ATA2021ATA2021 Annual Conference & Expo(Virtual*)Tuesdays and Thursdays in June 2021(ABSTRACTS)

Jointly provided by

In support of improving patient care, this activity has been planned and implemented by the American Telemedicine Association and the University of Virginia School of Medicine and School of Nursing is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

AMA PRA CATEGORY 1 CREDIT

The University of Virginia School of Medicine and School of Nursing designates this live virtual activity and enduring material, for a maximum of 8.0AMA PRA Category 1 Credits.™ Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ANCC CONTACT HOURS

The University of Virginia School of Medicine and School of Nursing awards 8.0 contact hours for nurses who participate in this educational activity and complete the post activity evaluation.

MOC II

Successful completion of this CME activity enables the participant to earn MOC points equivalent to the amount of CME credits claimed for the activity for a maximum of 8.0 MOC Part II (ABMS) points.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 8.0 MOC points [and patient safety MOC credit] in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

Oral Presentations

1. A Mixed‐Methods Evaluation of Telehealth Adoption in Frontier Critical Access Hospitals

Saira Haque

RTI International

Description: Report on our evaluation of the Center for Medicare and Medicaid Services (CMS) Frontier Community Health Integration Project (FCHIP) Demonstration on hospital administration, hospital finances, consumer access to health services and the community. This mixed‐methods evaluation of 8 participating critical access hospitals included key informant interviews, document review and Medicare Fee‐for‐Service claims analysis.

Abstract: Frontier areas generally have low population density at great geographic distance from population centers and services.As a result of the location, the Critical Access Hospitals (CAHs) that serve these areas might not be able to provide the services that are needed in the community. One way to ameliorate these challenges is through the use of telehealth. Policy and reimbursement considerations are among the most significant barriers to greater telehealth uptake. Thus, the CMS embarked on the FCHIP to learn how changes in payment models for telehealth impacted telehealth uptake and use.

We conducted a mixed‐methods evaluation of the 8 hospitals that participted in the FCHIP demonstration ofitsimpacts on hospital administration, hospital finances, patient/consumer access and spillover effects in the community. Quantitative methods involved Medicare fee for service claims analysis between August of 2013 and July of 2019. Qualitative methods were key informant interviews and document review. We found nominal impact on hospital administration and hospital finances, positive perceptions and mixed impact for consumer access and limited spillover effects.

Method: Mixed methods evaluation with qualitative and quantitative (claims analysis versus a comparison group)

Classification of Research: Regulatory & Policy Research

Results: We found varied results across the four domains of interest. For hospital administration, the FCHIP CAHs made changes for implementation, marketing and outreach. Low claims volumes resulted in nominal impacts on hospital finances. By the end of the demonstration, 6 out of the 8 participating sites billed for telehealth services, although all reported providing telehealth services. Spillover effects such as impacts on the surrounding regional health delivery system, providers of community‐based services and payers, varied. CAHs expanded the number of types of distant providers in order to offer more services to meet community needs.

Conclusions: Overall, CAHs reported that patient satisfaction was high and expressed the desire for more virtual services. Telehealth service was selection was informed by community needs, but formal needs assessments were not completed. Future work could include standardized, formal community needs assessments and assistance finding distant providers to meet those needs. Implementation support services helped CAHs integrate telehealth into clinical and operational workflows. However, billed telehealth services were fewer than reported services. This indicates a need for improved knowledge‐sharing and assistance around billing and reimbursement.

2. AN EVIDENCE‐BASED ROADMAP FOR THE PROVISION OF MORE EQUITABLE TELEMEDICINE

Ryan Jelinek

Hennepin Healthcare

Description: This talk will detail the process of building a telemedicine platform from the ground up at a safety net organization where equitale delivery of telemedicine was paramount. We hope to outline an evidence based roadmap for other organizations to consider as they refine their own processes.

Abstract: Like many other healthcare systems, Hennepin Healthcare had the opportunity to pivot towards a more robust telemedicine offering during the COVID‐19 pandemic. As a safety‐net organization with a substantial percentage of vulnerable patients, we were wary of this move over apprehension around potentially furthering existing health disparities in our community. We set out to analyze the gaps inequitabletelemedicine delivery in our communities and develop an evidence‐based road map for other organizations finding similar gaps.We leveraged LEAN problem‐solving strategies to identify modifiable gaps potentially inhibiting the delivery of equitable telemedicine.We implemented multiple tests of change and observed the frequency of telemedicine encounters across various sociodemographic groups over several months. After 8 months of observation and measurement, we were able to show significant improvement towards equitable access to telemedicine across minority racial and language demographics within our patient population. Using an evidence‐based approach, we have developed a roadmap for other organizations to improveequitableaccess and delivery of telemedicine that has resulted in significant improvement at our organization.

Method: Implementation Science

Classification of Research: Patient Experience

Results: With the deployment of the tests of change we have been able to realize significant improvements in the equitable delivery of telemedicine within our healthcare system. In November 2020, White, Black, and Hispanic populations accounted for 47.7, 24.8, 17.1% of telemedicine visits respectively (n = 10,181). This was a percent change of −12.4, +4.5, +9.3% respectively compared to initial data collected 9 months prior. Similar improvements were seen with language showing a percent change from March to November of 2020 of −12, +9.3, +1.2% for English, Spanish, and Somali respectively.

Conclusions: We present a roadmap for other organizations to examine when they begin considering more equitable delivery of telemedicine. We have shown that with this roadmap in place it is possible to start down a path towards a significantly more equitable distribution of this care delivery method. Telemedicine should be viewed as a means to breaking down access barriers to healthcare and a tool used to further the goal of broad healthcare equity across our communities. We hope to help re‐write the narrative around telemedicine to be considered a tool to drive health equity rather than just another technological advancement.

