile apps into psychiatric treatments professionalism and technology: competencies across the tele-behavioral health and e-behavioral health spectrum ageing report: policy challenges for ageing societies understanding older people's readiness for receiving telehealth: mixedmethod study covid-19 response team. severe outcomes among patients with coronavirus disease 2019 (covid-19) -united states epidemiology of covid-19 in a long-term care facility in king county, washington half of coronavirus deaths happen in care homes, data from eu suggests real-time detection of human falls in progress: machine learning approach the use of technology for mental healthcare delivery among older adults with depressive symptoms: a systematic literature review what will happen if coronavirus enters a refugee camp? available online at the potential impact of covid-19 in refugee camps in bangladesh and beyond: a modeling study efficacy of telepsychiatry in refugee populations: a systematic review of the evidence effectiveness and feasibility of telepsychiatry in resource constrained environments? a systematic review of the evidence is telepsychiatry equivalent to face-to-face psychiatry? results from a randomized controlled equivalence trial telehealth for global emergencies: implications for coronavirus disease 2019 (covid-19) addressing cost and time barriers in chronic disease management through telemedicine: an exploratory research in select low-and middleincome countries costs of home-based telemedicine programs: a systematic review telemedicine in the emergency department: a randomized controlled trial impact of critical care telemedicine consultations on children in rural emergency departments the role of telecardiology in supporting the decision-making process of general practitioners during the management of patients with suspected cardiac events telecardiology application in jordan: its impact on diagnosis and disease management, patients' quality of life, and time-and costsavings potential cost reductions for the national health service through a telecardiology service dedicated to general practice physicians impact of telemedicine on the practice of pediatric cardiology in community hospitals telemedicine is a useful tool to deliver care to patients with amyotrophic lateral sclerosis during covid-19 pandemic: results from southern italy affective improvement of neurological disease patients and caregivers using an automated telephone call service evaluation of a french regional telemedicine network dedicated to neurological emergencies: a 14-year study telemedically provided stroke expertise beyond normal working hours. the telemedical project for integrative stroke care the effects of telemedicine on racial and ethnic disparities in access to acute stroke care implementation of telemedicine and stroke network in thrombolytic administration: comparison between walk-in and referred patients long-term outcome after thrombolysis in telemedical stroke care can telemedicine improve adherence to resuscitation guidelines for critically ill children at community hospitals? a randomized controlled trial using high-fidelity simulation self-management maintenance inhalation therapy with ehealth (selfie): observational study on the use of an electronic monitoring device in respiratory patient care and research telemedicine in primary care for patients with chronic conditions: the valcrã²nic quasi-experimental study impact of telemonitoring home care patients with heart failure or chronic lung disease from primary care on healthcare resource use (the telbil study randomised controlled trial) home-based telemonitoring of simple vital signs to reduce hospitalization in heart failure patients: real-world data from a community-based hospital home telemonitoring of non-invasive ventilation decreases healthcare utilisation in a prospective controlled trial of patients with amyotrophic lateral sclerosis adjusted cost analysis of video televisits for the care of people with amyotrophic lateral sclerosis telehealth exercise-based cardiac rehabilitation: a systematic review and meta-analysis feasibility and acceptability of inpatient palliative care e-family meetings during covid-19 pandemic telemedically augmented palliative care: empowerment for patients with advanced cancer and their family caregivers treatment outcomes in depression: comparison of remote treatment through telepsychiatry to in-person treatment effectiveness of an integrated telehealth service for patients with depression: a pragmatic randomised controlled trial of a complex intervention telemedicine and virtual consultation: the indian perspective a quantitative systematic review of the efficacy of mobile phone interventions to improve medication adherence mobile text messaging for health: a systematic review of reviews effect of text messaging on risk factor management in patients with coronary heart disease: the chat randomized clinical trial design and rationale of the cardiovascular health and text messaging (chat) study and the chat-diabetes mellitus (chat-dm) study: two randomised controlled trials of text messaging to improve secondary prevention for coronary heart disease and diabetes mobile-based applications and functionalities for selfmanagement of people living with hiv mobile phone text messaging interventions for hiv and other chronic diseases: an overview of systematic reviews and framework for evidence transfer systematic review of studies of patient satisfaction with telemedicine telemedicine for clinical psychology in the highlands of scotland patient and clinician experiences with telehealth for patient follow-up care i'm not feeling like i'm part of the conversation" patients' perspectives on communicating in clinical video telehealth visits limitations of patient satisfaction studies in telehealthcare: a systematic review of the literature telemedicine and covid-19 implementation guide conflict of interest: sp is the vice president of immersive medicine at luxsonic technologies, a medical technology company specializing in virtual/augmented reality for medical education, collaboration, and training. the opinions expressed in this article are those of the authors and do not necessarily represent the decisions, official policy, or opinions of the affiliated institutions.the remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.copyright â© 2020 bhaskar, bradley, chattu, adisesh, nurtazina, kyrykbayeva, sakhamuri, moguilner, pandya, schroeder, banach and ray. this is an open-access article distributed under the terms of the creative commons attribution license (cc by). the use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. no use, distribution or reproduction is permitted which does not comply with these terms. key: cord-311000-abntwzuy authors: sommer, adir c.; blumenthal, eytan z. title: telemedicine in ophthalmology in view of the emerging covid-19 outbreak date: 2020-08-19 journal: graefes arch clin exp ophthalmol doi: 10.1007/s00417-020-04879-2 sha: doc_id: 311000 cord_uid: abntwzuy purpose: technological advances in recent years have resulted in the development and implementation of various modalities and techniques enabling medical professionals to remotely diagnose and treat numerous medical conditions in diverse medical fields, including ophthalmology. patients who require prolonged isolation until recovery, such as those who suffer from covid-19, present multiple therapeutic dilemmas to their caregivers. therefore, utilizing remote care in the daily workflow would be a valuable tool for the diagnosis and treatment of acute and chronic ocular conditions in this challenging clinical setting. our aim is to review the latest technological and methodical advances in teleophthalmology and highlight their implementation in screening and managing various ocular conditions. we present them as well as potential diagnostic and treatment applications in view of the recent sars-cov-2 virus outbreak. methods: a computerized search from january 2017 up to march 2020 of the online electronic database pubmed was performed, using the following search strings: “telemedicine,” “telehealth,” and “ophthalmology.” more generalized complementary contemporary research data regarding the covid-19 pandemic was also obtained from the pubmed database. results: a total of 312 records, including covid-19-focused studies, were initially identified. after exclusion of non-relevant, non-english, and duplicate studies, a total of 138 records were found eligible. ninety records were included in the final qualitative analysis. conclusion: teleophthalmology is an effective screening and management tool for a range of adult and pediatric acute and chronic ocular conditions. it is mostly utilized in screening of retinal conditions such as retinopathy of prematurity, diabetic retinopathy, and age-related macular degeneration; in diagnosing anterior segment condition; and in managing glaucoma. with improvements in image processing, and better integration of the patient’s medical record, teleophthalmology should become a more accepted modality, all the more so in circumstances where social distancing is inflicted upon us. [image: see text] in recent years, wide-scale implementation of telemedicine has become possible owing to significant technological advances that allow its application in a variety of medical fields, including ophthalmology. telemedicine is defined as the use of digital means and information sharing to provide health care from a distance. the emergence and availability of powerful hardware, advanced software, and fast communication technologies now allow ophthalmologists to diagnose and treat a variety of urgent and chronic eye conditions. caffery et al. [1] described 62 discrete teleophthalmology models of care, ranging from screening for eye diseases, various consultative services, triage, remote supervision, educational purposes, and emergency services. most teleophthalmology services rely on digital images captured by primary care physicians or trained technicians who utilize various in-clinic devices for anterior segment and fundus photography. the images are digitally transmitted to an ophthalmologist for realtime or later assessment. in ophthalmology, a high-volume specialty, telemedicine has the potential to improve patient experience, particularly in a primary care setting where access to specialists is not trivial and may offer a cost-effective alternative to face-to-face specialist consultation. furthermore, a quick and accessible tele-consultation during patients' routine primary care visit can highlight those in need of further faceto-face subspecialty care. this concept may play an important role in rural areas and poorly resourced countries and regions in which specialists required for screening and evaluations are often not available or accessible. moreover, the use of telemedicine can be useful in other special circumstances when access to medical care is limited, such as during natural disasters or when social distancing is required, as in an infectious disease outbreak. the covid-19 pandemic started in china at the end of 2019 and continues to expand without clear expectations as to when this global crisis will end. a patient suspected of having been exposed to the virus may be placed in preventive isolation before symptoms occur, and those who will eventually be found to have become infected by the sars-cov-2 virus may be kept in complete isolation for over a month until recovery [2] [3] [4] [5] . during this period, arranging and performing a consultation for an unrelated eye condition may be a challenging task. patients suffering from known chronic ocular conditions such as diabetic retinopathy (dr), age-related macular degeneration (amd), and glaucoma, who require routine ambulatory screening and monitoring under slit lamp examination, as well as patients undergoing monthly anti-vegf injections, requiring regular follow-up appointments and auxiliary tests, be it a visual field or an optical coherence tomography (oct) scan, are at significant risk of being lost to follow-up. common eye emergencies such as retinal detachments and acute angle-closure glaucoma, which require rapid diagnosis and intervention by a specialist, are cumbersome and difficult to address in this setting. prolonged quarantine, curfews, and stay-at-home directives may result in adverse psychological outcomes, including agoraphobia and xenophobia; thus, it may discourage patients to seek immediate medical attention and may limit their access to appropriate eye care [6] . additionally, in light of the strict isolation guidelines, a shortage of physicians may arise, as medical personnel could be sent to isolation after a potential exposure to the virus [7] . furthermore, examinations such as indirect ophthalmoscopy are extremely difficult to perform when dressed in personal protective equipment (ppe) such as face shields and eye safety goggles, and utilizing portable diagnostic equipment, such as a handheld tonometer or slit lamp, presents a wide range of accuracy, as compared with the gold standard stationary instruments at the clinic [8] [9] [10] . moreover, there is now a growing body of evidence suggesting the possible transmission wide-scale implementation of teleophthalmology has become possible owing to significant technological advances that allow its utilization in a variety of ocular conditions. the covid-19 pandemic poses special challenges that can be dealt with a proper understanding of the potential and utilization of telemedical services and address issues such as chronic disease management in the context of social distancing, prolonged isolation and quarantine periods. dedicated ophthalmology clinics equipped with remote screening devices that are self-operated, or that could be operated by minimally trained personnel, may bridge a gap in the availability of medical care in light of the challenges the current covid-19 pandemic. teleophthalmology has the potential to aid in a range of adult and pediatric, chronic and acute ocular conditions, and can be utilized for the purposes of dr screening, diagnosis of glaucoma, and monitoring for amd, to name a few. of the sars-cov-2 virus through the ocular surface [11] [12] [13] , even though infectivity of ocular secretions is not yet conclusive [13] . therefore, extra caution, personal protection, and proper disinfection are required when examining clinically or epidemiologically suspected patients at the eye clinic, even when those patients are equipped with personal protective means. although patients suspected for covid-19 infection are apparently less likely to present initially at the eye clinic, preliminary data suggests that nearly a third of covid-19 patients may have non-specific ocular manifestations consistent with conjunctivitis, such as epiphora, conjunctival hyperemia, and chemosis, similar to findings found as the result of other human coronaviruses infection [11, 13] . although these manifestations seem to typically occur in patients with more severe disease, one patient was demonstrated to present with conjunctivitis as the very first symptom [11] . likewise, a recent report examining the symptoms of the first confirmed covid-19 patient in italy presented bilateral conjunctivitis as a presenting symptom and concluded ocular secretion may be a potential source of infection as it contained the sars-cov-2 virus [14] . hence, the fact that ocular manifestations might be the very first sign of infection should not be overlooked when treating a patient known to be at risk of having acquired a covid-19 infection. for the foregoing reasons, a holistic view of the potential of remote care technologies for assessing patients with acute or chronic ophthalmic diseases, who require social distancing, quarantine, or isolation, is particularly relevant now, as the long-term duration and impact of the current outbreak are yet to be determined. a computerized search from january 2017 up to march 2020 of the online electronic database pubmed was performed, using the following search strings: "telemedicine," "telehealth," and "ophthalmology." the eligibility of the studies was initially verified by excluding non-relevant studies, after manually examining the titles and abstracts. the reference list in each relevant article was analyzed for additional relevant publications. articles in non-english languages were excluded if no adequate english translation was available. commentary, letters, and editorials were excluded. more generalized complementary contemporary research data regarding the covid-19 pandemic was obtained from the pubmed database. a total of 312 records, including covid-19-focused studies, were initially identified. after exclusion of nonrelevant, non-english, and duplicate studies, a total of 138 records were found eligible. ninety records were included in the final qualitative analysis as depicted in fig. 1 . telemedicine has been widely applied in dr screening which is the most common condition for disease-specific remote care in ophthalmology [1] . as millions of persons are being quarantined, remote screening is becoming more relevant than ever, dr is a major cause of morbidity among diabetic patients, and most of them experience no symptoms until macular edema or proliferative retinopathy are present. progression rate can be very rapid, to the point that an effective therapy reversing the condition in its entirety might not be available. thus, it is important to screen diabetic patients for the development and deterioration of any retinal disease. estimates of the potential reach of dr telemedicine screening, based on a 3229 survey sample of diabetic americans, showed that 87.7% had regular contact with primary care physicians and therefore could potentially receive timely screening for dr via a primary care setting [15] . tele-screening dr through incorporating artificial intelligence (ai) technologies can provide widespread and cost-effective screening, particularly among low-and middle-income populations, as well as tackle the health burden of dr at a global level [16] . as of this writing, evidence of covid-19 infection has been observed in more than 200 countries around the world. nevertheless, reports of successful implementation of teleophthalmology services can be found in geographically distinct countries. facilitating access for diabetic patients to regular fundus examinations by an ophthalmologist was demonstrated in a brazilian prospective comparative study of more than 1330 patients. fundus photography-based teleophthalmology screening for dr led to early dr diagnosis and referrals while managing to reduce costs at near 29usd per patient per referral [17] . in a retrospective observational study consisting of 1776 patients, a single-field 45°nonmydriatic color fundus photograph was remotely examined by a specialist and then compared with an in-person dilated fundus examination. the study demonstrated a high level of accuracy in detecting and classifying dr, although dme detection was found to a lesser degree [18] . a cross-sectional hospital-based study of 978 diabetic patients in riyadh, saudi arabia, demonstrated that remote non-mydriatic funduscopic screening photography could be useful for the initial detection of dr among diabetic patients [19] . similar results were shown in a large crosssectional study in chile [20] . in the uk, virtual retina clinics were found to be a cost-effective and clinically safe alternative to in-person specialist follow-up, including urgent referrals if needed. dr was the most common ocular condition found, followed by amd, retinal vein occlusion, choroidal nevus, a n d c e n t r a l s e r o u s c h o r i o r e t i n o p a t h y [ 2 1 , 2 2 ] . teleophthalmology status in other european countries was described by labiris et al. in their systematic review [23] . in a cluster-randomized clinical trial of eight diabetes clinics conducted by joseph et al. on 801 patients, 3-field 45°retinal images were remotely evaluated by a retina specialist who referred those in need of further examination according to their grading [24] . in the control group, all patients were referred for further in-person retinal assessment. an overall lower proportional yield of dr cases was presented in the control group. a web-based tele-screening program for dr in iran was described by safi et al. in a study conducted on 604 diabetic patients. interestingly, they found that cataract was the primary cause of impaired fundus image quality, a finding that has also been previously reported [25] . the indian health service-joslin vision network (ihs-jvn) teleophthalmology program established in 2000 is an example of one of the largest primary care-based telemedicine programs in the usa. in a recent article, fonda et al. [26] describe the program's workflow, imaging, reading technologies, and diagnostic protocols for screening and managing dr. they pointed out ai utilization as a key feature for enhancing their ability to triage patients with no or mild dr so that patients with more severe disease could be prioritized, and to shorten the reading latency for these patients' tests. canadian tele-screening guidelines for patients presenting with different stages of dr were proposed by boucher et al. these guidelines were mainly based on severity grading scales outlined by the international clinical diabetic retinopathy disease severity scale and the scottish dr grading scheme 2007. they suggested grading be based on two 45°image fields, a single widefield, or an ultra-widefield image that captures all seven-standard edtrs fields, and to use adjunct optical coherence tomography (oct) imaging if possible [27] . a novel method of imaging for dr screening was also proposed by afshar et al. in a cross-sectional study encompassing 2788 patients. for high-volume clinics, the study introduced a combination of a mobile ultra-widefield camera mounted in a van, and several fixed-location cameras [28] . the aforementioned examples illustrate how teleophthalmology can be utilized in order to reduce clinic crowding, reduce administrative purpose encounters, and remotely triage and identify those patients requiring an in-person examination. given the considerable weight of telemedicine applications in various aspects of dr, a working group of a large number of experts in clinical applications for telehealth in ophthalmology, known as the diabetic retinopathy telehealth practice guidelines working group, recently published an updated guideline for implementing and operating telehealth services for dr in a broad range of clinical settings [29] . chee et al. concluded that retina telemedicine applications, mainly in dr and retinopathy of prematurity (rop), are reliable and cost-effective and should be integrated into current clinical systems. nevertheless, they suggest telemedicine should be utilized as an adjunct modality to in-person office encounters, particularly in high-risk patients, and not as a standalone alternative to it [30] . likewise, vasseneix et al. demonstrated that although teleophthalmology is beneficial as a complementary decision support and triage tool, it cannot, yet, offer a standalone diagnostic solution in the case of patients presenting to the emergency department with acute vision loss. in over 50% of patients, a complementary in-person examination by an ophthalmologist was needed due to limited patient history and disorders not visible on fundus photography, particularly those involving the anterior segment, vitreous, and peripheral retina [31] . understanding patients' perceptions of telemedicine is important in improving patient adherence to treatment and follow-up. low referral completion after undergoing dr tele-screening is a drawback that should be noted, one which is not unique to teleophthalmology and which has been noted in face-to-face appointments and for other medical disciplines. in a large study conducted by zhu et al. they found that the phenomenon of limited engagement is particularly common in the elderly and low education level populations and that lack of knowledge and a negative attitude toward telemedicine might be more prominent than logistic barriers in predicting incomplete referral, thus emphasizing the importance of proper education and raising awareness [32] . similarly, improving patients' perception toward and promoting the use of teleophthalmology through proper education in low-income diabetic us population was also described [33] . addressing the aforesaid issues is crucial in the current pandemic state, facilitating treatment adherence and proper follow-up of chronic conditions. it is estimated that up to 15% of covid-19 cases in the usa were in infants under 1 year old [34] . telemedicine can also be used as an effective method for rop screening as proposed in numerous studies [35] [36] [37] [38] [39] [40] . management of various pediatric retinal diseases through teleophthalmology, including rop, was discussed in a review by jeng-miller and yonekawa. they concluded that although telemedicine applications in a pediatric setting exhibit numerous advantages, some unique limitations should be mentioned, such as the high cost of a pediatric widefield imaging camera, and that obtaining quality images can be difficult in neonates due to several anatomical and physiological factors [41] . a retrospective analysis of a 10-year regional telemedicine rop screening program reviewed the widefield digital imaging of 1181 infants. this study showed that tele-screening could be an effective modality in diagnosing and managing rop and proposed it as an effective tool that could address the workforce shortage in rop screening [42] . a prospective study conducted on 350 new-born infants demonstrated that widefield digital photography of the retina and external eye, remotely analyzed by a specialist, could detect additional retinal abnormalities besides rop, including retinal hemorrhages, congenital cataract, and optic nerve hypoplasia [43] . in a retrospective analysis, tele-screening for rop in preterm infants was found to be a useful and efficient approach for accessible screening, although it could not completely replace the gold standard binocular indirect ophthalmoscopy due to technical difficulties in imaging of the peripheral retina [44] . an approach for smartphone-based non-contact widefield fundus photography for remote screening of plus-disease was also described by patel et al. in a feasibility study conducted on 27 premature infants [45] . amd remains the leading cause of adult blindness in industrialized countries, where the type and frequency of follow-up depend on the severity of the disease and risk of progression [46, 47] . middle-aged adults and particularly the elderly are most commonly affected by covid-19, with older patients being more likely to develop severe disease. brady et al. present their findings including current experience with amd screening, remote care, and ai applications. they suggested that telemedicine utilization in managing amd requires more complex imaging modalities than what has usually been used for dr and that extending existing dr tele-screening methods to screen for amd is not recommended. for accelerating telehealth services implementation for amd, such as remote consultations with specialists, or consumer home monitoring, it was suggested to facilitate the combination of nonmydriatic fundus cameras and technologies such as oct and oct angiography [48] . notably, a dedicated ai-and cloud-based approach based on convolutional neural networks introduced by hwang et al. achieved equivalent diagnostic accuracy as that of a retinal specialist examination [49] . a prospective study conducted on 298 elder patients with cognitive complaints, including dementia, showed that teleophthalmology can be successfully utilized for various eye diseases screening. medical history, best-corrected visual acuity, intraocular pressure (iop), an examination of the eyelids and conjunctiva, and non-mydriatic retinal photography were performed by an orthoptist and later remotely examined by an ophthalmologist. most cases of newly diagnosed ocular disease were amd-related, followed by glaucoma, cataract, retinal nevi, and dr [50] . a nonrandomized study of 159 patients showed how remote diagnosis via digital fundus photography and non-dilated oct managed to achieve higher diagnostic accuracy in identifying referable amd cases when compared with an in-person dilated eye examination performed by a retinal specialist. of interest regarding the future of telemedicine in ophthalmology, once experienced, 76.7% of these patients preferred remote care over face-to-face standard examination [51] . telemedicine was also found to be efficient in long-term management (mean follow-up time of 2.4 ± 0.81 years) of patients treated with intravitreal anti-vegf injections for exudative amd [52] . as with dr, teleservices can be utilized in order to reduce clinic crowding, reduce administrative purpose encounters, and remotely identify patients in need of an in-person examination. incidental findings during tele-screening for specific ocular diseases are not uncommon. mastropasqua et al. reported incidental retinal abnormalities found among 1930 patients screened for dr in diabetes clinics, including amd in 10.52%, and optic disc abnormalities suspect for glaucoma in 15.27% [53] . although not incidental, laurent et al. reported their ability to detect spontaneous venous pulsations, a useful clinical sign for indirectly assessing intracranial pressure, utilizing a smartphone for video ophthalmoscopy [54] . a reliable and accurate tool able to detect optic disc edema was presented by bursztyn et al. as they presented their experience with the utilization of a portable handheld nonmydriatic fundus camera [55] . the diagnosis of urgent retinal conditions via teleophthalmology, such as a retinal detachment, was also demonstrated successfully [56] . a systematic review and meta-analysis of teleophthalmology utilization for amd and dr screening showed an or of 1.14 (95% ci: 0.52-2.53, p = 0.74) for any disease detection, and an or of 13.15 (95% ci: 8.01-21.61, p < 0.001) for patients' participation in the screening process. thus, this study suggests that teleophthalmology has similar outcomes to inperson, clinical care, while significantly increasing patient involvement in the screening process compared with inperson examinations [57] . digital retinal imaging could be beneficial for remotely training and educating ophthalmologists in managing rop [58] . a study was conducted on 852 patients, 10-23 years old, who underwent fundus photography by minimally trained technicians in a pediatric endocrinology clinic at vanderbilt university in nashville, tennessee, which was later remotely assessed by an ophthalmologist. this telemedicine program identified a higher percentage of dr via screening nonmydriatic images than prior studies have found through manual ophthalmic examinations [59] . although there is insufficient evidence regarding which precise populations would benefit the most from screening for open-angle glaucoma, given the risk of blindness from untreated glaucoma, effectiveness of treatment, and that early open-angle glaucoma patients are often asymptomatic, it was suggested that best practice informs healthcare providers with sufficient resources to screen all individuals over age 40 years [60] . the philadelphia telemedicine glaucoma detection and follow-up study described a tele-screening model that was deployed in seven primary care offices and four qualified health centers, screening more than 900 patients from diverse ethnic backgrounds. their diagnostic setup and model, utilizing telemedicine imaging in addition to demographic and clinical information (iop measurements, visual acuity, and family history of glaucoma), managed to achieve high detection rates of suspicious optic nerves and ocular hypertension [61] . among those patients, 17.1% had unreadable fundus photographs, which is consistent with previously reported rates (5-19.7%) from telemedicine programs using nonmydriatic cameras [62] . gan et al. present a plethora of telemedicine approaches for the remote management of glaucoma, via collecting information as iop measurements, central corneal thickness pachymetry, anterior segment imaging, fundus photography, and retinal nerve fiber layer imaging [63] . this information can be collected for each patient and then transmitted to a distant medical provider for interpretation, awaiting further instructions. they defined three levels of tele-programs, starting from the most minimalistic, consisting of glaucoma screening only, through diagnostic consultation, and up to the most inclusive, long-term comprehensive treatment monitoring. regarding the best diagnostic devices and technologies to consider, they describe several examples which are not currently in common clinical use, such as various thresholding algorithms for visual field assessment and web-and/or tablet-based approaches highly suited for remote testing, continuous iop monitoring systems, and ai software for image analysis that may play a fundamental and central role in future teleophthalmology programs. in a recent study on 200 adult glaucoma patients, telemedicine was demonstrated to be equally effective at identifying glaucomatous disease progression, when compared with in-clinic visits, and was supported as having a role in long-term care for glaucoma patients when combined with regular in-person examination, even regardless of special circumstances such as patients residing in distant rural areas, or the current covid-19 outbreak [64] . long-term retention among low-risk glaucoma patients was addressed and favorably demonstrated in a retrospective review summarizing research conducted at kaiser permanente [65] . a tele-screening program aimed at glaucoma in addis ababa, ethiopia, concluded glaucoma and glaucoma suspect prevalence to be 7.9% and 13.8%, respectively. aside from remote diagnosis, patients were also offered remote management and treatment recommendations [66] . accuracy and consistency of telemedicine techniques in comparison with the traditional clinical exam were also confirmed in a prospective study of 107 subjects who underwent automated tonometry, measurements of their refractive state, keratometry readings, a nonmydriatic retinal scan, and an oct, which provided a wealth of information, including measurements of central corneal thickness, angle anatomy, cup/disc ratio, retinal nerve fiber layer distribution, and posterior pole ganglion cell complex data [67] . tan et al. suggested that advances in ai can lead to improved glaucoma screening at lower cost and significantly extend the reach of screening encounters, compared with manual appointments. they noted that deep-learning algorithms for diagnosing glaucoma based on optic disc photographs and/or oct may be more accurate as compared with expert human graders [68] . in a large survey conducted among 92 lead consultant ophthalmologists in the uk, efficiency and patient safety were rated to be at least equivalent to in-person care, and more than 80% of them perceived glaucoma virtual clinics to be acceptable for their patients. of those not currently operating a glaucoma virtual clinic, 9/21(42.9%) respondents were planning to establish one [69] . teleophthalmology applications in managing anterior segment diseases were reviewed by hu and lorch [70] . they discussed various aspects including clinical context (screening and diagnosing), encounter settings (home, mobile health units, general practitioner (gp) office), feasibility (diagnostic accuracy, cost-effectiveness), and barriers to implementation (medico-legal aspects, reimbursement, disparities in care, and patient and provider attitudes). they concluded teleophthalmology to hold the potential for remotely delivering both acute and chronic diagnostic and therapeutic medical care to low-access patients. a teleophthalmology study conducted at the veterans affairs healthcare system on 256 patients, who underwent tele-screening followed by an in-person in-clinic examination on the same day, showed substantial agreement