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- W3004601430 abstract "Telemedicine (TM) has become a popular method of accessing medical services between providers and patients and is viewed as a cost-effective alternative to more traditional episodic face-to-face encounters. TM overcomes 2 barriers that patients face when seeking health care: distance and time. It is as effective as in-person visits for outpatient treatment of asthma, and it is a convenient way to provide inpatient consultations for patients when the allergist practices outside of the hospital. TM also has been used to manage patients with asthma in schools. Patients tend to be as satisfied with TM or they prefer TM over in-person visits, but infrequently they do prefer in-person visits. In addition to virtual visits using TM, there are several emerging technologies that are relevant to the practice of allergy/immunology including electronic diaries (eg, symptoms and medication use), wearable technology (eg, to monitor activity and vital signs), remote patient monitoring (eg, environmental exposures and medication adherence) as well as electronic medical records augmented with clinical decision support. We believe that the use of TM, particularly when combined with information technologies such as electronic health records, has the potential to cause a transformational change in the way care is delivered by altering the process of interaction between patient and provider. TM addresses the shortage of allergy specialists in rural and underserved urban communities and facilitates patient access to allergy services. As patients take more control of their health care, use of TM is likely to increase because a large part of the move to adopt TM is driven by patient preference. Telemedicine (TM) has become a popular method of accessing medical services between providers and patients and is viewed as a cost-effective alternative to more traditional episodic face-to-face encounters. TM overcomes 2 barriers that patients face when seeking health care: distance and time. It is as effective as in-person visits for outpatient treatment of asthma, and it is a convenient way to provide inpatient consultations for patients when the allergist practices outside of the hospital. TM also has been used to manage patients with asthma in schools. Patients tend to be as satisfied with TM or they prefer TM over in-person visits, but infrequently they do prefer in-person visits. In addition to virtual visits using TM, there are several emerging technologies that are relevant to the practice of allergy/immunology including electronic diaries (eg, symptoms and medication use), wearable technology (eg, to monitor activity and vital signs), remote patient monitoring (eg, environmental exposures and medication adherence) as well as electronic medical records augmented with clinical decision support. We believe that the use of TM, particularly when combined with information technologies such as electronic health records, has the potential to cause a transformational change in the way care is delivered by altering the process of interaction between patient and provider. TM addresses the shortage of allergy specialists in rural and underserved urban communities and facilitates patient access to allergy services. As patients take more control of their health care, use of TM is likely to increase because a large part of the move to adopt TM is driven by patient preference. Information for Category 1 CME CreditCredit can now be obtained, free for a limited time, by reading the review articles in this issue. Please note the following instructions.Method of Physician Participation in Learning Process: The core material for these activities can be read in this issue of the Journal or online at the JACI Web site: www.jacionline.org. The accompanying tests may only be submitted online at www.jacionline.org. Fax or other copies will not be accepted.Date of Original Release: February 2020. Credit may be obtained for these courses until January 31, 2021.Copyright Statement: Copyright © 2020-2021. All rights reserved.Overall Purpose/Goal: To provide excellent reviews on key aspects of allergic disease to those who research, treat, or manage allergic disease.Target Audience: Physicians and researchers within the field of allergic disease.Accreditation/Provider Statements and Credit Designation: The American Academy of Allergy, Asthma & Immunology (AAAAI) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The AAAAI designates this journal-based CME activity for a maximum of 1.00 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.List of Design Committee Members: Jay M. Portnoy, MD, Aarti Pandya, MD, Morgan Waller, MBA, BAPsych, BSN, RN, and Tania Elliott, MD (authors); Zuhair K. Ballas, MD (editor)Disclosure of Significant Relationships with Relevant Commercial Companies/Organizations: The authors