3. AUDIO ONLY ANNUAL WELLNESS VISITS: AN EXPERIENCE DURING COVID‐19 PANDEMIC

Saurabh Chandra, Tanya Tucker

Center For Telehealth, University of Mississippi Medical Center; Shannon Pittman, Babette Elmore, University of Mississippi Medical Center

Description: Annual Wellness Visits (AWVs) are allowed once a year for Medicare beneficiaries and provides value in early detection and prevention of diseases. Aplan of care is developed that incorporates the choices of patients. Relaxation of regulations by CMS has enabled eligible patients to derive the benefit from home.

Abstract: The current COVID‐19 pandemic has seen an unprecedented rise in the growth of Telehealth visits. Spurred by relaxation in the regulatory requirements, telehealth helped offset the decline in face‐to‐face visits (JAMA Internal Medicine, 2021:181(3)). Relaxation in regulatory requirements by CMS, like lifting of originating site restrictions and allowing Telehealth visits in the home of patients has enabled novel uses of telehealth for providing care to the patients at home.

One such service with a high proven value that can be provided at home using audio‐video or audio only equipment during the current public health emergency is the AWV. The Affordable Care Act of 2010 provided for an AWV for Medicare beneficiaries as of January 1, 2011. The AWV is an yearly appointment with the primary care provider with the objective of promoting health, earlier screening and detection of disease, and coordinating preventive services.

Method: Descriptive

Classification of Research: Access to Care

Results: In this study we share our experience in conducting AWVs at home by a registered nurse using audio only equipment. Since March 2020, almost 200 visits have been conducted each month. Eligible patients are identified from the EMR and receive a phone call from the staff prior to visit being scheduled. On the date of the appointment the patient is called and a pre‐designed script is followed that captures all the elements of the AWV. A visit note is documented and any concerns noted are communicated to the primary care physician.

Conclusions: There are several benefits of conducting AWVs at home. The patients are very relaxed during the telephone encounters. They aren’t burdened with securing transportation to a physical location, struggling with mobility issues once there and risking exposure to illness at a clinic. The patient feels comfortable being open and honest in the privacy of their own home. We’ve observed a lower no‐show rate for these appointments. The only concern has been the quantitative assessment of cognition that has the potential to being skewed and can be enhanced by direct visualization by adding the video component.

4. CHANGING THE CARE PATHWAY FOR PEDIATRIC VOIDING DYSFUNCTION

Aaron Martin

Children’s Hospital New Orleans/ LSU Health New Orleans

Description: Starting in April 2017, we began changing the way we care for children with pediatric voiding dysfunction. We developed a dedicated direct‐to‐home telemedicine clinic saving patients time, money, and lengthy trips to see a specialist.

Abstract:Objective: To change the care pathway of children with voiding dysfunction to save patients time and money without sacrificing quality of care.

Methods: Starting in April 2017, we developed a telemedicine clinicto provide better access to pediatric urology specialty care for children with voiding dysfunction in the state of Louisiana. Over the years, this process was modified to best capture a telemedicine‐naive population and streamline care delivery.

Results: After proving a sufficient market and successful telemedicine platform use, a full time APRN was employed to continue this clinic further enhancing clinical efficiency and access. Now it is a robust part of our practice and continues to expand with an in‐person hybrid model to better satisfy the patientsneeds.

Conclusions: A focused approach to telemedicine is needed to gradually change longstanding care pathways and enhance overall care for patients and clinicians alike.

Method: Implementation Science

Classification of Research: Quality Improvement

Results: After proving a sufficient market and successful telemedicine platform use, a full time APRN was employed to continue this clinic further enhancing clinical efficiency and access. Now it is a robust part of our practice and continues to expand with an in‐person hybrid model to better satisfy the patients’ needs.

Conclusions: A focused approach to telemedicine is needed to gradually change longstanding care pathways and enhance overall care for patients and clinicians alike.

5. COLLABORATION BETWEEN TELE‐ICU PROGRAMS HAS THE POTENTIAL TO OFFSET THE SHORTAGE OF CRITICAL CARE PHYSICIANS DURING EMERGENCIES

Craig Hertz, Martin Doerfler, Saurabh Chandra

Northwell Health; Hargobind Khurana, Providence St. Joseph Health

Description: The current COVID‐19 pandemic has highlighted the lack of adequate number of fellowship trained critical care physicians to manage highly complex patients in the ICU and beyond. Network of connected regional/national Tele‐ICU systems is a feasible solution to increase the availability of critical care physicians.

Abstract: Tele‐ICU technology was developed to offset the shortage of critical care physicians and enable provision of care for critically ill patients under the supervision of trained critical care providers. We hypothesized that the establishment of a network of connected programs can be a proactive solution to rapidly increase the availability of critical care physicians at remote sites that are in the midst of staffing shortages.

Northwell Health consisting of 23 hospitals, 40 Intensive Care Unit (500 ICU beds) serves the downstate NY area. During the initial COVID‐19 pandemic, Northwell Health rapidly expanded to 62; 1,000 ICU beds. The surge in patients required re‐deployment of non‐Critical Care providers to the ICU bedside. The Tele‐ICU program expanded from covering 176 beds pre‐pandemic to assisting with care for patients in approximately 450 beds via deployment of WiFi enabled mobile telehealth carts to the newly formed ICUs. To offset the shortage of critical care physicians, Northwell Health established a collaboration with Tele‐ICU program of Providence, St. Joseph Health (P/SJH) in the state of Washington that enabled the critical care physicians of P/SJH to participate in virtual rounding on critically ill COVID‐19 patients at Northwell Health.