for cataract and dr diagnosis, followed by glaucoma and amd in descending order [71] . a 1-year retrospective audit of a teleophthalmology consulting program of 709 patients in western australia showed that cataract was the most frequent diagnosis (42.7%) followed by glaucoma (11%), amd (4.4%), and dr (3.8%). among diagnoses made at the conclusion of the teleophthalmology consultation, urgent conditions could also be identified, such as external eye trauma, periorbital cellulitis, narrow-angle glaucoma, retinal/vitreous detachment, and retinal artery/vein occlusion [72] . alabi et al. described a novel application of telemedicine consultation in evaluating recovered donor corneas for transplant eligibility according to specific corneal findings in the epithelium, stroma, and endothelium. digital images were taken using a slit lamp, oct, and a specular microscope [73] . a handheld slit lamp with recording capabilities was reported to assist in tele-diagnosing anterior segment conditions in a correctional setting in australia [74] . inflammatory diseases could also be remotely diagnosed as described by schallhorn et al. when a young american soldier deployed at sea on a us navy aircraft carrier was admitted to the clinic with complaints of acute eye redness. the patient underwent a telemedicine consultation and was promptly diagnosed and treated for syphilitic uveitis [75] . providing clinical concepts and advice in a brief format was also described in a novel teleophthalmology educational tool utilized by ophthalmology residents and specialists, specifically in the context of anterior segment conditions [76] . telemedicine-assisted informed consent meetings prior to laser vision correction and refractive lens exchange procedures were found to be generally preferred among patients, who reported an equal satisfaction rate as those who had an in-person meeting with their surgeon [77] . a validation study of 99 patients demonstrated that telemedicine can offer a sensitive and specific monitoring modality for following the growth of choroidal and iris nevi in an ophthalmic oncology setting [78] . a similar retrospective observational pilot study on 71 patients exhibited 100% sensitivity and negative predictive value in growth detection when an examination was carried out by trained ultrasound technicians and remotely reviewed by an ophthalmologist [79] . notably, nankivil et al. introduced a robotic remotely controlled stereo slit lamp system, which allows 3d viewing and recording of the patient examination via a local network, internet, and satellite [80] . although only healthy subjects were tested with this system, it holds the potential for conducting a "distant face-to-face" slit lamp examination of the anterior segment of the eye. limiting ambulatory eye care to urgent conditions, particularly in high-volume procedures, may assist to limit the potential for virus transmission in the community. as the use of telemedicine continues to rise, cybersecurity and patient privacy will become more critical concerns for healthcare providers. ethical, legal, medico-legal, and regulatory aspects regarding telemedicine in ophthalmology are described in a review by gioia and salducci [81] . since telemedicine cannot be defined as an independent accredited professional discipline, they suggested certification courses via teleeducation should become a standardized process. moreover, a telemedicine task force in ophthalmology, involving the academic and research world, was suggested to be founded in order to discuss and establish legislation and guidelines for telemedicine applications in ophthalmology. in a special communication published in jama ophthalmology, a summary of an ophthalmic digital health workshop regarding safety, privacy, security, and effectiveness of ophthalmic digital devices and telemedicine platforms was presented. the panel strongly agreed that telemedicine is a cost-effective approach to improve timely access to care and early screening for dr, rop, and glaucoma [82] . an economic evaluation of the cost-effectiveness of teleophthalmology was reviewed by sharafeldin et al. specifically in the context of dr, amd, and glaucoma screening. teleophthalmology for glaucoma and dr was found to be more cost-effective when compared with in-person clinic examinations [83] . ai utilization in telemedicine, particularly in ophthalmology-a field that relies heavily on digital photography and imaging-has the potential to facilitate screening, diagnosis, and monitoring of various eye diseases in primary care and community settings and reduce unnecessary crowding in ambulatory health centers [84, 85] . other image processing methods, such as binarization and median filtration, have been utilized to produce highly accurate algorithms that can identify and pinpoint hard exudates in dr [86] . a major emerging aspect of teleophthalmology is home monitoring. self-measured clinical parameters can lead patients to better adhere to follow-up, specifically in light of a stay-athome directive. distortions and disturbances in the visual field and in visual acuity could be effectively monitored from distance by the patients themselves. an at-home monitoring device for the early detection of amd was shown to be effective for remotely managing patients at high-risk for choroidal neovascularization development, as presented in the home trial. a similar application of an at-home handheld mobile device demonstrated a high compliance rate among elderly patients with neovascular amd treated with ranibizumab, when asked for daily performance of visual hyperacuity tests. a mobile self-monitored modality presented recently has been shown to offer detection and characterization of metamorphopsia in amd patients and distinguish between dry and wet amd to some extent. future application for accessible at-home remote monitoring of retinal characteristics may be an oct test. as the pandemic accelerates the development and implementation of home monitoring technology platforms, most of the technologies presented above can be used for selfmeasurement of relevant parameters and have the potential to positively impact earlier detection and strict follow-up, and ultimately improve visual acuity outcomes in other ophthalmic diseases such as in glaucoma and dr. in addition to potential clinical benefits of utilizing teleophthalmology, other important aspects such as patient satisfaction and cost savings are encouraging. for example, an australian study demonstrated that patient satisfaction with teleophthalmology, namely, real-time video consultation for a variety of ocular conditions, was high with patients reporting that telemedicine enabled them to save both money and time [87] . similar results were also found specifically in the context of dr screening in rural areas [88] . utilizing telemedicine for rehabilitation in patients with low vision exhibited high satisfaction rates among participants and providers in a pilot study by bittner et al. [89] . nevertheless, a 2020 cochrane systematic review failed to demonstrate the benefits of using telemedicine for remote delivery of rehabilitation services to patients with low vision [90] . optometry services can also be remotely applied. phanphruk et al. described an app-based teleservice for the measurement of ocular alignment that was shown to be equally accurate to an in-clinic examination [91] . das et al. described how another dedicated app could assist teleophthalmology video consultations in rural areas in india; 16.23% of the 15,001 patients included in the s t u d y w e r e p r e s c r i b e d g l a s s e s u s i n g t h i s teleophthalmology platform [92] . teleophthalmology has repetitively been shown to aid in the screening and management of a range of adult and pediatric ocular conditions. it has the potential to increase access to primary and specialty care and overcome the unique barriers the covid-19 pandemic creates. teleophthalmology has so far been mostly utilized for screening of dr, whose prevalence continues to rise, diagnosis of glaucoma, and monitoring for amd. assisting primary care physicians to better triage patients with acute ocular complaints and promptly referring those most in need to an eye specialist were also described, thus widening the diagnostic and therapeutic options of teleophthalmology for ocular emergencies beyond the management of chronic conditions. the establishment of dedicated ophthalmology clinics equipped with remote screening devices that are self-operated, or that could be operated by minimally trained personnel, may bridge a gap in the availability of treatment in periods of lengthy quarantine and isolation, such as covid-19 patients are currently experiencing. for medical personnel, remote care is a safer alternative to in-person examination, also allowing more patients to be screened in any given period of time. advanced imaging techniques such as ultrawide field imaging, ai-based algorithms, and automated robot-based systems have the potential to accelerate teleophthalmology implementation and increase its utility. nevertheless, telemedicine relies heavily on network and internet capabilities, integration with current electronic medical records (emrs) and clinical workflow, and imaging quality. lastly, barriers in the legal, financial, bureaucratic, and conservatism arenas will need to be addressed on a country by country basis. the technological barriers described in this review still withhold and slow wide-scale implementation. with improvements in image processing, as well as better integration with emrs, teleophthalmology will likely become a far more accepted and utilized modality, all the more so in circumstances where social distancing is inflicted upon us. models of care in tele-ophthalmology: a scoping review home-care-for-patients-with-suspected-novel-coronavirusinfection-presenting-with-mild-symptoms-and-management-ofcontacts interim guidance. discontinuation of isolation for persons with covid-19 not in healthcare settings clinical characteristics of coronavirus disease 2019 in china clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study the psychological impact of quarantine and how to reduce it: rapid review of the evidence coronavirus disease 2019 (covid-2019) infection among health care workers and implications for prevention measures in a tertiary hospital in wuhan, china systematic review of the agreement of tonometers with goldmann applanation tonometry comparison of scleral tono-pen intraocular pressure measurements with goldmann applanation tonometry comparison of three different tonometers in eyes with angle closure characteristics of ocular findings of patients with coronavirus disease 2019 (covid-19) in hubei province, china the possibility of covid-19 transmission from eye to nose can the coronavirus disease 2019 (covid-19) affect the eyes? a review of coronaviruses and ocular implications in humans and animals sars-cov-2 isolation from ocular secretions of a patient with covid-19 in italy with prolonged viral rna detection estimates of the percentage of us adults with diabetes who could be screened for diabetic retinopathy in primary care settings strategies to tackle the global burden of diabetic retinopathy: from epidemiology to artificial intelligence teleophthalmology screening for diabetic retinopathy in brazil: applicability and economic assessment accuracy of detection and grading of diabetic retinopathy and diabetic macular edema using teleretinal screening non-mydriatic fundus camera screening with diagnosis by telemedicine for diabetic retinopathy patients with type 1 and type 2 diabetes: a hospitalbased cross-sectional study teleophthalmology: a strategy for timely diagnosis of sight-threatening diabetic retinopathy in primary care implementation of medical retina virtual clinics in a tertiary eye care referral centre clinical outcomes of a hospital-based teleophthalmology service: what happens to patients in a virtual clinic a systematic review of teleophthalmological studies in europe effectiveness of teleretinal imaging-based hospital referral compared with universal referral in identifying diabetic retinopathy: a cluster randomized clinical trial modeling a telemedicine screening program for diabetic retinopathy in iran and implementing a pilot project in tehran suburb the indian health service primary care-based teleophthalmology program for diabetic eye disease surveillance and management evidence-based canadian guidelines for tele-retina screening for diabetic retinopathy: recommendations from the canadian retina research network (cr2n) tele-retina steering committee a novel hybrid fixed and mobile ultra-widefield imaging program for diabetic teleretinopathy screening practice guidelines for ocular telehealth-diabetic retinopathy retinal telemedicine nonmydriatic fundus photography in patients with acute vision loss patients' perspectives on the barriers to referral after telescreening for diabetic retinopathy in communities patient perceived value of teleophthalmology in an urban, low income us population with diabetes cdc covid-19 response team (2020) coronavirus disease 2019 in children -united states pathophysiology, screening and treatment of rop: a multi-disciplinary perspective telemedicine for rop validity of a telemedicine system for the evaluation of acute-phase retinopathy of prematurity telemedicine approaches to evaluating acute-phase retinopathy of prematurity: study design the role of retinal photography and telemedicine in rop screening telemedical diagnosis of stage 4 and stage 5 retinopathy of prematurity telemedicine applications in pediatric retinal disease auckland regional telemedicine retinopathy of prematurity screening network: a 10-year review prospective observational study of universal newborn eye screening in a hospital and community setting in new zealand the validity of telemedicine-based screening for retinopathy of prematurity in the premature eye rescue program in hungary smartphone-based fundus photography for screening of plus-disease retinopathy of prematurity age-related macular degeneration: clinical presentation, etiology, and diagnosis age-related macular degeneration: treatment and prevention telemedicine for agerelated macular degeneration artificial intelligencebased decision-making for age-related macular degeneration teleophthalmology for screening for eye diseases in older patients with cognitive complaints evaluation of a remote diagnosis imaging model vs dilated eye examination in referable macular degeneration telemedicine in the management of exudative age-related macular degeneration within an integrated health care system why miss the chance? incidental findings while telescreening for diabetic retinopathy the detection of spontaneous venous pulsation with smartphone video ophthalmoscopy accuracy and reliability of a handheld, nonmydriatic fundus camera for the remote detection of optic disc edema diagnosis of retinal detachments by a tele-ophthalmology screening program teleophthalmology for age-related macular degeneration and diabetic retinopathy screening: a systematic review and meta-analysis imaging in retinopathy of prematurity pediatric diabetic retinopathy telescreening open-angle glaucoma: epidemiology, clinical presentation, and diagnosis philadelphia telemedicine glaucoma detection and follow-up study: methods and screening results philadelphia telemedicine glaucoma detection and follow-up study: analysis of unreadable fundus images telemedicine for glaucoma: guidelines and recommendations telemedicine in long-term care of glaucoma patients two-year outcomes of a pilot glaucoma suspect telemedicine monitoring program results from the first teleglaucoma pilot project in addis ababa tele-glaucoma vs clinical evaluation: the new jersey health foundation prospective clinical study glaucoma screening: where are we and where do we need to go? acceptability and use of glaucoma virtual clinics in the uk: a national survey of clinical leads teleophthalmology for anterior segment disease diagnostic accuracy of technology-based eye care services: the technology-based eye care services compare trial part i optometry-facilitated teleophthalmology: an audit of the first year in western australia novel use of telemedicine for corneal tissue evaluation in eye banking: establishing a standardized approach for the remote evaluation of donor corneas for transplantation telemedicine in the correctional setting: a scoping review military teleconsultation services facilitate prompt recognition and treatment of a case of syphilitic uveitis aboard a united states navy aircraft carrier at sea during combat operations without evacuation capability concept and uptake of just-a-minute clinical pearl: a novel tele-ophthalmology teaching tool informed consent in refractive surgery: in-person vs telemedicine approach tele-oncology: a validation study of choroidal and iris nevi tele-ophthalmology for the monitoring of choroidal and iris nevi: a pilot study robotic remote controlled stereo slit lamp medical and legal aspects of telemedicine in ophthalmology evaluating new ophthalmic digital devices for safety and effectiveness in the context of rapid technological development review of economic evaluations of teleophthalmology as a screening strategy for chronic eye disease in adults artificial intelligence screening for diabetic retinopathy: the real-world emerging application artificial intelligence and deep learning in ophthalmology an approach to automatic hard exudate detection in retina color images by a telemedicine system based on the d-eye sensor and image processing algorithms real-time teleophthalmology video consultation: an analysis of patient satisfaction in rural western australia use of expectation disconfirmation theory to test patient satisfaction with asynchronous telemedicine for diabetic retinopathy detection feasibility of telerehabilitation for low vision: satisfaction ratings by providers and patients telerehabilitation for people with low vision validation of strabis pix, a mobile application for home measurement of ocular