declare that they have no relevant conflicts of interest. Z. K. Ballas (editor) disclosed no relevant financial relationships.Activity Objectives:1.To understand the principles of the various types of telemedicine.2.To discuss the benefits and limitations of telemedicine and why one should consider learning how to participate in telemedicine.3.To inform healthcare providers of the impact of telemedicine on patient satisfaction and quality of patient-provider interactions.Recognition of Commercial Support: This CME activity has not received external commercial support.List of CME Exam Authors: Christine K. Rauscher, MD, Laura J. West, MD, Mosopefoluwa A. Lanlokun, MD, Maylene Xie, MD, Hey Chong, MD, PhD, Allyson Larkin, MD, and Merritt L. Fajt, MD.Disclosure of Significant Relationships with Relevant CommercialCompanies/Organizations: The examination authors declare no relevant conflicts of interest. Credit can now be obtained, free for a limited time, by reading the review articles in this issue. Please note the following instructions. Method of Physician Participation in Learning Process: The core material for these activities can be read in this issue of the Journal or online at the JACI Web site: www.jacionline.org. The accompanying tests may only be submitted online at www.jacionline.org. Fax or other copies will not be accepted. Date of Original Release: February 2020. Credit may be obtained for these courses until January 31, 2021. Copyright Statement: Copyright © 2020-2021. All rights reserved. Overall Purpose/Goal: To provide excellent reviews on key aspects of allergic disease to those who research, treat, or manage allergic disease. Target Audience: Physicians and researchers within the field of allergic disease. Accreditation/Provider Statements and Credit Designation: The American Academy of Allergy, Asthma & Immunology (AAAAI) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The AAAAI designates this journal-based CME activity for a maximum of 1.00 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. List of Design Committee Members: Jay M. Portnoy, MD, Aarti Pandya, MD, Morgan Waller, MBA, BAPsych, BSN, RN, and Tania Elliott, MD (authors); Zuhair K. Ballas, MD (editor) Disclosure of Significant Relationships with Relevant Commercial Companies/Organizations: The authors declare that they have no relevant conflicts of interest. Z. K. Ballas (editor) disclosed no relevant financial relationships. Activity Objectives:1.To understand the principles of the various types of telemedicine.2.To discuss the benefits and limitations of telemedicine and why one should consider learning how to participate in telemedicine.3.To inform healthcare providers of the impact of telemedicine on patient satisfaction and quality of patient-provider interactions. Recognition of Commercial Support: This CME activity has not received external commercial support. List of CME Exam Authors: Christine K. Rauscher, MD, Laura J. West, MD, Mosopefoluwa A. Lanlokun, MD, Maylene Xie, MD, Hey Chong, MD, PhD, Allyson Larkin, MD, and Merritt L. Fajt, MD. Disclosure of Significant Relationships with Relevant Commercial Companies/Organizations: The examination authors declare no relevant conflicts of interest. Telemedicine (TM) is defined by the Centers for Medicare & Medicaid Services as “the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision and information across distance.”1Centers for Medicare & Medicaid ServicesTelemedicine.https://www.medicaid.gov/medicaid/benefits/telemed/index.htmlDate: 2019Date accessed: October 31, 2019Google Scholar TM has become an increasingly popular method for accessing medical services between providers and patients and is viewed as a cost-effective alternative to more traditional types of visits that involve episodic face-to-face encounters. As patients take more control of their health care, it seems inevitable that this type of encounter will increase because a large part of the move to adopt TM is driven by patient preference. The use of TM can be traced back to as early as 1948.2Field M.J. Telemedicine: a guide to assessing telecommunications in healthcare.J Digit Imaging. 1997; 10: 28Crossref PubMed Google Scholar Currently, the technology is widely used across many medical specialties including Neurology, Ophthalmology, Psychiatry, Dermatology, and Allergy.3Portnoy J.M. Waller M. De Lurgio S. Dinakar C. Telemedicine is as effective as in-person visits for patients with asthma.Ann Allergy Asthma Immunol. 2016; 117: 241-245Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar, 4Vierhile A. Tuttle J. Adams H. tenHoopen C. Baylor E. Feasibility of providing pediatric neurology telemedicine care to youth with headache.J Pediatr Health Care. 2018; 32: 500-506Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar, 5Zapata M.A. Arcos G. Fonollosa A. Abraldes M. Olenik A. Gutierrez E. et al.Telemedicine for a general screening of retinal disease using nonmydriatic fundus cameras in optometry centers: three-year results.Telemed J E Health. 