Method: Proof of Concept

Classification of Research: Information Technology

Results: It took 3 weeks for multi‐disciplinary teams from both health systems to implement the collaboration between the 2 Tele‐ICU programs. The most complex task was setting up the remote VPN and EMR access and external vendor portal to connect to the mobile carts. We developed an innovative hybrid model that allowed for virtual rounding on an additional 40–60 patients per day by a remote critical care physician at P/SJH. A total of 12 shifts were performed by the P/SJH team with rounding on approximately 350 patients.

Conclusions: Our findings demonstrate the proof‐of‐concept of establishing a network of connected Tele‐ICU programs as a rapidly scalable and sustainable paradigm for the provision of support from critical care physicians for non‐critical care teams at the bedside. In spite of the challenges and limitations, we hope our study has showcased an innovative hybrid model which can be adopted by various regional/national Tele‐ICU systems to develop collaborations to rapidly overcome one of the biggest challenge in providing standardized highly complex care to critically ill patients during the current (or future) pandemic(s): the availability of critical care trained physicians.

6. COMPANIONSHIP WELLNESS PROGRAM: VIRTUAL TECHNOLOGY APPLICATION TO ADDRESS SOCIAL ISOLATION FOR HOSPITALIZED PATIENTS DURING COVID‐19

Adarsha Bajracharya

UMass Memorial

Description: Companionship Wellness Program was developed to support hospitalized English and Spanish speaking patients identified as being lonely or at risk of loneliness through virtual visits by student volunteers to improve their mood and reduce feelings of loneliness during their hospital stay.

Abstract: Social isolation and loneliness in hospital acute care settings have contributed to the current health crises with disproportionate effects on older adults, people of color, and lower income persons. The condition of loneliness is prevalent in approximately 20% of the elderly population of the United States and has been found to increase the risk of high blood pressure, heart disease, depression, dementia, and death. Hospital efforts to reduce COVID‐19 disease exposure, by limiting visitor privileges, has exacerbated the problem of loneliness and isolation among admitted patients. Applications to conduct audio‐video communication using smartphones and tablet PCs are widely prevalent in our society and these wereprovided when needed at our hospital. The Companionship Wellness Program was created to provide virtual visits to hospitalized English and Spanish‐speaking patients with COVID‐19 infection who were identified as currently suffering from or assessed as at risk for feelings of isolation by the hospital staff. Virtual companionship wellness visits were conducted by medical and nursing student volunteers using a hospital supported and HIPAA‐compliant telehealth platform. We sought to understand feasibility of our program and its impact on patients and student volunteers.

Method: Implementation Science

Classification of Research: Quality Improvement

Results: Between December 21, 2020 and February 26, 2021, 78 patients were referred for CWP visits, and 43 were paired with student volunteers. Patients who did not participate were discharged prior to volunteer match or withdrew consent. All patients who participated expressed satisfaction with their conversations and would recommend the program to others. One patient, for example, explained, “when they brought in the video of someone who was not taking care of me, it was nice to talk about everyday things.” Student volunteers affirmed that the experience reinforced the importance of understanding their patients’ lives outside the hospital and of offering emotional support.

Conclusions: Our work indicates that the use of telehealth applications to conduct virtual companionship wellness for isolated hospitalized patients is both feasible and accepted by patients and hospital staff. Our preliminary evaluation indicates that this program helped improve patients’ mood, reduce their loneliness in the hospital, and improved their overall hospital experience. This program also provided educational experience to student volunteers and helped them develop a more holistic understanding of their patients. By applying existing technology, we established a system to support companionship for isolated patients, an effort we intend to continue past the end of the present pandemic.

7. COST OF DELIVERING IN‐PERSON VS VIRTUAL PEDIATRIC SICK VISITS: ESTIMATES USING A MODIFIED TIME‐DRIVEN ACTIVITY‐BASED COSTING (TDABC) APPROACH

Kit Simpson, Kathryn King, James McElligott, Sara Ritchie, Mary Dooley

Medical University of South Carolina

Description: Studies on the cost of delivering telehealth are needed. We use a modified micro‐costing approach to compare the cost of care delivered virtually versus in‐person using a pediatric sick‐visit as example. Easy to implement, time‐driven activity‐based costing (TDABC) provides critical insights for planning long‐term integration of telehealth into healthcare operations.

Abstract: When the COVID‐19 pandemic struck, telehealth and virtual visits (TH) became essential for both patients and providers. The urgent need to convert in‐person care to TH meant few health systems had time to plan and be deliberate in their TH approach. TH programs already in place were scaled quickly and improvisations were common. We are now at the stage where we must make strategic decisions for a streamlined, sustainable TH approach and identify the best opportunities for improvement. The cost and value of TH services developed during the pandemic scale‐up should inform our choices. Published cost studies report costs from the perspective of patients, payers, and populations using macro‐costing or pricing survey approaches. Largely missing from the literature are micro‐costing studies of TH versus in‐person care. Using a pediatric sick visit (CPT code 99213) as example, we analyzed TH versus in‐person care using TDABC composed of: 1) recorded qualitative interviews with provides; 2) iterative workflow mapping; 3) use of EHR time stamps for validation; 4) application of standard cost weights for wages; and 5) using clinic CPT billing code mix for complexity weights. The results were validated using EHR time stamps and billing data from 2019 and 2020.

Method: Cost Analysis

Classification of Research: Cost Analyses

Results: Workflows for CPT code 99213 varied from 18–31 minutes in length, depending on the need for laboratory tests and prescription review. Using TDABC, the cost of clinic personnel for an in‐person sick visit before COVID‐19 varied between $59.13‐$70.80 and $41.20‐$50.91 for physician (MD) and nurse practitioner (NP), respectively. During COVID‐19, the cost of an in‐person visit increased to a range of $98.44‐$117.09 and $62.68‐$79.07 for MD and NP, respectively. The cost of a telehealth visit was lower than in‐person clinic visits both before and during COVID‐19, with a cost of $50.67 and $33.03 for MD and NP, respectively.