alignment app-based tele ophthalmology: a novel method of rural eye care delivery connecting tertiary eye care center and vision centers in india publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations acknowledgments the authors would like to thank debby mir phd for her thoughtful scientific editing of the manuscript. conflict of interest the authors declare that they have no conflict of interest.ethical approval this article does not contain any studies with human participants or animals performed by any of the authors. key: cord-323273-q53wf6au authors: olivia li, ji-peng; liu, hanruo; ting, darren s.j.; jeon, sohee; chan, r.v.paul; kim, judy e.; sim, dawn a.; thomas, peter b.m.; lin, haotian; chen, youxin; sakomoto, taiji; loewenstein, anat; lam, dennis s.c.; pasquale, louis r.; wong, tien y.; lam, linda a.; ting, daniel s.w. title: digital technology, tele-medicine and artificial intelligence in ophthalmology: a global perspective date: 2020-09-06 journal: prog retin eye res doi: 10.1016/j.preteyeres.2020.100900 sha: doc_id: 323273 cord_uid: q53wf6au the simultaneous maturation of multiple digital and telecommunications technologies in 2020 has created an unprecedented opportunity for ophthalmology to adapt to new models of care using tele-health supported by digital innovations. these digital innovations include artificial intelligence (ai), 5th generation (5g) telecommunication networks and the internet of things (iot), creating an inter-dependent ecosystem offering opportunities to develop new models of eye care addressing the challenges of covid-19 and beyond. ophthalmology has thrived in some of these areas partly due to its many image-based investigations. tele-health and ai provide synchronous solutions to challenges facing ophthalmologists and healthcare providers worldwide. this article reviews how countries across the world have utilised these digital innovations to tackle diabetic retinopathy, retinopathy of prematurity, age-related macular degeneration, glaucoma, refractive error correction, cataract and other anterior segment disorders. the review summarises the digital strategies that countries are developing and discusses technologies that may increasingly enter the clinical workflow and processes of ophthalmologists. furthermore as countries around the world have initiated a series of escalating containment and mitigation measures during the covid-19 pandemic, the delivery of eye care services globally has been significantly impacted. as ophthalmic services adapt and form a “new normal”, the rapid adoption of some of telehealth and digital innovation during the pandemic is also discussed. finally, challenges for validation and clinical implementation are considered, as well as recommendations on future directions. consolidation of tele-health, the development of 5 th generation wireless networks 152 (5g), artificial intelligence (ai) approaches such as machine learning (ml) and deep 153 learning (dl), and the internet of things (iot), as well as digital security capabilities 154 such as blockchain, have created an extraordinary ecosystem for new opportunities 155 in healthcare and other industries ). these developments could 156 potentially address some of the most urgent challenges facing health service in 2019, who started developing a framework for the adoption of digital innovations 189 and technology in healthcare. the who recommendations on digital interventions in 190 healthcare promotes assessment on the basis of 'benefits, harms, acceptability, 191 feasibility, resource use and equity considerations', and views these tools as still 192 very much that -tools -in the journey to achieving universal health coverage and 193 sustainability (world health organisation 2019). there are several digital interventions that have been prioritised for review by the 196 who. of relevance to this discussion are: the use of client-to-provider telemedicine 197 to complement health service delivery; the use of provider-to-provider telemedicine; 198 targeted customised health information transmission; health worker decision making 199 support; digitised health information tracking; and education. in all these scenarios, 200 the review highlights the need for monitoring of patient safety, privacy, traceability, 201 accountability and security, with plans in place to address any breaches. processes 202 for these have been innate within the pharmaceutical and other medical devices 203 industries, and new technological entrants to this traditional sector should consider 204 these during development of the services. there will also be ethical conundrums that 205 have yet to be articulated and debated. the engaged clinician should seek to be 206 involved in the development of these new advances to closely align any innovations 207 to solve unmet clinical needs. simultaneously, clinicians should examine if any 208 innovation complies with quality, ethical, and sustainable healthcare, as legislation 209 invariably lags behind such momentous leaps in innovation. telemedicine enable clinicians to evaluate their patients remotely. this can be 216 desirable for several reasons. first, telemedicine can facilitate more efficient and 217 equitable distribution of limited healthcare resources. this allows delivery of care to 218 distant areas where there is a shortage of doctors and other professionals, reduces 219 travel and the associated carbon footprints, and connects patients with rare diseases 220 to speciality care and address the transport challenges some patients face. waiting 221 times could be reduced through increased capacity and access to care for both 222 chronic and acute disease patient. in the acute setting, patients could receive 223 immediate specialist input even if one is not available locally. second, amid the covid-19 pandemic and in mitigating infection risk in the 226 healthcare setting, real-time telemedicine has been rapidly incorporated into routine 227 care delivery. the patient population telemedicine aims to serve is no-longer focused 228 on targeting remote regions. instead it is rapidly becoming a new standard of care. it 229 enables triaging prior to patients' arrival into hospital to avoid unnecessary visits and 230 exposure risks and has been adopted by multiple centres across the world 231 j o u r n a l p r e -p r o o f (hollander and third, video-consultations in combination with innovative service design already exist 235 that further limits patient journeys and clinic visits whilst maximising the quality of the 236 telemedicine consultation. in scotland, optometric practices have been set up 237 strategically across some regions to provide primary eye care services (nhs 238 scotland 2020). smart phones attached to slit-lamps enable ocular biomicroscopic 239 videography, empowering ophthalmologists to view the patient's examination 240 features in real-time without the patient attending. also, simplification of image 241 sharing of data such as oct scans can be achieved by screen sharing, which has 242 long been a challenge both within ophthalmology and in radiology due to the variety 243 of available formats and software. devices such as tonometers may be prohibitively expensive. effective tele-screening programmes require multiple components. first, there 251 should be a reliable, cost-effective and operator-friendly data gathering system. a 252 preferred goal is to achieve longitudinal consistency of data format to facilitate 253 comparisons. the device itself should be simple, with mechanisms in place to 254 facilitate data transmission to the iot. ideal designs should involve networks where 255 multiple, simpler devices can communicate with a central station. system updates 256 would involve the central stations to enable streamlined logistics and cost efficiency, 257 particularly if the network has widely dispersed simpler devices. second, the data must be processed and enabled to identify the disease of interest. 260 the most frequently adopted model at present is the use of trained persons to read 261 the collected images, as in diabetes tele-retinal screening programmes. whilst larger 262 numbers can be screened this way in comparison to direct clinician reviews, it 263 remains a costly and resource intensive process involving highly trained graders. 264 while dl is starting to be incorporated to this process, the potential benefits from this 265 adaptation are unknown. regulatory bodies recognise the potential of ai in 266 healthcare, and the fda has approved the use of an ai algorithm for the diagnosis of 267 dr in the primary care setting (abramoff et al. 2018 ). finally, the outcome must be conveyed in a timely manner to the patient and the 270 healthcare provider to facilitate appropriate medical management. this 271 communication again could involve a clinician consultation, but most normal 272 outcomes may be communicated in an automated manner such as via a smart 273 phone app or text message. 274 275 j o u r n a l p r e -p r o o f beyond simply replicating current services albeit remotely, the collection, storage 276 and transmission of offer the potential of combining telemedicine with ai. when used 277 prospectively with longitudinal data, vast swathes of new knowledge such as disease 278 progression and real-world, real-time incidence calculation could be harnessed. if 279 well adopted, the data collected would enter the realms of big data, and far exceed 280 the capabilities of data capture that most individual studies are able to achieve. 281 moreover, this could grow into a consistent source of longitudinal data which would 282 be valuable in the development of disease progression forecasting capabilities, 283 incorporating ai. 284 285 2.2 5 th generation (5g) telecommunications 286 287 5g wireless communications was designed to meet the challenges of serving large-288 scale complex network connections. these networks have extremely low latency, 289 higher capacity, and improve the speed of data transmission through the use of 290 higher frequency millimetre waves compared to existing networks (simko and 291 mattsson 2019). latency in 5g transmission can be less than 1 millisecond of delay 292 compared to about 70milliseconds on the 4g network, and give significant 293 improvement to the users' perception of the service (samsung 2015) . download 294 speeds on 5g networks can be increased 20 fold from the current 1 gigabit per 295 second on 4g (nordrum, clark, and staff. 2017) . and all this magnitude increase in 296 function whilst simultaneously reducing energy consumption by the connected 297 devices (agiwal, roy, and saxena 2016). 5g networks will deliver an end-to-end 298 latency of less than 5 milli-seconds and over-the-air latency of less than one 299 millisecond -which is one-tenth of the 4g network latency (samsung 2015) . 300 301 5g utilises small cells, which are miniature base stations that have low power 302 requirements. however, because 5g transmits at higher frequencies, signal 303 attenuation becomes a greater challenge, and these base stations need to be placed 304 closer than 4g base stations (every 250 meters or so) (national academies of 305 sciences et al. 2019). to ensure consistent signal transmission, base stations will 306 need to be densely populated. despite the base stations being smaller in size, the 307 increased infrastructure needs of a 5g network with these cells will not be practical 308 in sparsely populated rural regions. thus whilst telemedicine has been traditionally 309 regarded as being able to contribute to healthcare delivery to these areas in a 310 meaningful way, it may in fact continue to exclude those who already struggle to 311 access physical care. 312 313 in addition to being able to support increasing bandwidth demands from users and 314 patients, 5g enables ultra-high-definition (uhd) multimedia streaming with 315 enhanced user experience. the high-resolution images can be more easily 316 transferred. better quality and reliable video-consultations with improved patient 317 experience may contribute to forging better physician-patient relationship. real-time 318 slitlamp examinations streamed in high-definition has the potential to become 319 j o u r n a l p r e -p r o o f common place. with imperceptible latency, the clinician could control a slit-lamp 320 remotely whilst looking at a mobile device displaying the eye being examined 321 remotely. the immersive experience promised by 5g can also be used to augment 322 the learning experience, particularly the visually-based tasks such as surgery. despite these great expectations, 5g will not be the panacea for all connectivity 325 challenges. the reported speeds assume that every network is using 5g, but not 326 surprisingly the implementation of 5g will be gradual as new cells are built and 327 installed. this incremental adoption of expensive infrastructure means that the 328 network will need to remain compatible with legacy networks, and with other 329 operators who may be implementing at a different speed (rashid 2020) . 330 331 in being compatible, and with the networks essentially being a patchwork of wireless 332 connections incorporating various generations, the same vulnerabilities found in 333 older generation networks will remain. well-knowns flaws of the data packet 334 transmission protocol that is used across the different generations of networks, the 335 general packet radio service (gprs) tunneling protocol (gtp), include not 336 validating users' physical location permitting attackers to spoof locations and 337 allowing attackers to impersonate other users or use false credentials, so the 338 impersonated subscriber is charged for costs incurred. attackers can block all 339 connections stemming from a single node so legitimate subscribers cannot access a 340 connection in the given geographical region, in a denial-of-service attack (rashid 341 2020). the most basic requirements of connectivity in healthcare are security and 342 reliability, and despite the impressive numbers 5g promises, it may be still some 343 time before these two basic tenets are consistently achieved. 344 345 2.1.1 5g and the covid-19 pandemic 346 347 the lockdown orders across the world has brought a sudden strain on existing 348 cellular networks. as countries responded, work, education, healthcare, and most 349 other human interactions were suddenly pushed onto the virtual arena. the 350 pandemic has shown that telemedicine is not only reserved for the remote and 351 underserved. in fact, telemedicine can routinely serve the wider population if it can 352 be shown to be safe, efficient, and inclusive, with measures to ensure security, 353 robustness and capacity, particularly in densely populated regions with massive 354 competing demands for bandwidth. though few examples currently exist, 5g telemedicine has already been 357 implemented. in china, the successful utilisation of a 5g telemedicine network was 358 reported in sichuan province (hong et al. 2020 process is time-consuming and costly, but also makes ophthalmology one of the 454 specialities particularly well-suited to dl techniques and its real-world application. 455 the application of dl to ophthalmic images, such as digital fundus photographs and 456 visual fields, has been reported to achieve the automated screening and diagnosis of 457 common vision-threatening diseases, including diabetic retinopathy (dr) ( healthcare is notably slower. there is a real risk that high hopes for the new 568 technologies described elsewhere in this paper will flounder upon the reality of 569 healthcare systems that remain digitally immature. some barriers to innovation in 570 healthcare are perfectly legitimate, for example the real risk that sub-optimal 571 deployment of a digital technology could lead to patient harm. other barriers are 572 entirely artificial, and foremost among these are the perverse incentives created by 573 billing and tariff systems. in the uk, for example, there has only recently been a 574 move to correct the imbalance between poorly reimbursed remote consultations and 575 well reimbursed face-to-face consultations (brennan, serle, and clover 2018). 576 577 when a technology has successfully navigated the ethical, financial, regulatory, and 578 safety barriers to implementation in healthcare, the rate of attrition remains high. in 579 order to be scalable beyond local pilots, the technology must either fit in seamlessly 580 with existing clinical practice, or it must be sufficiently compelling to cause clinical 581 practice to change (as we have seen with oct platforms in ophthalmology). the 582 failure of the uk's national programme for it is a case study for this 583 phenomenon(robertson, bates, and sheikh 2011). where local adoption has been 584 successful, innovations can be slow to spread through a fragmented system, with 585 funding for spread of innovation often a small fraction of the research and 586 development budget (collins 2018) . a partial solution to these challenges has been the creation of innovation units 589 embedded in hospitals and academic medical centres (e.g. cleveland clinic 590 innovations and the digital clinical lab at moorfields eye hospital). these units can 591 help to develop digital technologies that improve healthcare delivery in the real world, 592 rather than developing solutions that can't easily be incorporated into routine practice. 593 while innovation units can earmark resources, a major enabler is their ability to bring 594 together multi-disciplinary teams that allow the development of useful solutions. 