2017; 23: 30-36Crossref PubMed Scopus (24) Google Scholar Unlike models of health care that focus on continuous improvement of the current system, the use of TM, particularly when combined with information technologies such as electronic health records (EHRs), has the potential to cause a transformational change in the way care is delivered by altering the process of interaction between patient and provider. Currently, it has undergone 5 of the 9 steps of transformational change described by Tipton (see Table I)6Tipton B. Nine stages of transformational change. RS Tipton, PBC, Denver, CO2019https://teamtipton.com/nine-stages-of-transformational-change/Date accessed: November 14, 2019Google Scholar and is now moving beyond Tolerance toward Acceptance by most health care organizations. Once the technology has passed the tolerance stage, it is difficult to return to the old way of care, which was restricted to episodic in-person visits. The move toward continuous healing relationships between patients and providers has become inevitable. We anticipate rapid movement toward Agreement and eventually expect Advocacy to become widespread.Table IThe 9 stages of transformational change as described by Tipton6Tipton B. Nine stages of transformational change. RS Tipton, PBC, Denver, CO2019https://teamtipton.com/nine-stages-of-transformational-change/Date accessed: November 14, 2019Google ScholarStageDescription1. Status quoStatus quo is the current situation in which patients travel to the provider for in-person visits.2. DenialDenial is the first step to the change. The provider’s attitude is “the technology is not ready” or “you can’t do that and get good outcomes.”3. Righteous resistanceOnce the technology starts to be used, this stage involves anger over the change and reluctance to use it.4. PleadingAt this stage, the technology is being used but there is a desire for the old way. “It worked just fine before, why do we have to do it this new way?”5. Despair or skepticismThe new technology is now being used but users are not happy about it. They look for any opportunity to point out its flaws.6. ToleranceOnce it is being used routinely, tolerance sets in. Users have to learn to live with the new technology. At this stage, there is no return to the old way.7. AcceptanceAcceptance occurs when users feel that the new and old ways are equally acceptable.8. AgreementAt this point, the new way has proven to be superior to the old way and users are happy to use it. There may be a few holdouts, but they are few.9. AdvocacyThe new way is so well accepted that there is a desire to spread the good news about it to others. Open table in a new tab TM is on its way to becoming routine in medical practice. It is likely that in the future, the terms tele-, mobile, virtual, remote, distant, facilitated, and nonfacilitated all will become obsolete as their use becomes routine.7Waller M. Taylor L. Portnoy J. The medical virtualist: is pediatric patient care using telemedicine, a new specialty?.Pediatr Ann. 2019; 48: e243-e248Crossref PubMed Scopus (7) Google Scholar The use of TM will be simply seen as how health care is done. The assumption is that if technology can deliver what the patient needs to where the patient is located when they want it, then it will happen. Traditionally, patient care has centered around discrete visits to a health care provider who uses information obtained during the visit to make a diagnosis and to recommend treatment. This places the provider in a gatekeeper position because many treatments cannot be obtained without either a prescription or a provider’s order. Patients who want to manage their own health without seeking a provider’s input have limited resources for doing so including over-the-counter medications, homeopathic treatments, and alternative medicine remedies. Most effective treatment options are unavailable unless a provider gives access to it. In theory, this is because patients lack enough medical knowledge to determine what they need and to use prescription treatments effectively and safely. The problem with this model of care is that it is expensive, inconvenient, and in some cases unnecessary. In general, patients who want on-demand services frequently seek care in urgent care facilities. According to Consumer Reports, the number of urgent care facilities has increased from 6400 in 2014 to 8100 in 2018.8Findlay S. When you should go to an urgent care or walk-in health clinic.https://www.consumerreports.org/health-clinics/urgent-care-or-walk-in-health-clinic/Date: 2018Date accessed: November 14, 2019Google Scholar The use of TM may be able to reduce unnecessary urgent care visits by delivering a convenient alternative while also providing continuity of care for patients. In one study of 28,222 