Conclusions: As healthcare providers plan for sustained TH operations, our TDABC approach helps inform: identifying which TH programs to maintain; determining how to improve TH efficiency; and understanding the least costly mixes of TH and in‐person visits. Moreover, this approach is feasible to use under virtual working conditions; requires minimal provider time; can be implemented quickly; captures important variations in the process of care that affect costs; and generates detailed cost estimates that have “face validity” with providers. This TDABC approach is relevant for process improvement and use in cost effectiveness, return on investment, and other types of economic evaluations.

8. DEVELOPING ORGANIZATIONAL GUIDELINES TO SUPPORT VIRTUAL MENTAL HEALTH WALK‐IN MODELS

Melissa Edwards

Ontario Centre of Excellence for Child and Youth Mental Health

Description: The Ontario Centre of Excellence for Child and Youth Mental Health, in collaboration with a stakeholder advisory committee, developed provincail guidelines for implementing virtual walk‐in service models for the child and youth mental health sector in Ontario. This presentation will provide an overview of the guidelines.

Abstract:Background/context: The current global pandemic has prompted mental health providers to quickly pivot to virtual services to maintain continuity for existing clients and increase accessibility for current, new and potential clients. In Ontario’s child and youth mental health (CYMH) sector, virtual services, such as virtual walk‐in models, have the potential to increase access and support navigation and pathways within the system (e.g. Lal & Adair, 2014).

Theoretical frameworks/methods/results: The Ontario Centre of Excellence for Child and Youth Mental Health, in collaboration with a stakeholder advisory committee, developed guidelines for implementing virtual walk‐in service models for the CYMH sector in Ontario. This guideline is rooted in an implementation science framework and draws on evidence from various sources: literature, advisory committee input, stakeholder feedback obtained via survey and key informant interviews.

Impact/relevance to the advancement of the field: With the fast‐paced emergence of digital technologies, CYMH organizations are working rapidly to implement virtual services while struggling with implementation due to the absence of clear guidelines. Guidelines are intended to ensure adherence to best practice, consistency, and ultimately, safe, quality care (WHO, 2014). The availability of an organizational guideline for virtual walk‐ in models is timely and in demand across healthcare systems.

Method: Implementation Science

Classification of Research: Quality Improvement

Results: The Ontario Centre of Excellence for Child and Youth Mental Health, in collaboration with a stakeholder advisory committee, developed guidelines for implementing virtual walk‐in service models for the CYMH sector in Ontario. This guideline is rooted in an implementation science framework and draws on evidence from various sources: literature, advisory committee input (n = 9), stakeholder feedback obtained via survey (n = 57) and key informant interviews (n = 3). Highlights of the guideline will be presented during the session.

Conclusions: With the fast‐paced emergence of digital technologies, CYMH organizations are working rapidly to implement virtual services while struggling with implementation due to the absence of clear guidelines. Guidelines are intended to ensure adherence to best practice, consistency, and ultimately, safe, quality care (WHO, 2014). The availability of an organizational guideline for virtual walk‐ in models is timely and in demand across healthcare systems.

9. DEVELOPING PERSONALIZED DIABETIC RETINOPATHY RECOMMENDATIONS WITH TELERETINAL IMAGING

Christina Weng

Baylor College of Medicine ‐ Ophthalmology; Poria Dorali, Zahed Shahmoradi, Taewoo Lee, University of Houston ‐ Cullen College of Engineering

Description: While teleretinal imaging (TRI) is a viable screening tool for detecting diabetic retinopathy, questions still remain as to how to incorporate it into the existing screening guidelines. This study develops a mathematical model‐based decision support tool that provides personalized screening recommendations, which effectively integrates teleretinal screening and traditional clinical screening.

Abstract: Diabetic retinopathy (DR) is the leading cause of blindness within working‐age American adults. While retinal screening can be effective at preventing DR‐related vision loss, traditional clinical screening (CS) practice suffers from poor patient compliance rate due to unfavorable cost, inconvenience, and limited accessibility. To address this, TRI has recently emerged as a viable alternative, which facilitates inexpensive, moderately accurate screening exams that can be more conveniently administered by primary physicians. However, questions still remain as to how to best integrate TRI into the existing DR screening system such that patients with limited access can truly benefit from this new technology.

This study aims to maximize the benefit of TRI by developing an evidence‐based decision support tool that provides personalized TRI‐inclusive screening recommendations for patients with various characteristics. A mathematical model utilizing a Markov decision process is developed to identify optimal, TRI‐inclusive yearly screening recommendations for each patient based on the patients probability of having sight threatening diabetic retinopathy and compliance behavior so as to maximize QALYs while minimizing cost over time. This model is then applied to a cohort of 500,000 hypothetical patients to analyze benefits of TRI‐based screening policy compared to current practice.

Method: Mathematical Modeling

Classification of Research: Access to Care

Results: The model is applied to a cohort of 500,000 hypothetical patients with variable TRI and CS compliance rates between 0% to 100%. Compared to the current practice of recommending annual clinical screening, the model advocates the use of TRI, recommending TRI screening for 88.46% of all possible cases. Simulation analysis shows that for patients following the model‐based recommendations utilizing TRI, blindness prevalence decreases by 15.05% (95% CI; 14.88%‐15.23%) while cost/QALY decreases by 7.07% (95% CI; 6.93%‐7.23%) as opposed to patients following annual CS recommendations.

Conclusions: The mathematical model offers an effective and flexible decision support tool for primary physicians and eye care professionals to provide personalized, TRI‐based DR screening recommendations. Our results strongly favor the integration of TRI into current DR screening systems for the vast majority of patients. Additionally, our simulation analysis indicates that patients can have superior health outcomes while paying less when they are provided these personalized TRI‐inclusive recommendations as opposed to rigid annual clinical screening policies seen in current practice.