595 these include, among others, engineers, developers, behavioural scientists, 596 intellectual property specialists, and clinicians. the development of local capabilities 597 to drive digital innovation mirrors the acceptance that national initiatives, such as 598 emr deployment, can be more successful when driven from "bottom up" process 599 whereby local solutions are integrated in a modular fashion (aanestad and jensen 600 2011). a key enabler to this modular approach to innovation is the adoption of shared 603 interoperability standards. without these standards, we run the risk of creating a 604 complex ecosystem of technologies that are incapable of communicating with each 605 other. ophthalmology is particularly retrograde on this, with most devices using 606 vendor-specific file formats. vendor-neutral approaches will improve the ability of ai 607 algorithms, for example, to work on a common data substrate. these standards have 608 long been suggested, but we are now beginning to see concerted effort towards their 609 adoption, for example smart-on-fhir, a standards-based interoperable apps 610 platform for ehr (mandel et screening programmes, whilst also utilising the data generated during the screening 755 process to aide in the further development of existing and new algorithms. figure 4 756 demonstrates the electronic systems that are already in place to streamline the 757 management of a patient's journey, with virtual integration of each step of their 758 journey from registration to ehr to management of images. myriad dl programmes 759 are being developed for dr diagnosis, with several models evolving into clinical 760 adoption. training datasets and diagnostic performance for optic disc pathology using oct. 1128 the widespread availability of such an algorithm could extend the utility of fundus 1129 images acquired in non-ophthalmic centres. compared to optic disc images, vf data are characterized by low dimensionality and 1132 high noise, and such datasets could be refined using unsupervised ml algorithms. the two most reported unsupervised algorithms are clustering and component 1134 analysis ( the most intractable problem of treating amd is the frequent and time-consuming 1207 appointments requiring review, evaluation and possible subsequent intravitreal 1208 injection. since amd treatment is determined mainly from the va and oct findings, 1209 telemedicine could be as useful as face-to-face office consultation. a meta-analysis 1210 in 2018 suggested that teleophthalmology for amd is as effective as face-to-face 1211 examination, and potentially increases patient participation in screening ( in 2015, the first prospective randomized study to assess the efficacy of telemedicine 1217 for both in the initial screening and recurrence monitoring of neovascular amd was 1218 reported in canada (li et al. 2015) . best corrected visual acuity, iop, color fundus 1219 photography, and macula oct were incorporated in a "store and forward" 1220 telemedicine model. those in the telemedicine arm attended a local ophthalmologist 1221 who performed the screening, and the data was stored on a database, which was 1222 then reviewed electronically by a retina specialist. in those referred for initial 1223 screening of neovascular amd, there was no statistically significant difference in 1224 patient waiting times to further diagnostic tests and to treatment. there was also no 1225 significant difference in patient satisfaction except for parking issues. in those 1226 monitored for recurrence, there was no significant difference in the visual outcome 1227 between groups (20/184.8 vs. 20/180.7, p=0.99). this "store and forward" model still utilizes an ophthalmologist as the initial screener. while a technician can be for initial data acquisition used for screening, telemedicine 1231 can be applied further so that initial screening and subsequent monitoring can be 1232 remote, out of the clinical setting and into the home. home monitoring and self-care have taken centre stage in modern medicine. 1237 remote in-home monitoring is currently practiced to monitor acute and chronic 1238 diseases such as body temperature to assess a upper respiratory infection, blood 1239 pressure for hypertension (noah et the alleye tm application ( figure 5) , which similarly tests hyperacuity, but examines 1311 a larger area of the macula (12 degrees compared to 3 degrees of field) has 1312 demonstrated its ability to detect neovascular amd and discriminately classify 1313 between dry and wet disease ( prove to be important during pandemic as well as in the future to limit in-person visit 1325 only when needed. 1326 1327 the use of telemedicine for amd in the united states has centered on amd 1330 screening and remote-monitoring systems with some utilising artificial intelligence 1331 applications but as yet there are no large-scale programs for either screening or 1332 monitoring of amd (brady and garg 2020). there are unique challenges to the 1333 screening and monitoring of amd with lack of consensus on the suitability of the 1334 disease for population screening, and the need for octs rather than simple fundus 1335 photographs as used in dr screening and ai algorithms (brady and garg 2020). the 1336 mayo the virtual clinics accounted for approximately 40% of amd service appointments. with the introduction of the virtual clinics, patients were followed up with a mean of 1359 5.3 weeks compared to 6.9 weeks in the period of conventional clinics. refractive error is a key public health concern with more than 650 million people 1388 suffering from insufficient or no refractive correction globally (global burden of 1389 disease study 2015) with the incidence of myopia increasing and poised to escalate 1390 further with urbanization and higher literacy rates (pan, ramamurthy, and saw 2012). adding to this, the optometrist to population ratio is 1:10,000 in high-income 1395 countries and 1:600,000 in low and middle-income countries (di stefano 2001). to evaluate refractive error, traditional visual acuity examination is time-consuming, 1398 and requires the availability of equipment, and examiners skilled in the art of 1399 prescribing spectacles. the procedure is also challenging for people with difficulty in 1400 expressing themselves, such as young children, the elderly, and patients with verbal costly investments for its equipment as well as the hiring of experienced examiners. 1406 consequently, economic implications due to incorrect dispensing remain high even 1407 in developed countries (vitale et al. 2006) . providing good quality refraction services 1408 acceptable to the general population is greatly needed. while myopia alone increases the risk posterior segment complications, these risks 1411 are notably increased in pathologic myopia (pm) when potentially blinding posterior 1412 segment pathological changes appear as a result of the globe elongation 1413 (grossniklaus and green 1992 the focus of tele-myopia has been on to prediction of refractive error from easily 1426 obtainable and consistent methods proven in other disease; namely, using the 1427 acquisition of fundus photographs. to be able to accurate define refractive error to 1428 enable a prescription that is acceptable to the patient would be a significant leap 1429 forward in solving the burden of refractive error. several advanced techniques that assess refractive error accurately have been 1432 developed, and patients were found to be sufficiently motivated to report their symptoms at least 1598 once a month with a good correlation between the two dry eye questionnaires 1599 (r=0.67), underscoring the potential utility of a tele-health approach for monitoring telemedicine presents different challenges in comparison to screening. screening is 1620 repetitive and elective, and the process can be planned with clarity for the input, 1621 processing and outputs. for diagnosis, on the other hand, a telemedicine diagnostic 1622 service must consider a much wider variety of conditions and include more abnormal 1623 conditions. in addition, it is more challenging to streamline and process input data in 1624 manner that achieves high diagnostic accuracy. achieving such accuracy requires 1625 highly trained personnel. clinical agreement between the clinical and e-diagnosis, high (97%) patient 1635 satisfaction, and 37% reduction of unnecessary referral to the hospital eye services. 1636 moreover, the referrals (with digital images if necessary) were processed within 24 1637 hours, enabling a timely triage and management of any urgent and sight-threatening 1638 diseases. when this programme went live throughout southeast scotland, the 1639 referral-to-consultation waiting time was reduced from 14 weeks to 4 weeks. the 1640 foundation of this integration project enabled the safe delivery of eye care services 1641 during the covid-19 pandemic with many primary and urgent eye care services 1642 enabling non-hospital patient care (nhs scotland 2020). a cloud-based referral system in the uk has demonstrated that more than half of 1645 referrals for possible retinal pathologies to hospital eye services from optometrists 1646 could be avoided with a consultant ophthalmologist reviewing fundus photographs of 1647 the referred patients (kern et al. 2019 ), similar to the pathway shown in figure 6 . 1648 although there are still many factors to be addressed such as safety, economic 1649 benefit, patient satisfaction, and outcomes for those patients who were not referred, 1650 there are notable advantages such as timely patient triage, enhanced provider 1651 correspondence and education. this system enabled the referring doctor to be able 1652 to receive the patient outcome via the platform, allowing each case to be an 1653 educational opportunity. the safety of remote triage in emergency ophthalmology still needs to be 1656 demonstrated. one early study showed that of 500 patients who were triaged 1657 remotely in an emergency unit, 1% had delayed treatment due to misdiagnosis 1658 (bourdon et al. 2020 ). prior to widespread adoption of tele-triage, the potential for 1659 harm needs to be more accurately characterised as well as mechanisms put in place 1660 to mitigate the shortcomings of remote reviews. since in the absence the visual isolation of cases in an effort to stop transmission. with the mitigation approach, the 1677 study found that 8 of 10 people may still be affected, resulting in 510,000 deaths in 1678 the uk and 2.2 million deaths in the us by the end of the pandemic. the study 1679 suggested infected cases could be significantly decreased with a suppression 1680 strategy ("lockdown"), which involved closing schools/universities, case isolation, 1681 household quarantine and social distancing. as country after country began imposing "lockdown" measures, including 1684 quarantines and travel bans in an unprecedented scale (parmet and sinha 2020). other specialties, telemedicine was employed to follow-up routine patients, and to 1701 triage and manage new patients presenting to ophthalmology departments. telephone consultations alone could suffice for some patients, but the addition of 1703 video features allows the clinician additional information to more appropriately triage 1704 a patient. live video information can be particularly useful in specialties such as 1705 oculoplastics (kang et al. 2020 ) and strabismus, but also in external eye diseases 1706 where corneal infiltrates may be observed. furthermore, telemedicine allows for non-1707 verbal communication and aids in fostering physician-patient engagement. effective 1708 triage not only keeps many patients out of the hospital but can also shorten the 1709 patient's journey once they arrive in hospital. a patient with classic symptoms of a 1710 retinal detachment may bypass the emergency department and be referred directly 1711 to a vitreoretinal surgeon. the rapid introduction of telemedicine and teleophthalmology during the pandemic 1714 has moved beyond the traditional model of connecting specialists with patients from 1715 remote and underserved regions. instead it has the potential to become the new 1716 standard of care, in particular for triaging patients prior to their hospital attendance. 1717 the new telemedicine systems replacing routine care needs evaluation to ensure 1718 patient safety. governments such as the china and the us have taken steps to facilitate the rapid 1721 upscaling of these services, with the chinese national health insurance agency 1722 covering virtual consultation fees, and the us centres for medicare and medicaid 1723 services (cms) implementing temporary waivers to enable flexibility within the 1724 healthcare system (webster 2020). the manifold surge in uptake reported by cms is 1725 staggering: nearly 1.7 million beneficiaries receiving telehealth services in the last 1726 week of april, 2020 compared to around 13,000 beneficiaries a week prior to the 1727 pandemic (verma 2020). of the 9 million beneficiaries who used a telehealth service 1728 three months from mid march 2020, 30% were conducted over the telephone 1729 suggesting there is still significant work to be done in terms of telecommunications 1730 network, healthcare facilities and clinicians adopting new applications, and 1731 consideration of patient factors. as countries consider the model of eyecare in the post-covid-19 "new normal", 1734 there are several key considerations (table 6) . first, services must allow for 1735 sustainable social distancing measures for protection of patients, staff and the public. 1736 second, those at high risk of serious morbidity and mortality with covid-19 should 1737 be facilitated to isolate wherever possible with access to services at home. third, 1738 plans must be in place for the management of patients who develop eye conditions 1739 concurrently with covid-19. fourth, contingency to manage the 'surge' of patients 1740 who have had deferred appointments or presented late as a result of "lockdown". 1741 fifth, services should have the agility to expand and shut down to essential 1742 provisions responsively in preparation for future peaks of covid-19, and indeed 1743 other future pandemics. finally, there should be measures in place to continually 1744 assess the outcomes of these services to ensure quality of care. the covid-19 pandemic has come at a time when many technologies and the 1747 necessary infrastructure are mature and already established. much can be achieved 1748 with simple and universally available technologies such as telephones, messaging, 1749 and video-calling, albeit via safer and secure applications. subsequently, more 1750 sophisticated eye examinations via telemedicine can occur. this pandemic has 1751 significantly altered the landscape of health care delivery and may have permanent 1752 implications. time is still needed to establish the safety telemedicine on a massive 1753 scale, but the paradigm shift in acceptability to both patients and doctors will be 1754 profound. aside from the technical and infrastructural challenges, there are concerns 1755 over how patients will respond to such a shift in healthcare delivery, and if the loss of 1756 rapport gained from physical interaction will cause harm. clinicians are also 1757 discovering that face-to-face healthcare delivery in the post-covid era has also 1758 changed. face masks and social distancing result in loss some of the non-verbal 1759 communication, impede the delivery of empathy. though there is physical distancing 1760 over a video-consultation, patients are able to see their doctor, and both are able to 1761 see the facial expressions of the other. acceptance in both patients and physicians is 1762 on the increase (pappot, taarnhoj, and pappot 2020; hao 2020). even when 1763 teleophthalmology services have been rapidly adopted during the pandemic, 1764 feedback from a prospective study of 66 patients in an oculoplastics service reported 1765 62% preferred the video consultations to face-to-face, and in this group ranging from 1766 18 years to 88 years (mean 50.7 years), 92% would recommend video consultation 1767 to others (kang et al. 2020 it would not be possible to provide care at pre-covid-19 levels whilst practicing 1776 social distancing and maintaining a safe environment for patients and staff alike. 1777 new models of care are being and need to continue to be rapidly upscaled to enable 1778 safe delivery of care until an effective vaccine or treatment is found for covid-19. the overriding principle of safe care in the covid-19 in ophthalmic practice is 1781 minimizing exposure: mainly by reducing the number and duration of in-person clinic 1782 visits. assessments, tests, consultations and even pharmacy and interventions need 1783 to be minimised to those essential for safe care. the integration of 1784 teleophthalmology will be fundamental and can be utilised at multiple points of a 1785 patient's eye care journey. telemedicine can be and already is being adopted for strabismus. figure 7 provides an example of semi-automated remote triage 1797 workflow for emergency ophthalmology. non-ophthalmologist health care workers including optometrists, nurses and 1800 technicians should be trained in multiple skills if possible so that a single person may 1801 perform several tasks such as assessment of visual acuity and intraocular pressure, 1802 instead of patients moving through a number of different clinical staff each 1803 performing a specific task. this improves efficiency and limits exposure risk. 1804 furthermore, integrating second opinion services to primary care and optometry 1805 practices may enable more appropriate referral into specialized eye units. these measures protect patients and health care workers and contribute to the 1808 larger public health measures. telemedicine also enable ophthalmologists in 1809 isolation to continue to contribute in clinical work and lessen the impact of key staff 1810 shortages. 1811 1812 this current climate provides the perfect ecosystem to reassess care delivery and to 1815 adopt the synergistic and complementary digital technologies discussed above, 1816 incorporating teleophthalmology and ai utilising and facilitated by 5g networks, iot 1817 and big data analysis. there is widespread media interest and raising of public 1818 awareness of the role telemedicine has already started to play in risk mitigation 1819 during the pandemic. 