TM encounters between 24,040 patients and 277 primary care physicians, respiratory infections were diagnosed in 35% of encounters and 69% resulted in a prescription. Had the patients not used TM, 43% of the patients reported that they would have gone to an urgent care or retail clinic instead, 29% would have gone to their doctor’s office, 15% would have done nothing, and 6% would have gone to an emergency department.9Martinez K.A. Rood M. Jhangiani N. Kou L. Rose S. Boissy A. et al.Patterns of use and correlates of patient satisfaction with a large nationwide direct to consumer telemedicine service.J Gen Intern Med. 2018; 33: 1768-1773Crossref PubMed Scopus (57) Google Scholar So, although TM is not the only alternative to urgent care, it provides a convenient care equivalent that allows for diagnosis and treatment. Although TM does not remove the provider from a central role in guiding medical care, it can reduce the inconvenience and expense of obtaining it. TM overcomes 2 barriers that patients face when seeking health care: distance and time. TM also alters the dynamics of medical encounters by placing an artificial barrier between patients and providers. This slightly reduces the provider’s authority as the central health care professional, and therefore it equalizes the hierarchy between the provider and the patient. Some patients prefer that because they feel more empowered to state their concerns and express their desires without feeling intimidated by the provider. This may account for the observation that patients tend to be equally satisfied with TM or they prefer TM over in-person visits, but infrequently they do prefer in-person visits.10Taylor L. Capling H. Portnoy J.M. Administering a telemedicine program.Curr Allergy Asthma Rep. 2018; 18: 57Crossref PubMed Scopus (14) Google Scholar Another important reason that the use of TM has increased is its impact on health care costs. Physicians are increasingly facing pressure to meet relative value unit goals. No-show appointments or cancellations can place a financial burden on providers.11Greiwe J. Using telemedicine in a private allergy practice.J Allergy Clin Immunol Pract. 2019; 7: 2560-2567Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Missed health care appointments are estimated to cost $150 billion to the US health care system. TM can not only serve to improve access to rural communities12Taylor L. Waller M. Portnoy J.M. Telemedicine for allergy services to rural communities.J Allergy Clin Immunol Pract. 2019; 7: 2554-2559Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar but may also be valuable in filling no-show slots on a provider’s clinic schedule. Reasons for no-shows include work restrictions, transportation, forgetfulness, and a perceived lack of value on the part of the patient.13Ofei-Dodoo S. Kellerman R. Hartpence C. Mills K. Manlove E. Why patients miss scheduled outpatient appointments at urban academic residency clinics: a qualitative evaluation.Kans J Med. 2019; 12: 57-61Crossref PubMed Google Scholar By making follow-up appointments more accessible through TM, these barriers can be minimized, leading to fewer no-shows and improved patient compliance. A study from Alaska in collaboration with Mayo Clinic for high-risk patients with breast cancer demonstrated a low percentage of no-shows to the clinic (3.3%) while maintaining high patient satisfaction.14Pruthi S. Stange K.J. Malagrino Jr., G.D. Chawla K.S. LaRusso N.F. Kaur J.S. Successful implementation of a telemedicine-based counseling program for high-risk patients with breast cancer.Mayo Clin Proc. 2013; 88: 68-73Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar In addition, although it is thought that TM would only be useful in those rural settings where there is a high demand for access to care, we also see value of TM in urban settings. Studies have demonstrated the benefit of TM in urban settings as well for monitoring blood pressure and telepsychiatry.15Bove A.A. Homko C.J. Santamore W.P. Kashem M. Kerper M. Elliott D.J. Managing hypertension in urban underserved subjects using telemedicine--a clinical trial.Am Heart J. 2013; 165: 615-621Crossref PubMed Scopus (54) Google Scholar,16Spaulding R. Cain S. Sonnenschein K. Urban telepsychiatry: uncommon service for a common need.Child Adolesc Psychiatr Clin N Am. 2011; 20: 29-39Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar The nuts and bolts of getting started with TM and how to use it in clinical practice have been reviewed recently.17Shih J. Portnoy J. Tips for seeing patients via telemedicine.Curr Allergy Asthma Rep. 2018; 18: 50Crossref PubMed Scopus (23) Google Scholar Basically, before implementing a TM program it is necessary to determine which aspects of health care could be improved with the use of the technology and then to arrange to provide them that way. There are many perceived barriers that practices and