10. DIABETES TELEHEALTH SOLUTIONS: IMPROVING SELF‐MANAGEMENT THROUGH REMOTE INITIATION OF CONTINUOUS GLUCOSE MONITORING

Robin Gal¹, Nathan Cohen¹, Roy Beck¹, Peter Calhoun¹, Brian Bugielski, Heidi Strayer¹, Davida Kruger², Richard Bergenstal³, Terra Cushman⁴, Amanda Haban⁵, Korey Hood⁶, Mary L. Johnson³, Teresa McArthur⁷, Beth Olson⁸, Ruth Weinstock,⁹ Sean Oser¹⁰, Tamara Oser¹⁰, and Grazia Aleppo¹¹

¹Jaeb Center for Health Research, ²Henry Ford Health System, ³International Diabetes Center Park Nicollet, ⁴Henry Ford Health System, Detroit, Michigan, ⁵UW, ⁶Stanford University School of Medicine, ⁷Cecelia Health, ⁸Lagoon Health, ⁹SUNY Upstate Medical University, ¹⁰University of Colorado School of Medicine, Department of Family Medicine and State Network of Colorado Ambulatory Practices & Partners (SNOCAP), and ¹¹Northwestern University Feinberg School of Medicine

Description: Telehealth provides an opportunity to increase access to continuous glucose monitoring (CGM) and empower patients living with diabetes by providing more data for self‐management. Despite the compelling evidence of the benefits of CGM, many individuals with type 1or type 2 diabetes using insulin have not adopted the use of CGM.

Abstract: The purpose of this study was to evaluate the feasibility of initiating CGM through telehealth as a means of expanding access. Adults with type1or type 2 diabetes using insulin and interest in starting CGM selected a CGM system. CGM was initiated with a CDCES providing instruction via videoconference or phone. The primary outcome was days per week of CGM use during the last 4 weeks. A1c was measured at baseline and 12 weeks. All participants were using CGM at 12 weeks, with 94% using CGM at least 6 days per week during weeks 9 to 12. Mean HbA1c decreased from 8.3 at baseline to 7.2 at 12 weeks and mean TIR increased from an estimated 48% 8197; to 59%, an increase of approximately 2.7 hours/day. Substantial benefits of CGM to quality of life were observed, with reduced diabetes distress, increased satisfaction with glucose monitoring, and fewer perceived technology barriers to management. Remote CGM initiation was successful in achieving sustained use and improving glycemic control after 12 weeks as well as improving quality‐of‐life indicators. If widely implemented, this telehealth approach could substantially increase the adoption of CGM and potentially improve glycemic control for people with diabetes using insulin.

Method: Observational

Classification of Research: Clinical Outcomes

Results: Mean HbA1c decreased from 8.3 ± 1.6 at baseline to 7.2 ± 1.3 at 12 weeks (P < 0.001). CGM metrics were consistent with this finding, with mean time in range (70‐180 mg/dL, 3.9‐10.0 mmol/L) increasing from an estimated 48% ± 18% at baseline to CGM‐measured 59% ± 20% (P < 0.001) and mean glucose concentration decreasing from an estimated 196 ± 46 mg/dL (10.9 ± 2.6 mmol/L) at baseline to CGM‐measured 170 ± 36 mg/dL (9.4 ± 2.0 mmol/L) (P < 0.001) over the 12 weeks of the study.

Conclusions: Telehealth has the potential to replace clinic visits for the management of diabetes. In this study, we demonstrated that a virtual approach outside the clinic can be used for successful CGM initiation and incorporation into diabetes self‐management for adults with T1D or T2D using insulin. There was a substantial reduction in HbA1c with a low frequency of hypoglycemia in most participants, with an increase of about 2.7 hours per day in the amount of time in range spent with glucose levels between 70 and 180 mg/dL. This study has demonstrated that CGM can be successfully initiated outside the practice setting.

11. EVALUATION OF A CUSTOMIZED ALGORITHM FOR DETECTION OF DIABETIC RETINOPATHY IN DIABETIC CLINICS IN INDIA

Sheila John¹, Ramachandran Rajalakshmi², Viswanathan Mohan³ and Sangeetha Srinivasan⁴

¹Department of Teleophthlamology, Sankara Nethralaya, ²Dr. Mohan’s Diabetes Specialities Centre and Madras Diabetes Research Foundation, ³Dr. Mohan’s Diabetes Specialties Centre, and ⁴Vision Research Foundation

Description: To examine the effectiveness of a computer‐assisted device for onsite screening for diabetic retinopathy (DR) at diabetic outpatient clinics using 7‐fields photography system.

Abstract: The DR algorithm was developed by the Health Technology Innovation Centre using 7‐field dilated images (185,971). Diabetic clinics in and around Chennai, India, were selected. Individuals with already known and newly diagnosed type 2 diabetes were included in the study. 107 and 112 participants from 2 districts underwent fundus photography with mydriatic seven‐field digital retinal colour photography system per the Early Treatment Diabetic Retinopathy Study Scale (ETDRS) protocol. The paramedical staff, fundus photographer and optometrists in diabetic clinics were trained to take fundus photographs with dilation. 438 eyes of 219 participants underwent 7‐field mydriatic imaging system. The fundus images were captured at the physicians or diabetologists facility/clinic at the time of their regular diabetic check‐up. Diabetic retinopathy was defined according to the International Clinical Diabetic Retinopathy Disease Severity Scale by an ophthalmologist. The same retinal photos were assessed by the algorithm in both eyes for presence or the absence of DR and examined for sensitivity and specificity.

Method: Observational

Classification of Research: Clinical Effectiveness

Results: 84% of 438 eyes were identified as having DR on the 7‐field photography by an ophthalmologist. The algorithm showed 91% sensitivity and 100% specificity in detecting DR when using the 7‐field dilated photography when compared to the ophthalmologist.