1820 1821 the emergency department may be a good candidate for widespread introduction of 1822 virtual triage prior to attending in person. the patient benefits as they may discover 1823 they do not need to attend in person, and can be treated with medicines prescribed 1824 remotely. if they do need to attend, their in hospital journal may be much more 1825 efficiently managed, being seen directly by the specialists if appropriate. additionally, 1826 with the maturation of chatbots, much of the patient counselling can be done 1827 seamlessly from the video consultation. the healthcare providers too reap the benefits of reduced in person attendance, 1830 costs associated with additional time and space utilisation, as well as use of personal 1831 protective equipment at a time where sustainability must also always be considered. 1832 staff who are able to work from home can contribute, facilitating efficient use of 1833 human resources. reduced attendances also reduces the general workforce risk of 1834 covid-19, avoiding the highly undesirable scenario of transmission between 1835 clinicians and patients. safety of such systems, the remote triaging and automated counselling need to be 1838 evaluated, and until then, clinicians need to oversee each consultation as is standard 1839 process prior to the pandemic. 1840 1841 the figure below demonstrates how a virtual video-based triaging system, with semi-1842 automated features such as registration and counselling, might work. when patients 1843 register, there can be early algorithmic assessment of their presenting complaint. 1844 symptoms such as flashing lights and floaters, new binocular double vision and new 1845 anisocoria will invariably require in-person examination, and as such can be directed 1846 early to a physical appointment without the patient waiting for a full virtual 1847 assessment first. patients who do not necessarily require clinician input, such as 1848 mild dry eyes or chalazia, or followup patients who have seen resolution of their 1849 symptoms, for example treated pre-septal cellulitis or contact-lens related keratitis, 1850 can be directed to a chatbot or video for discussion. the remaining patients will be 1851 connected to a clinician when can proceed with a full history and basic examination 1852 which may involve visual acuity assessment using web-based tools. for conditions 1853 that may be managed remotely, such as early pre-septal cellulitis, mild recurrent 1854 anterior uveitis or indeed early non-vision involving contact lens associated keratitis, 1855 medication can be prescribed and sent to the patient via a dedicated delivery service 1856 or local phamarcy. if necessary, plans can be made for the patient to attend in 1857 person for review. digital transformation through the adoption of teleophthalmology and ai is more than 1869 simply buying new software and hardware, and the next section explores some of 1870 the key challenges to be overcome. real-world validation has proven to be challenging. the size and heterogenous 1877 nature of the digital health sector with its constant and rapid evolution has created a 1878 complex environment for physicians, healthcare providers, patients and regulatory 1879 bodies in assess these tools to address unmet clinical needs (mathews et al. 2019) . 1880 there is a need for a rigorous and transparent validation framework, which has some 1881 flexibility in being applied to a broad range of technological innovations. one 1882 proposed framework suggests evaluation based on technical and clinical 1883 considerations, usability, and cost (mathews et al. 2019 ). technical evaluation is the most obvious, and is the first step to validation. this is 1886 the fundamental aspect of the technology, and should address if the technology 1887 performs its purported function, its accuracy and robustness. for example, does a 1888 video consultation platform enable patients to register to a virtual waiting room and 1889 be connected to the appropriate clinicians in a safe and effective manner, with due 1890 consideration for data protection. clinical validation approaches should reflect those that are well established in clinical 1893 research, but can be tailored for digital technologies. such studies are still 1894 uncommon and may be at least in part due to the lack of clinical experts 1895 simultaneously engaged with technological advances (hatef, sharfstein, and 1896 labrique 2018) the cost of prospective clinical trials as a comparison to existing gold 1897 standards may be off-putting for some in the technology sector who seek rapid 1898 product cycles and returns. usability, and also accessibility, and the intended user of the technology must be 1901 assessed. clinicians may need new skills in order to effectively use the tools. the 1902 effectiveness of their use by patients unsupervised should be assessed, as well as 1903 consideration of those who face barriers in adopting the technologies. cost, and cost effectiveness, as well as the longer term costs should be estimated. 1906 costs may be obvious, such as purchasing the rights to an algorithm, or hidden, 1907 such as increased referrals seen through telemedicine screening services. 1908 implications for all stakeholders needs to be considered, from the patient to clinician, 1909 to funding bodies as well as the state. regulatory bodies attempt to provide guidance for users and payers. workflow disruption and security and privacy concerns (ajami and bagheri-tadi 1986 2013). some of these issues might be potentially overcome with education and 1987 training of the end-users and provision of financial incentives by the government for 1988 meaningful use of ehr system (patel et al. 2013 (patel et al. ). 1989 (patel et al. 1990 after validating the technological and clinical performance, cost-effectiveness 1991 represents the next hurdle to be overcome before the implementation of a specific 1992 tele-health programme. a notable example was reported in the uk where a large 1993 randomised controlled trial in england evaluating the cost-effectiveness of tele-health 1994 intervention for long-term conditions (including heart failure, chronic obstructive 1995 pulmonary disease, and diabetes) demonstrated no additional benefit when 1996 compared to standard care (henderson et al. 2013) . that said, tele-ophthalmology 1997 intervention, particularly for dr screening, has proven to be a cost-effective 1998 approach and is already being implemented in many countries, including the us, uk, 1999 and singapore, at nationwide levels (kirkizlar et orbis international uses a free online ophthalmic telemedicine program partnering 2025 doctors in developing countries with expert mentors internationally (prakalapakorn, 2026 smallwood, and helveston 2012). in a survey of this offering, they reported e-2027 dl algorithm uses the "black box" approach where clinical features that confirm a 2071 diagnosis are not apparent. to underscore the reasons prompting a specific 2072 diagnosis by algorithms would be highly beneficial as it allows for clinicians to 2073 understand assess if the correct features were identified, and to offer new insight into 2074 diseases not previously known. this lack of explainability is a hurdle both for clinician 2075 and patient trust. it is challenging when there is disagreement between the algorithm 2076 and the patient and root cause analysis stops short. it is not possible to know if there 2077 is an inherent error in the algorithm that might be corrected. processes need to be in 2078 place such disagreements, such as an independent third party of a multi-disciplinary 2079 team meeting as would occur where there is clinical uncertainty. there needs to be recognition though, that ai may be proven to be more accurate 2082 than a physician, and detect features humans cannot, as demonstrated by an 2083 algorithm being able to identify sex from fundus photographs (poplin et al. 2018 ). thus it becomes harder to adjudicate between the clinician and ai, when the 2085 adjudicator will invariably be another clinician, in particular if the ai decision making 2086 process is unexplainable. in these cases, it may become unethical not to use ai, 2087 even though we do not fully understand how they work. it is unlikely though, that an 2088 individual algorithm will be able to replace the holistic role of a physician, and 2089 increasingly the role of the physician could evolve the use of ai for specific tasks, 2090 and digest the various outputs to collectively to manage the patient. education on the use and appraisal of ai systems should be incorporated into 2093 medical school programs, and clinicians already in practice will need training to 2094 facilitate its adoption when the technology reaches maturation for clinical practice. technically able staff who would not form part of existing human resources will need 2096 to be recruited, and work with clinicians to champion adoption. in cases of poor 2097 image quality, automated processes may be able to enhance those images and 2098 enable their reading by the algorithm. however, those with residual artefacts will 2099 remain ungradable and require referral to a clinician. 2100 2101 early ai algorithms were tested on images collected in the clinical trials setting with 2102 strict inclusion and exclusion criteria (burlina et al. 2017 with the rapid advancement in digital technology, including ehr, smartphone and 2219 4g/5g technologies, tele-health is likely to pave the way for assessment and 2220 management in the field of ophthalmology. in order for a comprehensive and robust 2221 teleophthalmology platform to thrive, a well-planned eye care delivery system must 2222 exist that considers the resources that are available in specific regions. in 2018, the aao telemedicine task force published an information statement 2225 regarding the development and implementation of teleophthalmology, including 2226 validation of a teleophthalmology programme against a reference standard, 2227 requirement and standards of data acquisition and communication devices, 2228 competency and qualification of involved personnel, quality assurance, and data 2229 protection (american academcy ophthalmology (aao) telemedicine task force 2230 2018). in principle, it is recommended that a tele-health programme should be 2231 implemented and integrated with evidence-based clinical practices where traditional 2232 process of care is already established (american academcy ophthalmology (aao) 2233 telemedicine task performing the specific given task. the replicability of these frameworks may also 2259 vary from country to country due to cultural differences. understanding the prevalence of the common ocular diseases at a national public 2262 health level, country-specific, is paramount as it helps policymakers and relevant 2263 stakeholders to maximise the cost-effectiveness of the tele-medicine programmes by 2264 targeting highly prevalent diseases. in addition, common diseases that are 2265 dependent on image-based diagnosis with universally agreed-upon, evidence-based 2266 classifications (e.g. dr, amd, glaucoma and cataract) should also be prioritised in 2267 the set-up of teleophthalmology programmes. the data derived from tele-health may 2268 also be harnessed to generate big data research and to offer more diverse 2269 information such as patient journey education and disease progression forecasting 2270 (mccall 2020). aspiring to health equality and protection of vulnerable groups should 2271 be a key consideration in every stage of digital innovation and implementation. 2272 2273 the existing digital technologies are predominantly focussed on diagnosis. ai of the 2274 future can increasingly play a role in the guidance of treatment, such as prediction of 2275 how likely patients are to respond to treatments such as intra-vitreal injections in wet 2276 amd or dmo. increasing use of ai in the prediction of refractive outcomes following 2277 cataract surgery can help refine lens selection. for children requiring patching or 2278 those requiring accommodation exercises, digital solutions may be able to help 2279 adherence to treatments, with gamification and introduction of incentives for 2280 compliance, although debate will exist around if such use of technology is desirable 2281 for children. recently, ml associating perimetric cone sensitivities to local oct in patients with 2284 retinitis pigmentosa was applied to predict visual function in lebers congenital 2285 amaurosis (lca) (sumaroka et al. 2019 ). though the training dataset was small, 2286 cone vision improvement potential in some lca was shown to be predictable. this 2287 may permit individual prediction of likely response to treatments and influence 2288 selection to clinical trials so that those with maximal potential gains are selected. increasingly, isolated algorithms will integrate data from across modalities, and 2291 across disciplines. the utilisation of multi-modal imaging is important for specific 2292 diagnosis (for e.g., determination of the neovascular amd subtype, diagnosis of 2293 glaucoma and etc). multi-modal machine learning can be used to evaluate whether 2294 the predictive or diagnostic power of the ai algorithms will increase with the addition 2295 of more imaging modalities. additionally, data from history, and other metrics such 2296 as blood pressure hba1c can be used to increase the predictive power of the 2297 algorithms, and data collected from other specialities such as endocrinology and 2298 rheumatology could contribute. 2299 2300 multi-modal inputs may be help improve the diagnostic and predictive power of ai 2301 systems, and move closer to simulating the decision-making process of a clinician, 2302 but deployment of such multi-modal algorithms in the real-world setting can be 2303 difficult. if the ai has been trained using the ground truth generated by a multi-modal 2304 imaging and additional biomarkers but during clinical use only a limited data is 2305 collected, then that algorithm may not be applicable. therefore a balance needs to 2306 be achieved between what is practical for routine clinical use versus a complex 2307 algorithm that incorporates multiple inputs. 2308 2309 ai may also play a role in interpreting genetic diseases, such as those with variable 2310 expressivity and phenotypes. dl has been applied in genomics but still remains in its 2311 infancy. there have been studies that have shown some success with various challenges exist, such as the lack of explainable ai, balanced datasets representing 2318 both disease and healthy states, and integration of heterogeneous data, which is 2319 akin to some of the challenges presented by multi-modal algorithms discussed 2320 above (koumakis 2020). medical schools and medical training programmes also need to adapt and 2323 incorporate understanding of digital innovations into training. clinicians should learn 2324 to interpret studies on areas such as ai or dl algorithms (ting, lee, and wong 2019) 2325 to know if and when such technologies would be suitable for their practice. medical 2326 students should also learn to conduct remote consultations, be that video or 2327 telephone based only. without the patient being physically present, the focus of 2328 consultations changes somewhat with the importance of excluding pathologies that 2329 require in person assessment rather than simply managing the presenting complaint. 2330 nuanced changes to communication strategies need also to be developed adapted 2331 for virtual consultations, and clinicians need to develop at least some basic 2332 understanding of the technical aspect of each platform to enable simple trouble-2333 shooting for new users. finally patient attitudes need to be studied whilst recognising 2334 these will evolve, as any reaction to something novel. education driven by evidence 2335 and not politics or other motivations, communicated effectively to reach a wide 2336 audience will be crucial in influencing patients to make their own considered 2337 decisions. conclusions 2340 2341 myriad innovations have created a milieu ripe for telemedicine in ophthalmology to 2342 thrive and covid-19 has hastened the development and embracement of these 2343 digital technologies. the growing ai and telecommunications technologies can 2344 potentially transform the delivery of the data-rich and image-dependent specialty of 2345 ophthalmology globally. 