practitioners face when implementing TM. These include the need to learn how to use the technology and a concern that patient care will be compromised by its use. In addition to poorer patient outcomes, providers are concerned that the provider-patient relationship will be diminished, leading to reduced patient satisfaction. The most common barrier that allergists face is simply knowing how to get started. Although it is possible to obtain the necessary equipment and supplies to implement a TM service, the requirements may seem daunting at first. For that reason, many first-time TM providers initially contract with one of the TM platforms. These offer various options. One option is for a provider to join an online practice. This space is largely dominated by companies that provide health care services to employers and health plans, such as American Well (www.americanwell.com), Teladoc (www.teladoc.com), MdLive (www.mdlive.com), or Doctor on Demand (www.doctorondemand.com). These companies largely provide virtual urgent care services, although virtual primary care is an area gaining traction.18Marcin J.P. Rimsza M.E. Moskowitz W.B. The use of telemedicine to address access and physician workforce shortages.Pediatrics. 2015; 136: 202-209Crossref PubMed Scopus (136) Google Scholar Another option is to use an established platform only for the technical aspects of TM while maintaining control of a private practice. This could be used to see patients who live at a distance, extend hours of service to evenings and weekends, and provide on-call services. A provider may also opt to provide asynchronous TM services. One option is to join a platform that provides e-consultations to other practices such as Rubicon MD (www.rubiconmd.com) and AristaMD (www.aristamd.com). Another option involves joining a practice that reviews patient-entered health information and makes treatment decisions on the basis of those data inputs such as DirectDerm (www.directderm.com), Curology (www.curology.com), Lemonaid (www.lemonaidhealth.com), and Zipnosis (www.zipnosis.com). And similarly, to the synchronous TM space, a practice may opt to include these capabilities (text, photo upload, online intake) in their practice. It is important to note, however, that to date reimbursement exists only for synchronous TM encounters and remote patient monitoring (RPM). When used for patient care, TM can be separated into triage or second opinion care, proxy care, and virtual visits. One use of triage or second opinion care TM is to screen patient appointments for appropriateness. An example of this is the use of e-consults in which a referring provider sends a brief description of their patient with specific questions to a specialty service for review and recommendations regarding treatment. In one study, 13.4% of e-consults sent to an allergy service resulted in diagnostic, therapeutic, or alternative referral recommendations, 59.8% resulted in an in-person Allergy/Immunology consult, and the rest required additional information before a recommendation could be made.19Phadke N.A. Wolfson A.R. Mancini C. Fu X. Goldstein S.A. Ngo J. et al.Electronic consultations in allergy/immunology.J Allergy Clin Immunol Pract. 2019; 7: 2594-2602Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar This led to reduced wait times for in-person visits despite an increase in the overall number of consults to the allergy service. Proxy care involves the use of TM-based virtual intensive care units or emergency departments, which provide intensive care or emergency specialist expertise to patients who need specialized care when providers with less expertise are present on site. Using TM, an intensivist can guide an on-site provider in the care of patients with complex problems. This virtual intensive care unit model has been shown to improve mortality and/or length of stay as well as staff acceptance, particularly in rural areas with specific patient populations.20Ramnath V.R. Khazeni N. Centralized monitoring and virtual consultant models of tele-ICU care: a side-by-side review.Telemed J E Health. 2014; 20: 962-971Crossref PubMed Scopus (17) Google Scholar Staicu et al21Staicu M.L. Holly A.M. Conn K.M. Ramsey A. The use of telemedicine for penicillin allergy skin testing.J Allergy Clin Immunol Pract. 