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• W3100700508 abstract "BACKGROUND ON TELEHEALTH UTILIZATION Telehealth can be an important tool for increasing access to care and has become key during the pandemic.1–3 During the initial implementation of our surgery department's telehealth program, we had stringent criteria to identify appropriate patients for this program.4 After demonstrating the safety of this program, we expanded the criteria to all postoperative patients except those meeting exclusion criteria (eg, postoperative surgical complications, open wounds/drains/staples/sutures/pathology requiring in-person evaluation/discussion, and so on). Although there are numerous benefits of telehealth that even our group has reported on, we have also demonstrated patients may still encounter barriers that affect utilization and their ability to access these programs.1,4–6 As part of an ongoing quality improvement effort at our institution, we evaluated patient utilization of our telehealth program before the pandemic to identify possible barriers or disparities.5,6 This analysis revealed several important findings that suggest patients still encounter barriers when trying to obtain surgical care virtually. In fact, surgical patients had 2× increased odds of not showing up for their telehealth visit as compared to an in-person visit.6 We also identified notable disparities in utilization among various demographic groups.5,6 For instance, married patients were more likely to show up for their visit with a no-show odds ratio (OR) of 0.60 (compared to patients who are single).6 Similarly, when we evaluated cancellations, approximately 12% of married patients and 32% of single patients failed to complete their telehealth visits, respectively.5 These findings suggested that patient support systems may play a powerful beneficial role in access to healthcare, including telehealth access.5,6 Furthermore, our data show that racial disparities may not be alleviated by telehealth programs. For example, in our analysis of cancellations, almost 40% of non-White patients never completed their telehealth visit as compared to 19% of Whites.5 Additionally, our group identified African Americans at greater risk of no-showing for either traditional or telehealth visits (OR >2.4; with Whites as reference).6 Age also was inversely correlated with no-show rates in a telehealth clinic, as younger patients were more likely to no show for their visit as well.6 Finally, our institution's statewide county data showed similar trends in no-show rates between traditional and telehealth clinics, suggesting that nongeographic factors likely still impact a patient's ability to receive telehealth care.6 Even when patients are able to access the telehealth platform, some patients may still have a preference against telehealth visits.5,7 Others may still experience technical difficulties (eg, lack of equipment, portal access to the electronic medical record, or technology skills) that limit the effectiveness of these platforms.5,7 Screening patients for barriers that they may encounter while trying to obtain care in a telehealth setting is vital to the success of such programs. Overall, our previous experience shows that telehealth care is not without its limitations and should not be considered a cure-all for surgical access issues.5,6 Our group created the following recommendations based upon our institutional experience to identify potential barriers that patients may encounter in a telehealth setting. These recommendations are meant to offer suggestions surrounding potential screening techniques to identify surgical patients requiring additional assistance or resources to optimize their access to telehealth. They should not be used to exclude any particular demographic or group from being seen via telehealth, thereby creating additional disparities for those requiring additional assistance or resources. GUIDANCE FOR IDENTIFYING POTENTIAL BARRIERS Standardize Expectations Around Telehealth Visits Although telehealth has been well received by some patients, providers should still set appropriate expectations for these visits.1,4,8 Consistent information should be conveyed across all patient interactions. We recommend that all providers and other health care team members be able to discuss the following: a. Telehealth visits are considered standard-of-care visits and standard practice for all visit types (new patient, post-operative, return visit) and diagnoses where they are offered. b. A trained provider will evaluate the patient during the telehealth visit. c. If necessary, in-person appointments may still be scheduled. d. The telehealth platform is a secure application that is compliant with the Health Insurance Portability and Accountability Act. Assess the Patient's Technological Knowledge and Access to Relevant Resources Some patients may not know how to navigate the telehealth platform or lack the appropriate technology resources. Our institution has shown that approximately 14% of telehealth visit cancellations with subsequent failed completion of the visit are associated with technology issues.5 To minimize the chance that such issues affect patient follow-up, we recommend that, while in the hospital or recovery area, early discussions regarding future telehealth care and trialing of the platform occur before the patient is discharged. These early discussions may also identify patients with limited access to necessary resources (eg, lack of video-capable phone or computer, appropriate time/privacy/space, or internet access, among others). Patients without these necessary resources clearly require in-person evaluations unless assistance can be provided to address these limitations. Given the suspected impact of non-geographic factors on telehealth access, it may be prudent to consider a social work consultation when resource limitations are identified.6 Finally, although telehealth appointments are presumed to be convenient, providers should still assess the patient's best availability for the appointment (eg, morning, day of the week, evening, weekend, among others). We recommend consideration of the following questions to potentially identify patients who could encounter technology and resource barriers while seeking care in a telehealth clinic. Open-ended questions should be used when appropriate to promote discussion regarding these issues.9,10 - What equipment with camera and video capabilities do you have access to? - What type of internet access do you have? - When did you last sign into the patient portal of the electronic medical record? What device did you use to sign on? What problems did you have with logging onto the portal? - Have you used the telehealth platform before? How did it go and what issues did you encounter? - What questions do you have about how to start your telehealth visit? - What are some possible locations where you would feel comfortable completing the telehealth visit? - What days and times are you available to be seen in our telehealth clinic? Assess the Patient's Baseline Understanding of and Comfort With Telehealth Patients may have varying levels of familiarity with telehealth. Although some may have extensive experience, others may be less familiar with this care modality or even have a preference against telehealth visits.5,7 For this reason, providers should understand the level of familiarity or comfort that patients have with telehealth encounters. For those with little to no exposure, it may be even more important to standardize expectations and provide reassurances. It may be prudent to remind them of the other benefits of telehealth including minimizing travel time, reduced parking time, and the ability to complete the visit in the comfort and privacy of their own home. If patients express discomfort with the idea of telehealth, providers should explore these concerns. We recommend consideration of the following screening questions before scheduling a patient for a telehealth appointment: - What have you previously heard about being evaluated in a video clinic? - How many times have you been seen by a provider in a video or phone clinic? - How comfortable are you being seen in a video clinic? - What is your understanding of who will be seeing you in the video visit? - What concerns do you have with being seen in a telehealth clinic? - Surgical providers often need to perform a virtual or visual examination in place of the physical examination during these visits. How do you feel about this? Assess the Patient's Social Support Structure As previously stated, patients with comparatively less social support according to our departmental data may potentially be less likely to complete the telehealth visit.5,6 The beneficial effects of social support systems on health have already been previously described.11 Similar to patients having an in-person appointment, patients who are identified as having a lack of social support may still require careful consideration and an in-depth discussion when scheduling them for a telehealth visit. These patients may benefit from social work consultation as well. The followings questions may be used to elicit patient input on their social support systems: - Who else lives at home with you? - Who, if anyone, typically comes to your health appointments with you? - Who do you plan to have attend your telehealth visit with you? - When you are unable to care for yourself, who helps to care for you? - How would you describe your current support system? CONCLUDING THOUGHTS As surgical providers, it is important to identify any early barriers to follow-up care in a telehealth setting and tailor the surgical plan accordingly. These measures are unlikely to identify all possible barriers for patients and it may be difficult for providers to ask every question provided here. Nevertheless, having some conversation that includes some version of the above elements can be an important first step in optimizing telehealth care and access for patients. Additional studies are necessary to further tailor these approaches and identify other opportunities for improving equity and access to care for patients." @default.
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• W3100700508 date "2020-11-17" @default.
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• W3100700508 title "Practical Guidance for Early Identification of Barriers in Surgical Telehealth Clinics" @default.
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