5g, iot and ai are starting to be introduced into 2346 ophthalmology, but the potential for reliably linked machines such as octs and 2347 fundus cameras and algorithms changing ophthalmic service delivery is significant, 2348 and is likely to become more prevalent as the 5g network coverages grows, 2349 enabling a more mature iot. these technologies may be able to make key 2350 contributions towards the provision of quality, sustainable eye care to all patients, 2351 and experiences from the pandemic has revealed the utility of telemedicine even in 2352 well-resourced and densely populated. challenges associated with implementation 2353 of these technologies remain, including validation, patient acceptance, and education 2354 and training of end-users on these technologies. physicians must continue to adapt 2355 to the changing models of care delivery, and collaborate with broader teams 2356 involving technology experts and data scientists to achieve universal quality and 2357 sustainable ophthalmic services. the dash box refers to automated pathway, which could proceed without an 3540 ophthalmologist reviewing the case and images. example of 'simple' case: dry amd diagnosed and recorded but no clinical action 3543 required and clinician oversight not required. example of 'complex case: macular hole potentially suitable for surgery, with 3546 clinician alerted and further clinical decision to be made. table 1 . countries, their national screening strategies and the adoption of tele-screening and artificial intelligence in diabetic retinopathy screening. were well received by users, with 96% of 107 users wishing to continue 2028 its use, and 94% of the 78 not using the system wishing to do so. whilst success in 2029 terms of patient and physician satisfaction has been demonstrated with this 'store-2030 and-forward from a medicolegal perspective, physician-patient interaction in tele-health is 2040 currently considered the same as face-to-face consultation. though physicians are 2041 concerned about missing a diagnosis or finding (due to inadequate medical 2042 information or suboptimal image quality), the digital images used could serve as a 2043 powerful objective evidence of the consultation. another noteworthy aspect is that 2044 laws governing physician-patient interactions are disparate across states and 2045 countries. having an overarching regulation of telemedicine would expedite the 2046 introduction and implementation of telemedicine in routine healthcare service regulation of telemedicine is also evolving. the centres of medicare and medicaid cms) broadened provision of telehealth services as part of the emergency 2055 response to the covid-19 pandemic to enable provision of care whilst limited 2056 community spread of the virus 5.2 challenges in clinical deployment of ai 2063 2064 ai has remained largely constrained to the research domain with few examples of 2065 real-world adoption in ophthalmology and healthcare more generally. there are 2066 many contributing factors for this. whilst there is enormous interest and increasingly 2067 robust evidence for the role of ai in dr screening building nation-wide information infrastructures in 2363 healthcare through modular implementation strategies using telemedicine to screen for 2366 retinopathy of prematurity pivotal trial of an 2368 autonomous ai-based diagnostic system for detection of diabetic retinopathy in 2369 primary care offices automated and computer-assisted detection, classification, and 2372 diagnosis of diabetic retinopathy improved automated detection of diabetic retinopathy on a 2375 publicly available dataset through integration of deep learning pivotal trial of an autonomous ai-based diagnostic system for detection of diabetic 2379 retinopathy in primary care offices home monitoring of retinal 2382 sensitivity on a tablet device in intermediate age-related macular degeneration next generation 5g wireless networks: a 2385 comprehensive survey vision network validation study: pilot image stabilization phase barriers for adopting electronic health records 2390 (ehrs) by physicians' novel use of telemedicine for corneal tissue evaluation in eye 2393 banking: establishing a standardized approach for the remote evaluation of donor 2394 corneas for transplantation results of the national program for the 2398 prevention of blindness in childhood by retinopathy of prematurity in argentina 2399 optic cup segmentation methodologies for glaucoma image detection: a survey telemedicine 2404 for ophthalmology information statement augmented intelligence in health care a new low-cost, compact, auto-phoropter for refractive assessment in 2408 developing countries web-based longitudinal remote assessment of dry eye 2410 symptoms l'examen qualitatif de la fonction maculaire can 2414 home monitoring allow earlier detection of rapid visual field progression in 2415 glaucoma? integrating holistic 2417 and local deep features for glaucoma classification improved access and cycle time with an 2420 ''in-house'' patient-centered teleglaucoma program versus traditional in-person 2421 assessment detecting preperimetric glaucoma 2423 with standard automated perimetry using a deep learning classifier integrating diabetic retinopathy screening 2427 within diabetes education services in australia's diabetes and indigenous primary care 2428 clinics' the 2430 accuracy of accredited glaucoma optometrists in the diagnosis and treatment 2431 recommendation for glaucoma promising artificial intelligence-machine learning-deep 2433 learning algorithms in ophthalmology validation of near eye tool for refractive 2435 assessment (netra) -pilot study development and validation of a smartphone-based visual acuity 2438 test (peek acuity) for clinical practice and community-based fieldwork artificial intelligence screening for 2442 diabetic retinopathy: the real-world emerging application representation learning: a review and 2444 new perspectives', ieee transactions on pattern analysis and machine intelligence who warns governments 'this is not a drill' as coronavirus 2447 infections near 100,000 worldwide diagnostic accuracy of ophthalmoscopy vs telemedicine in 2450 examinations for retinopathy of prematurity recent developments in clinical 2452 terminologies -snomed ct, loinc, and rxnorm' machine learning of the progression of intermediate 2456 age-related macular degeneration based on oct imaging teleconsultation in primary ophthalmic emergencies during the covid-19 lockdown 2460 in paris: experience with 500 patients in causes of vision loss worldwide, 1990-2010: a systematic 2464 analysis predicting glaucomatous 2467 progression in glaucoma suspect eyes using relevance vector machine classifiers 2468 for combined structural and functional measurements telemedicine for retinopathy of 2471 prematurity telemedicine for age-related macular degeneration improving accuracy for intraocular lens selection in 2475 cataract surgery tariff set for sweeping change from next year neural networks to identify glaucoma with 2480 structural and functional measurements ranibizumab versus verteporfin for 2483 neovascular age-related macular degeneration automated diagnosis of 2487 plus disease in retinopathy of prematurity using deep convolutional neural 2488 networks failing to 2490 plan and planning to fail. can we predict the future growth of demand on uk eye 2491 care services? optical coherence tomography machine learning 2494 classifiers for glaucoma detection: a preliminary study automated grading of age-related macular degeneration from color fundus 2498 images using deep convolutional neural networks expert diagnosis of plus disease in retinopathy of prematurity from 2505 computer-based image analysis a telemedicine program for diabetic retinopathy in a veterans 2509 joslin vision network eye health care model medicare telemedicine health 2512 care provider fact sheet automated detection of glaucoma from topographic features of 2516 the optic nerve head in color fundus photographs comparison of machine learning and traditional classifiers in glaucoma 2520 diagnosis healthy china 2030: moving from blueprint to action 2522 with a new focus on public health characteristics of severe retinopathy of prematurity patients in 2524 china: a repeat of the first epidemic? gene expression inference 2526 with deep learning 2528 'peripapillary atrophy detection by sparse biologically inspired feature manifold artificial 2531 intelligence in diabetic eye disease screening effectiveness of different monitoring modalities in the 2535 detection of neovascular age-related macular 2536 degeneration: the home study interexpert agreement 2538 of plus disease diagnosis in retinopathy of prematurity accuracy and reliability of remote 2542 retinopathy of prematurity diagnosis detection of clinically significant retinopathy of prematurity using 2545 wide-angle digital retinal photography: a report by the american academy of 2546 ophthalmology deep learning approaches 2549 predict glaucomatous visual field damage from oct optic nerve head en face 2550 images and retinal nerve fiber layer thickness maps evaluation of the svone: a handheld virtual clinics in 2554 glaucoma care: face-to-face versus remote decision-making' diabetic retinopathy in tanzania: prevalence and risk factors at entry into a 2558 regional screening programme adoption and spread of innovation in the nhs virtual glaucoma clinics: patient acceptance and 2562 quality of patient education compared to standard clinics neighborhood 2570 consortium multitrait analysis of glaucoma identifies new risk loci and 2574 enables polygenic prediction of disease susceptibility and progression cryotherapy for retinopathy of prematurity: ophthalmological outcomes at 10 years medicare costs for 2580 neovascular age-related macular degeneration clinically applicable deep learning for diagnosis and referral 2585 in retinal disease', nature medicine low vision enhancement with head-mounted video 2588 display systems: are we there yet? lessons learned from a community-academic project using telemedicine for eye 2591 screening among urban latinos coherence tomography images of the optic nerve head wide-field digital 2597 retinal imaging versus binocular indirect ophthalmoscopy for retinopathy of 2598 prematurity screening: a two-observer prospective, randomised comparison vision 2020: the right to sight. a global initiative for the 2601 elimination of avoidable blindness progress in examining cost-effectiveness of ai in diabetic retinopathy 2603 screening', the lancet digital health can we stop the current 2605 epidemic of blindness from retinopathy of prematurity? revised 2608 indications for the treatment of retinopathy of prematurity: results of the early 2609 treatment for retinopathy of prematurity randomized trial heads-up surgery for vitreoretinal 2612 procedures: an experimental and clinical study 2614 'dermatologist-level classification of skin cancer with deep neural networks impact of non-pharmaceutical interventions (npis) to reduce covid19 2618 mortality and healthcare demand stanford university network for diagnosis of retinopathy 2623 of prematurity (sundrop): five years of screening with telemedicine concerns about exercise are related 2627 to walk test results in pulmonary rehabilitation for patients with copd global causes of blindness and distance vision impairment 1990-2020: a 2633 systematic review and meta-analysis screening for primary 2635 open-angle, glaucoma in the primary care setting: an update for the us preventive 2636 services task force surveillance of sight loss due to delay in ophthalmic 2638 treatment or review: frequency, cause and outcome global cost of correcting vision impairment from uncorrected 2641 refractive error prevalence of age-related macular degeneration in the united states quebec population and telehealth: a 2647 survey on knowledge and perceptions comparison of a novel cell phone-based refraction 2650 with subjective refraction', investigative ophthalmology & 2651 visual science telemedicine for 2653 glaucoma: guidelines and recommendations automated identification of diabetic retinopathy 2655 using deep learning potential biases in 2657 machine learning algorithms using electronic health record data diabetic retinopathy and age-related macular degeneration in the self-management education and regular 2663 practitioner review for adults with asthma retinopathy of prematurity: a global perspective of the epidemics, population 2667 of babies at risk and implications for control global, regional, and national 2669 incidence, prevalence, and years lived with disability for 301 acute and chronic 2670 diseases and injuries in 188 countries, 1990-2013: a systematic analysis for the global 2671 burden of disease study disease detection in diabetic retinopathy screening using two-field photography comparing machine learning classifiers for diagnosing glaucoma from standard 2678 automated perimetry interpretation of automated perimetry for glaucoma by neural 2681 network smartphone guided wide-field imaging for retinopathy of prematurity 2684 in neonatal intensive care unit -a smart rop (srop) initiative' a deep learning algorithm 2688 for prediction of age-related eye disease study severity scale for age macular degeneration from color fundus photography video consultations for covid-2692 19 pathologic findings in pathologic myopia 2697 'randomized trial of a home monitoring system for early detection of choroidal 2698 neovascularization home monitoring of the eye (home) study development and validation of a deep learning algorithm for 2703 detection of diabetic retinopathy in retinal fundus photographs performance of a deep-learning algorithm vs manual grading for detecting 2708 diabetic retinopathy in india acceptability and use of glaucoma virtual clinics in the uk: a national survey of 2711 clinical leads beneficial effects of spatial remapping for reading 2714 with simulated central field loss practice patterns in retinopathy of 2717 prematurity treatment for disease milder than recommended by guidelines 2720 'a treat and extend regimen using ranibizumab for neovascular age-related macular 2721 degeneration clinical and economic impact diabetes mellitus medication use and 2723 catastrophic healthcare expenditure among adults aged 50+ years in china and india: 2724 results from the who study on global ageing and adult health (sage) automatic extraction of retinal 2727 features from colour retinal images for glaucoma diagnosis: a review doctors are using ai to triage covid-19 paitents. the tools may be here to 2730 stay reducing blindness from retinopathy of 2736 rop) in argentina through collaboration telemedicine glaucoma detection and follow-up study: methods and screening 2743 results improving access to eye care among persons at high-risk of glaucoma 2747 in philadelphia -design and methodology: the philadelphia glaucoma detection and 2748 treatment project innovation and entrepreneurship: 2750 harnessing the public health skill set in a new era of health reforms and 2751 investment 2754 'long-term pattern of progression of myopic maculopathy: a natural history study retinopathy of prematurity cost effectiveness of telehealth for patients with 2761 long term conditions (whole systems demonstrator telehealth questionnaire study): 2762 nested economic evaluation in a pragmatic classifying visual field data shedding light on telemedicine & online prescribing: the need to 2766 balance access to health care and quality of care smartphone use in ophthalmology: 2768 what is their place in clinical practice? virtually perfect? telemedicine for covid-19', n engl 2770 2020. 2772 'telemedicine during the covid-19 pandemic: experiences from western china practice guidelines for ocular telehealth-2777 diabetic retinopathy, third edition' lawn, and group born too soon preterm 2779 birth action rule extraction for glaucoma detection with 2782 summary data from stratusoct diode laser photocoagulation for threshold 2784 retinopathy of prematurity. a randomized study characteristics and risk factors associated with 2788 diagnosed and undiagnosed symptomatic dry eye using a smartphone application international committee for the classification of retinopathy of, prematurity international council of ophthalmology cost analysis of remote telemedicine 2795 screening for retinopathy of prematurity an adaptive threshold based image 2797 processing technique for improved glaucoma detection and classification systematic review of current devices for 24-h intraocular pressure monitoring standards of medical care for 2805 type 2 diabetes in china telemedicine screening of retinal 2807 diseases with a handheld portable non-mydriatic fundus camera a pilot study to 2810 improve access to eye care services for patients in rural india by implementing 2811 real-time teleophthalmology in 2814 rural western australia diabetic retinopathy in china: population-2818 based studies and clinical and experimental investigations feasibility of a novel remote daily monitoring system for age-related macular 2821 degeneration using mobile handheld devices: results of a pilot study 2824 'metamorphopsia score and central visual field outcomes in diabetic cystoid 2825 consortium informatics in retinopathy of prematurity research. 2016. 2830 'plus disease in retinopathy of prematurity: improving diagnosis by ranking disease severity and using quantitative image analysis uddin. 2020. 