Conclusions: The algorithm showed high sensitivity and specificity in this group when utilizing a dilated 7‐field photography system. Further studies may be designed to evaluate the algorithm in undilated settings.

12. FOXTROT: FORWARD OPERATING BASE EXPERT TELEMEDICINE RESOURCE UTILIZING MOBILE APPLICATION FOR TRAUMA

William Gensheimer

Air Force; Kyle Miller, Navy; Gary Legault, US ARMY; Jennifer Stowe, US ARMY

Description: Our team designed and created a mobile application for Teleophthalmology using AI and mobile phones. This application was recently fielded in Afghanistan. We plan on presenting our results and plan for the future.

Abstract: Tele ophthalmology is an important tool to address eye care disparities in the health care system for underserved populations such as poor and rural communities. Access to eye care can reduce the risk of death and improve the quality of life for patients. In military medicine, teleophthalmology has been shown to improve and extend ophthalmic care in a combat zone and can prevent unnecessary aeromedical evacuations. However, there are currently no widely adapted mobile phone applications for teleophthalmology in medicine and few studies have demonstrated that ocular diagnostic testing on smartphones can be accurate and repeatable. Moreover, there are no commonly employed artificial intelligence (AI) solutions to support teleophthalmology using a mobile device. There are commercially available hardware and software applications that can assist a user in obtaining smartphone images and videos of the fundus, but there are no widely available commercial solutions that integrate image capture with AI and DL image processing and teleophthalmology consultations. The primary purpose of our research is the development of an operationally secure, HIPPA compliant, mobile application (mApp) to provide ophthalmic care to any remote deployed location through a teleophthalmology called Forward Operating Base EXpert Telemedicine Resource Utilizing MObile Application for Trauma (FOXTROT).

Method: Implementation Science

Classification of Research: Clinical Effectiveness

Results: FOXTROT was fielded in Afghanistan field hospitals. Based on an independent assessment, FOXTROT saved the Military $2.4M by preventing costly medical evacuations out of theater. Results were published in JAMA. And FOXTROT recently won 2 awards (1) ARMY MODELING AND SIMULATION (M&S) AWARD 2019 and (2) FEDERAL HEALTH IT (FEDHEALTHIT) INNOVATION AWARD 2020

Gensheimer WG, Miller KE, Stowe J, Little J, Legault GL. Military Teleophthalmology in Afghanistan Using Mobile Phone Application. JAMA Ophthalmol. 2020:138(10):10534‐1060.

Conclusions: There is currently limited access to ophthalmic care at forward‐operating bases, especially with ocular trauma. Teleophthalmology is currently limited in the military and in the civilian sector. FOXTROT teleophthalmology mApp improved and extend ophthalmic trauma care in remote deployed environments.

13. IMPACT OF A STANDARDIZED TELE‐ULTRASOUND EDUCATION AND INTERPRETATION PROGRAM WITHIN THE PRIMARY MATERNITY PROVIDERS’ OFFICES

Sina Haeri

Access Physicians

Description: Traditionally, families with at‐risk pregnancies living in critical access communities have had to travel to a Radiologist or Maternal‐Fetal Medicine specialist in larger metropolitan areas for advanced imaging. Our aim has been go train local resources via telehealth so that families can get services locally.

Abstract:Methods: In this retrospective cohort study we examined all remote ultrasound examinations performed at our rural partner sites. None of the sites were a Maternal‐Fetal Medicine clinic, and involved training and utilization of local sonographers. The program included initial competency assessment, on‐going sonographer feedback and CME, and ultrasound interpretation by an MFM.

Results: During the study period a total of 16,230 ultrasound examinations were performed, of which 3,890 (24%) exams included an abnormal finding. Of the abnormal exams, 806 (21% of abnormal exams, 5% of overall exams) included a finding not detected by a sonographer (exam labeled as normal) with 402 (50%) placental/fluid problem, 236 (29%) a soft‐marker of aneuploidy, 99 (12%) growth problem, and 82 (10%) a congenital cardiac defect.

Discussion: Implementation of a standardized tele‐ultrasound program within the primary maternity providers office (including free‐standing birthing centers) led to an additional 5% detection of abnormalities in exams otherwise labeled as 8220; normal 8221; by the sonographers, with 10% including congenital heart defects. Our data support that advanced ultrasound exams can be provided to patients utilizing tele‐ultrasound saving families valuable windshield time. The training of local sonographers aids critical access communities with workforce development and retention.

Method: Descriptive

Classification of Research: Quality Improvement

Results: Implementation of a standardized tele‐ultrasound program led to detection of an additional 5% abnormalities missed by a sonographer. The most clinically significant impact included the 10% congenital heart defects as (if undetected prenatally) many of these neonates would require transport shortly after birth. The median time to program maturation (sonographer training) was 8 weeks.

Conclusions: Implementation of a standardized tele‐ultrasound program within the primary maternity provider’s office (including free‐standing birthing centers) led to an additional 5% detection of abnormalities in exams otherwise labeled as “normal” by the sonographers, with 10% including congenital heart defects. Our data support that advanced ultrasound exams can be provided to patients utilizing tele‐ultrasound saving families valuable windshield time. The training of local sonographers aids critical access communities with workforce development and retention.

14. IS TELEHEALTH THE NEW NORMAL FOR OUTPATIENT PSYCHIATRY APPOINTMENTS?

Saurabh Chandra¹, Yunxi Zhang² Barbara Jones², Jessica Polakovic², Scott Rodgers²

¹Center For Telehealth, University of Mississippi Medical Center, ²University of Mississippi Medical Center

Description: This study examines the trends in outpatient Psychiatry visits conducted via Telehealth during the current pandemic (Jan‐Dec 2020).