2018; 6: 2033-2040Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar described a program of inpatient allergy consults to perform penicillin testing using TM when a physician assistant was present at the patient’s location. An allergist guided the consult using TM by interpreting antibiotic skin test results and recommending oral challenges. Virtual visits are used to connect patients and providers when an in-person visit is inconvenient and not necessary (see Fig 1). Such visits can occur synchronously (the patient and the provider are online at the same time) or asynchronously (the patient and the provider are not online at the same time). Both types of virtual visits overcome the barrier of distance by permitting the encounter to occur without the patient having to travel to where the provider is located. Asynchronous visits also overcome the barrier of time by permitting encounters to occur without the need to schedule the patient and the provider to be online at the same time. Asynchronous care occurs when the patient and the provider are not online at the same time. Two types of asynchronous care include store & forward and RPM, which is discussed later in this review. Store & forward occurs when clinical information (eg, imaging studies, laboratory results, procedure results, and patient questions) are sent from one location to an intermediate location where the information is stored (see Fig 1). A provider subsequently accesses the information for interpretation and patient management. The advantage of this is that patients and providers do not need to be available at the same time and they both can be located anywhere. Patients can travel for medical tests to a facility that is convenient to them and providers can access test results as soon as they are available, reducing waiting times. Recommendations also can be communicated asynchronously, though it also may be necessary to have a synchronous visit to discuss test results depending on the nature of the information. Examples of store & forward include imaging results from a remote radiology location, laboratory results, images of a rash sent to a dermatologist for diagnosis, pulmonary function tests, and patient portals that permit communication between a patient and the provider. Patients also can use this technology to schedule office appointments and to rate providers on Web sites. The use of TM for synchronous patient care can be done using either facilitated or unfacilitated visits (Fig 1). The difference between the need for these types of visit is whether a complete physical examination is necessary. In an unfacilitated visit, patients use their own equipment to connect with the provider. As a result, they can be located virtually anywhere that has an Internet connection, though some states limit this to specified types of locations such as hospitals, clinics, schools, and patient homes. Although a complete physical examination inclusive of listening to the heart and lungs or visualizing the tympanic membrane is not available for this type of visit, unless the patient has purchased a peripheral device (eg, digital stethoscope and otoscope), an examination reliant upon observation (evaluation of general appearance, palor, skin conjunctiva, oropharynx) and patient participation (eg, patient self-palpation of the sinsuses, abdomen, following commands for neurologic and musculoskeletal) can provide substantial information depending on the condition being evaluated. Unfacilitated visits also have been referred to as direct-to-consumer encounters. This is because the visit is being initiated by the patient as opposed to by the provider. Facilitated visits require a patient to travel to a facility where digital examination equipment and a facilitator are available to perform an examination (see Fig 1). This is referred to as the near location to emphasize the patient’s importance in the interaction. During a facilitated visit, the patient uses the provider’s equipment. The near location should be equipped with a TM room that is designed to look like a traditional examination room. The TM equipment usually is incorporated into the room in as unobtrusive a manner as possible. Although the necessary credentials of the telefacilitator are not defined, for allergy visits the facilitator usually is a nurse or respiratory therapist. Recently, a telehealth facilitator certificate program has been described, which hopefully will standardize this role.22Chandra S. Papanagnou D. Hollander J.E. Telehealth facilitator certificate program.Ann Emerg Med. 2016; 68: S155Abstract Full Text Full Text PDF Google Scholar A clinical TM cart with a camera, microphone, and speaker provides the 2-way video connection between the near and distant locations. It should permit transmission of information from digital examination equipment to the provider. The provider is located at the distant location. This can be anywhere that has a reliable Internet connection. The provider should see the patient in a screen that is near to the camera so that the patient sees the provider looking at them (Fig 2). A typical arrangement consists of 2 screens: one for patient interaction and the other for interaction with the EHR. The video connection with the patient often permits 2 windows to be open: one to see the patient and the other to examine parts of the patient’s body using high-resolution cameras. Facilitated visits are typically" @default.
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