2834 'oculoplastic video-based telemedicine consultations: covid-19 and beyond self-management in patients with 2839 copd: theoretical context, content, outcomes, and integration into clinical care collaborative care 2843 and teleglaucoma: a novel approach to delivering glaucoma services in northern 2844 tele-ophthalmology for age-related macular 2847 degeneration and diabetic retinopathy screening: a systematic review and meta-2848 analysis development and validation of a 2851 deep-learning algorithm for the detection of neovascular age-related macular 2852 degeneration from colour fundus photographs covid-19 and health care's digital 2854 revolution retinopathy of prematurity care: 2856 patterns of care and workforce analysis 2862 'identifying medical diagnoses and treatable diseases by image-based deep 2863 learning implementation of a cloud-based referral platform 2866 in ophthalmology: making telemedicine services a reality in eye care improving patient access to prevent sight 2869 loss: ophthalmic electronic referrals and communication (scotland)', public health preventing 2872 diabetes blindness: cost effectiveness of a screening programme using digital non mydriatic fundus photography for diabetic retinopathy in a primary health care setting 2874 in south africa diabetic 2876 retinopathy--results of a two year screening programme in two medical units in 2877 singapore 2879 'evaluation of telemedicine for screening of diabetic retinopathy in the veterans 2880 health administration the efficacy of a nurse-led 2882 preoperative cataract assessment and postoperative care clinic 2885 'fifteen-year cumulative incidence of age-related macular degeneration: the beaver 2886 dam eye study experiences with developing 2888 and implementing a virtual clinic for glaucoma care in an nhs setting a technician-delivered 'virtual clinic' for 2891 triaging low-risk glaucoma referrals deep learning models in genomics; are we there yet? grader variability and the importance 2896 of reference standards for evaluating machine learning models for diabetic 2897 retinopathy glaucoma screening: analysis of conventional and telemedicine-2900 friendly devices telemedicine-friendly, portable tonometers: an 2903 evaluation for intraocular pressure screening tele-ophthalmology and conventional ophthalmology using in remote 2909 greece a mobile medical unit a systematic review of 2911 teleophthalmological studies in europe deep learning at chest radiography: automated 2913 classification of pulmonary tuberculosis by using convolutional neural networks laser therapy for retinopathy of prematurity. laser rop 2916 study group deep learning' deep learning is effective for 2919 classifying normal versus age-related macular degeneration oct images a multicenter, retrospective pilot study of resource use and costs 2925 associated with severity of disease in glaucoma media health literacy, ehealth literacy, and the 2928 role of the social environment in context prevalence of diabetic retinopathy and visual 2931 impairment in patients with diabetes mellitus in zambia through the implementation 2932 of a mobile diabetic retinopathy screening project in the copperbelt province: a cross-2933 sectional study prospective evaluation of 2935 teleophthalmology in screening and recurrence monitoring of neovascular age-related 2936 macular degeneration: a randomized clinical trial automatic differentiation of 2939 glaucoma visual field from non-glaucoma visual filed using deep convolutional 2940 neural network' development and evaluation of a deep learning system 2942 for screening retinal hemorrhage based on ultra-widefield fundus images', 2943 translational vision science and technology deep learning for detecting retinal detachment and discerning macular status 2947 using ultra-widefield fundus images a deep learning 2950 system for identifying lattice degeneration and retinal breaks using ultra-widefield 2951 fundus images efficacy of a deep learning 2953 system for detecting glaucomatous optic neuropathy based on color fundus 2954 photographs an automated grading system for detection 2957 of vision-threatening referable diabetic retinopathy on the basis of color fundus 2958 photographs prevalence of primary 2961 open angle glaucoma in a rural adult chinese population: the handan eye study association 2964 between a centrally reimbursed fee schedule policy and access to cataract surgery 2965 in the universal coverage scheme in thailand neural networks to identify 2967 glaucomatous visual field progression 2973 'prediction of myopia development among chinese school-aged children using 2974 refraction data from electronic medical records: a retrospective, multicentre machine 2975 learning study glaucomatous optic neuropathy using fundus photographs replacing the amsler grid: a new method for 2985 monitoring patients with age-related macular degeneration a 2988 novel smartphone ophthalmic imaging adapter: user feasibility studies in hyderabad a novel tele-2991 eye protocol for ocular disease detection and access to eye care services', 2992 telemedicine and e-health 2994 'novel telemedicine device for diagnosis of corneal abrasions and ulcers in resource-2995 poor settings smart on 2997 fhir: a standards-based, interoperable apps platform for electronic health records deep-3000 learning classifier with an ultrawide-field scanning laser ophthalmoscope detects 3001 glaucoma visual field severity deep-learning classifier with an ultrawide-field scanning 3004 laser ophthalmoscope detects glaucoma visual field severity 15 ways silicon valley is harnessing big data for health a proposal for the dartmouth 3011 summer research project on artificial intelligence laser 3014 photocoagulation for stage 3+ retinopathy of prematurity from machine to machine: an 3016 oct-trained deep learning algorithm for objective glaucomatous damage in fundus photographs 3019 'current and next generation portable screening devices for diabetic retinopathy glaucoma screening 3023 in nepal: cup-to-disc estimate with standard mydriatic fundus camera compared 3024 to portable nonmydriatic camera wilt, and 3028 us preventive serv task force cardiovascular disease risk assessment with the ankle-brachial index in adults: 3030 u.s. preventive services task force recommendation statement coordination of diabetic retinopathy screening in the 3033 kimberley region of western australia' hybrid deep learning on single wide-field optical 3036 coherence tomography scans accurately classifies glaucoma suspects 3039 'stanford university network for diagnosis of retinopathy of prematurity 3040 (sundrop): 24-month experience with telemedicine screening discrimination by artificial 3043 intelligence in a commercial electronic health record-a case study ultra-widefield 3046 fundus imaging: a review of clinical applications and future trends the national 3050 academies collection: reports funded by national institutes of health the transformational impact of 5g: proceedings of a workshop-in 3052 brief copyright 2019 by the national academy of sciences. all rights reserved cost-effectiveness of a national telemedicine diabetic retinopathy screening 3058 program in singapore impact of remote patient 3063 monitoring on clinical outcomes: an updated meta-analysis of randomized controlled 3064 trials 5g bytes: small cells explained', 3066 ieee spectrum associations 3069 between metamorphopsia and foveal microstructure in patients with epiretinal 3070 membrane turning the tide of corneal blindness a national 3074 telemedicine network for retinopathy of prematurity screening eye 3077 care quality and accessibility improvement in the community (equality) for 3078 adults at risk for glaucoma: study rationale and design clinical study on the initial experiences of french vitreoretinal 3081 surgeons with heads-up surgery worldwide prevalence and risk factors 3083 for myopia telemedicine and e-health solutions for 3085 covid-19: patients' perspective' covid-19 -the law and limits of quarantine ophthalmologists are 3089 more than eye doctors-in memoriam li wenliang global estimates of visual impairment: 2010' smartphone-based fundus 3094 photography for screening of plus-disease retinopathy of prematurity variation in 3097 electronic health record adoption and readiness for meaningful use the efficacy of automated "disease/no 3101 disease" grading for diabetic retinopathy in a systematic screening programme the past, present, and future of virtual and 3104 augmented reality researcb: a network and cluster analysis of the literature costs of a community-based glaucoma detection 3108 programme: analysis of the philadelphia glaucoma detection and treatment project prediction of cardiovascular risk factors from retinal fundus 3112 photographs via deep learning orbis telemedicine 3114 users nhs diabetic eye screening programme. summary statistics: 3116 england danq: a hybrid convolutional and recurrent deep neural 3118 network for quantifying the function of dna sequences validation of smartphone based retinal photography for diabetic 3121 retinopathy screening ensuring 3123 fairness in machine learning to advance health equity artificial intelligence deep learning algorithm for 3127 discriminating ungradable optical coherence tomography three-dimensional 3128 volumetric optic disc scans integrated 3130 model of primary and secondary eye care for underserved rural areas: the l v prasad 3131 eye institute experience 5g networks will inherit their predecessors' security issues the current state of 3136 teleophthalmology in the united states deep learning 3143 versus human graders for classifying diabetic retinopathy severity in a nationwide 3144 screening program evaluation of a deep 3148 learning image assessment system for detecting severe retinopathy of prematurity randomized, double-masked, sham-controlled trial of ranibizumab for 3152 neovascular age-related macular degeneration: pier study year 1' balaji anitha, raj deepa, rajendra pradeepa prevalence of diabetic retinopathy in urban india: the 3156 chennai urban rural epidemiology study (cures) eye study, i', investigative 3157 ophthalmology & visual science glaucoma 3159 patient knowledge, perceptions, and predispositions for telemedicine 3162 'speed of telemedicine vs ophthalmoscopy for retinopathy of prematurity diagnosis the rise and fall of england's national 3165 programme for it ranibizumab for neovascular age-related macular 3168 degeneration 3170 'screening for retinopathy of prematurity employing the retcam 120: sensitivity and 3171 specificity deep learning versus human graders for classifying diabetic retinopathy 3174 severity in a nationwide screening program the relationship 3177 between variability and sensitivity in large-scale longitudinal visual field data global and regional diabetes prevalence 3182 estimates for a deep learning 3189 framework for predicting response to therapy in cancer virtual ophthalmology: 3191 telemedicine in a covid-19 era the role of teleophthalmology in the management 3193 of diabetic retinopathy unsupervised machine learning with independent component analysis to 3197 identify areas of progression in glaucomatous visual fields the glaucoma book: a practical, evidence-based 3200 approach to patient care 6g the next hyper-connected experience for all some studies in machine learning using the game of checkers 3204 (reprinted from the english national screening programme for sight-threatening 3207 diabetic retinopathy fully 3212 automated detection and quantification of macular fluid in oct using deep 3213 learning accuracy of a self-3215 monitoring test for identification and monitoring of age-related macular 3216 degeneration: a diagnostic case-control study reliability and diagnostic performance of a novel mobile app for hyperacuity 3219 self-monitoring in patients with age-related macular degeneration deep learning in neural networks: an overview machine learning to analyze the prognostic 3225 value of current imaging biomarkers in neovascular age-related macular 3226 degeneration artificial intelligence in retina telemedical evaluation 3230 and management of retinopathy of prematurity using a fiberoptic digital fundus 3231 camera costs and consequences of automated 3235 algorithms versus manual grading for the detection of referable diabetic retinopathy telemedicine for rop development of a deep residual learning algorithm 3241 to screen for glaucoma from fundus photography why 'exponential growth' is so scary for the covid-19 coronavirus tackling covid-19 with telemedicine 5g wireless communication and health effects-a 3247 pragmatic review based on available studies regarding 6 to 100 ghz image processing 3250 based automatic diagnosis of glaucoma using wavelet features of segmented optic 3251 disc from fundus image evaluation 3254 of telemedicine for slit lamp examination of the eye following cataract surgery potential lost 3257 productivity resulting from the global burden of uncorrected refractive error prevalence, risk factors 3260 and burden of diabetic retinopathy in china: a systematic review and meta-analysis 3263 'prevalence of glaucoma in a rural northern china adult population: a population-3264 based survey in kailu county, inner mongolia teleophthalmology: improving patient outcomes? virtually 3268 controlled computerised visual acuity screening in a multilingual indian population', 3269 rural and remote health telemedicine in the management of exudative age-related macular degeneration 3275 within an integrated health care system global prevalence of vision impairment and blindness: magnitude 3279 and temporal trends treatment potential for macular cone 3282 vision in leber congenital amaurosis due to cep290 or nphp5 mutations: 3283 predictions from artificial intelligence automatic detection of pathological myopia using variational level 3286 set artificial intelligence using a deep learning 3290 system with transfer learning to predict refractive error and myopic macular 3291 degeneration from color fundus photographs strategies to 3296 improve early diagnosis in glaucoma strategies for improving early 3298 detection of glaucoma: the combined structure-function index global 3301 prevalence of glaucoma and projections of glaucoma burden through 2040 a 3302 systematic review and meta-analysis the royal college of ophthalmologists telemedical evaluation of 3305 ocular adnexa and anterior segment diabetic retinopathy: global prevalence, 3307 major risk factors, screening practices and public health challenges: a review artificial intelligence-assisted 3310 telemedicine platform for cataract screening and management: a potential model of 3311 care for global eye health artificial intelligence for anterior segment diseases: 3314 emerging applications in ophthalmology psychosocial impact of covid-3316 19 pandemic lockdown on people living with eye diseases in the uk effect of high-vacuum 3318 setting on phacoemulsification efficiency artificial 3320 intelligence, the internet of things, and virtual clinics: ophthalmology at the digital 3321 translation forefront digital technology and covid-3324 19 development and 3330 validation of a deep learning system for diabetic retinopathy and related eye 3331 diseases using retinal images from multiethnic populations with diabetes deep learning in estimating 3336 prevalence and systemic risk factors for diabetic retinopathy: a multi-ethnic study an ophthalmologist's guide to 3339 deciphering studies in artificial intelligence telemedicine and diabetic 3341 retinopathy: review of published screening programs automated detection of 3343 exudative age-related macular degeneration in spectral domain optical coherence 3344 tomography using deep learning', graefe's archive for what is the real gold standard for rop screening? the concept 3348 of virtual clinics in monitoring patients with age-related macular degeneration an observational study to assess if automated diabetic retinopathy 3353 image assessment software can replace one or more steps of manual imaging grading 3354 and to determine their cost-effectiveness automated diabetic retinopathy image assessment 3358 software: diagnostic accuracy and cost-effectiveness compared with human 3359 graders the persistent 3361 dilemma of microbial keratitis: global burden, diagnosis, and antimicrobial 3362 resistance patient attitudes toward telemedicine for 3365 diabetic retinopathy evaluation 3368 of birth weight and gestational age in infants with treatment requiring retinopathy of 3369 prematurity in rope-sos trial deep learning for 3372 predicting refractive error from retinal fundus images effectiveness of self-management programmes in diabetes management: a 3376 systematic review early impact of cms expansion of medicare telehealth during covid-19 the changing 3380 scenario of retinopathy of prematurity in middle and low income countries: unique 3381 solutions for unique problems costs of refractive correction of 3383 distance vision impairment in the united states the philadelphia glaucoma detection 3387 and treatment project: detection rates and initial management agreement among 3390 pediatric ophthalmologists in diagnosing plus and pre-plus disease in retinopathy of 3391 prematurity the end of cordon sanitaire in 3393 wuhan: the role of non-pharmaceutical interventions prevalence and ethnic pattern of 3396 diabetes and prediabetes in china in 2013 an artificial intelligence approach to detect visual 3400 field progression in glaucoma based on spatial pattern analysis virtual health care in the era of covid-19 the pathophysiology and treatment of 3404 glaucoma: a review the impact of covid policies on acute ophthalmology 3407 services-experiences from moorfields eye hospital nhs foundation trust aging barriers influencing mobile health 3410 usability for older adults: a literature based framework (mold-us)' non-contact smartphone-based fundus imaging compared to 3414 conventional fundus imaging: a low-cost alternative for retinopathy of prematurity 3415 screening and documentation validation of an independent web-based tool for measuring visual acuity 3418 and refractive error (the manifest versus online refractive evaluation trial): 3419 prospective open-label noninferiority clinical trial economic evaluation of a home-based age-related macular degeneration 3422 monitoring system saving sight in 3424 china and beyond: the lifeline express model the war on diabetic retinopathy: where are we 3426 now? teleophthalmic approach for detection of corneal diseases: 3429 accuracy and reliability programme for the prevention of blindness and deafness: 3431 global initiative for the elimination of avoidable blindness who director-general's opening remarks at the media 3435 briefing on covid-19 -11 service innovation in glaucoma management: using 3437 a web-based electronic patient record to facilitate virtual specialist supervision of a 3438 shared care glaucoma programme universal artificial 3443 intelligence platform for collaborative management of cataracts impact of different visual field testing paradigms on 3446 sample size requirements for glaucoma clinical trials 3448 'content design and system implementation of a disease diagnosis and treatment and its preliminary practice in guangdong artificial intelligence for teleophthalmology-3452 based diabetic retinopathy screening in a national program: a modelled economic 3453 analysis study metamorphopsia and vision-related quality 3455 of life among patients with age-related macular degeneration beijing eye public health care 3459 project a new computer-based pediatric vision-screening test diabetes china 3465 national, and group metabolic disorders study global prevalence 3473 and major risk factors of diabetic retinopathy the 3475 optimum time to employ telephotoscreening to detect retinopathy of prematurity unsupervised gaussian 3479 mixture-model with expectation maximization for detecting glaucomatous 3480 progression in standard automated perimetry visual fields detecting glaucomatous change in visual fields: analysis with an optimization 3485 framework detection of longitudinal visual field progression in glaucoma 3488 using machine learning perioperative cataract op management by means of teleconsultation automatic diagnosis of pathological myopia from heterogeneous biomedical data optimizing glaucoma 3497 screening in high-risk population: design and 1-year findings of the screening to 3498 prevent (stop) glaucoma study' 2020. 3500 'detecting glaucoma based on spectral domain optical coherence tomography imaging 3501 of peripapillary retinal nerve fiber layer: a comparison study between hand-crafted 3502 features and deep learning model 