Abstract: When adapting to the new normal of living with the coronavirus, health care delivery via telehealth has garnered unprecedented attention, especially in the ambulatory setting. Spurred by relaxation in the regulatory requirements, telehealth helped offset the decline in face‐to‐face visits (JAMA Internal Medicine, 2021;181(3)). However, over time there has been a gradual decline in the number of telehealth visits in most specialties requiring ongoing analysis of provider and patient preferences, appropriate use cases for telehealth visits and associated reimbursement and revenue generation in an effort to sustain the growth and benefits of telehealth in the post‐pandemic era. We report our experience in the Department of Psychiatry and Human Behavior in 2020 and demonstrate the enormous value of telehealth by analyzing and comparing all outpatient visits conducted via telehealth and in‐person under the Department of Psychiatry and Human Behavior between January and December 2020 at the University of Mississippi Medical Center.

Method: Descriptive

Classification of Research: Access to Care

Results: Results show that psychiatry appointments via telehealth dramatically surged in April, accounting for 96.3% of all completed appointments, and started declining in May to a plateau around 40‐45% of all outpatient visits. With the total number of visits similar to the corresponding pre‐pandemic period, this indicates patient preference for telehealth visits over in‐person visits. In addition, there is a significant difference (p < 0.0001) in the cancellation (35.4% vs 11.7%, in‐person vs telehealth) and no‐show rates (27.3% vs 16.5%, in‐person vs telehealth) between the two visit types. Furthermore, the reimbursement percentage of telehealth visits was higher than in‐person visits (42.7% vs. 35.3%).

Conclusions: Our study indicates that telehealth has found a sustained niche in clinical psychiatry since the COVID‐19 outbreak. Further analysis of patient demographics, financial class, and reason for visits is currently underway to identify variables that contribute to the success of telehealth in the field of psychiatry.

15. IVR TECHNOLOGY USE BY PATIENTS WITH HEALTH FAILURE: UTILIZATION PATTERNS AND COMPLIANCE

Esra Ben Ismail

University of Ottawa Heart Institute

Description: Heart failure (HF)is the leading cause of cardiovascular morbidity and health care utilization worldwide.Maximizing the efficacy of Interactive voice response (IVR) and increasing its use in remote monitoring can lower HF costs and patient hospitalization rates.

Abstract: IVR is an automated telephony system that leverages existing telephone lines for monitoring patients post‐discharge from a hospital, for early intervention. Limited evidence exists on the pattern of use and success of IVR technology among patients with HF, and how IVR affects their compliance. This study explores the pattern of IVR use by HF patients in the IVR program at the University of Ottawa Heart Institute (UOHI), describes theircharacteristics andIVRpatterns of use in relation to compliancebehavior (e.g., weighing themselves, medication compliance) andservices utilization (i.e., hospital readmission). Secondary data collected by the IVR system at UOHI were used in this analysis. The system is based on an algorithm that triggers automated telephone calls to patients at a predetermined time for six months after discharge: Day 2, Weeks 1, 2, 4, 6, 8, 10, and 12. The results show a peak of completed calls at Week 1 (78%), followed by a steady decline until Week 12 (54.9%). Week 12 showed the lowest rates of hospital readmissions (5.5%) whereas, week 4 had the highest rate (10.6%). These results will be providing information in scoping outwhat HF patient characteristics IVR appeals best to.

Method: Secondary Data Analysis

Classification of Research: Access to Care

Results: A total of 902 HF patients were considered with a mean age of 70 years (59.4% male). The highest rate of follow‐up calls was at Week 2 (nurses calling back 7.8% of the patients); 58.8% of those patients were male. There was a positive correlation between compliance behavior and lack of service utilization. Throughout the whole 6 months, more than 90% of patients who were taking their medications regularly and weighing themselves every day were not readmitted into hospitals. More analysis will be done to further explore the characteristics and cluster of patients that IVR works best on.

Conclusions: The increased use of IVR in remote patient monitoring will allow for a cheaper and more accessible form of at‐home recovery. The pattern of IVR use may vary across patients, but there are benefits associated with the use of this technology in relation to HF patients’ behavioral changes and readmissions. Leveraging IVR technology to support other conditions, especially during a pandemic, may be beneficial for patients to avoid unnecessary visits to the hospital and complications due to delay in seeking care.

16. LAUNCHING A SUCCESSFUL VIRTUAL DIABETES PROGRAM TO IMPROVE A1C DURING COVID 19 PANDEMIC

Renu Joshi, Salim Saiyed

UPMC Pinnacle

Description: During COVID 19 pandemic diabetic patientshad disadvantage of not being able to be evaluated by their endocrinologist. We embarked on developing a virtual Diabetes boot camp program to improve A1c outcomes in this high‐risk population with frequent virtual visits with Diabetes educator and dietitians.

Abstract:Background: Patients with diabetes had worsening of glycemic control during pandemicdue to lack of follow up.

Goals: Start virtual “Boot Camp” with diabetes educators &#38; dietitians to improve glycemic control for high A1c &#62; 8 as a pilot study in Endocrinology office

Team: Endocrinologist, IT, Educators Nutritionists, executive assistant

Implementation: EHRregistry was created for patients with A1c &#62; 8 TIDEPOOL software was downloaded andutilized to share real time glucose readingswith Diabetes team. EHR referral was developed tohave patients join &#34; boot Camp&#34; Endocrinologists were trained with concept of BOOT Camp and education was shared with both providers and patients. Patients were scheduled weekly for 12 virtual visits alternating with dietitian and educators for 30 min. Real‐time education and change of therapy was made based of glucose downloads &#38; dietary patterns. Follow up was scheduled with provider in 12 weeks. The program was conceptualized in June and initiated in September with over 70 patients scheduled in the program. Fifteen patients have completed the 3 months virtual boot Camp with a majority of 75 % showing an improvement in A1c. The next phase of program has now been extended to primary care clinics and indigent population.

Method: Implementation Science

Classification of Research: Quality Improvement

Results: Seventy patients have been enrolled, and 15 patients have completed the full 3‐month program. 11/15 patents (75 %) have shown improvement in A1c, and 9/15 patients showed improvement in weight.

Patients have been engaged and find it useful due to real time changes in behavior and medications based on weekly patterns. Flexibility to do visits from home has been very successful. Virtual visits have been more engaging than telephone visits. Our low cost free clinic patients have also been able to benefit from this program. Financial analysis shows improvement as well. Early results of patients’ feedback has been very positive

Conclusions: A complete virtual BOOT CAMP based on team of diabetes educators and dietitians is beneficial to diabetic patients with high A1c .The success of the program is attributable to engagement and real time data monitoring of glucoses which can be shared with patients. The patients like the virtual format as it provides care in the comfort of their home. Both the dietitians & educators have received positive feedback about the program. We have demonstrated that completely virtual program which is first of its kind during Pandemic can improve outcomes. The effect of extended program to undeserved population is awaited.

17. MATERNAL‐FETAL TELEMEDICINE (TELEMFM): EXAMINING THE IMPACT OF A NATIONAL HUB AND SPOKE MODEL ON CRITICAL ACCESS COMMUNITIES

Sina Haeri

Access Physicians

Description: Maternal‐Fetal telemedicine remains regionalized without adoption of a national hub and spoke modelk relying on staff travelling to the spoke at set intervals (i.e. weekly) leaving the community without access inbetween clinic days. Our aim was to examine the impact of a program utilizing local resources with daily teleMFM access.

Abstract:Background: Traditionally, teleMFM programs have focused on outpatient services utilizing a regional hub and spoke model with subspecialty ancillary staff (i.e. sonographers) travelling to the spoke at set intervals. Our aim was to examine the impact of our national teleMFM hub and spoke model, which is transport pattern agnostic and relies on training local staff to provide subspecialty support via telemedicine.

Methods: In this cross‐sectional study we estimated the quantitative impact of our teleMFM program through number of deliveries outside of the community, along with referring provider perception using a survey tool. In each instance, the clinic was staffed by a U.S.‐based MFM and referral base included midwives, family practitioners, and obstetricians.

Results: During the study period a total of 3,479 outpatient visits were performed on 1,097 new referrals from 51 community maternity providers. Overall 66 (6%) patients required delivery outside of their home community with the majority due to need for higher level of neonatal care after delivery. Survey of the referring providers demonstrated that over 60% of the clinicians felt that (1) teleMFM improved access to care, (2) allowed for time‐sensitive referrals, and (3) led to referral of patients with cases they were not comfortable managing.

Method: Survey/Qualitative (Some descriptive data included as well)

Classification of Research: Clinical Effectiveness

Results: During the study period a total of 3479 outpatient visits were performed on 1097 new referrals from 51 community maternity providers. Overall 66 (6%) patients required delivery outside of their home community with the majority due to need for higher level of neonatal care after delivery. Survey of the referring providers demonstrated that over 60% of the clinicians felt that (1) teleMFM improved access to care, (2) allowed for time‐sensitive referrals, and (3) led to referral of patients with cases they were not comfortable managing.

Conclusions: Implementation of a national hub and spoke model teleMFM care utilizing local resources and staff allowed 94% of families with at‐risk pregnancy to remain close to home during their prenatal care and delivery saving valuable windshield time and supporting critical access communities.

18. PATIENT TRENDS AND SHIFT POINTS IN ADVANCE CARE PLANNING

Connie Ducaine

Vital Decisions

Description: Using a telehealth approach, Vital Decisions has worked with more than 300,000 U.S residents resulting in the completion of thousands of advance care planning (ACP) documents. An analysis of this robust data set offers insight into the ACP decisions and factors that are incorporated into the decision making process.

Abstract: It has been noted in the literature that patients who are dealing with complex medical situations and approaching end of life benefit from developing an ACP. What is less widely reported is how these individuals define specific care paths via their advance care plans and what they identify as their shift points between levels of care. Using a multi‐session telehealth approach, Vital Decisions has worked with more than 300,000 people, which has resulted in the completion of 1,000s of documents. An analysis of these ACP assets offers insight into the ACP decisions and factors that are incorporated into the decision making process.

Method: Survey/Qualitative

Classification of Research: Clinical Outcomes

Results: Vital Decisions has synthesized the information contained in 1,000 ACP documents to discern the following:

• age at which people with an advanced illness begin to articulate a desire for comfort care versus selective measures versus full treatment

• differences in the preferred treatment options when one considers the patient’s zip code, state or region of the country

• differences in ACP preferences based on gender

• frequency in which patients document the length of time they deem the selected treatment option to be appropriate

• who is most often identified as an individual’s healthcare proxy

• frequency in which patients identify a secondary proxy

Conclusions: The results of this analysis sheds light on certain subgroups of patients and their preferences related to ACP while supporting the notion that this work cannot solely be done via a static document based on a series of yes/no questions. ACP is an iterative process in which members must consider their values, priorities and preferences. The data gleaned from this analysis offers providers insight into patients’ willingness to consider specific measures, under what circumstances those measures would be considered appropriate by the patient and for what time period. Exploring patient perspectives encourages us to identify and address any existing biases.

19. PERSPECTIVES OF PATIENTS AND FAMILIES ON THE QUALITY, OPPORTUNITIES, AND CHALLENGES OF TELEHEALTH AT A LARGE PEDIATRIC HOSPITAL

Emre Sezgin, Yungui Huang, Deborah Lin

Nationwide Children’s Hospital

Description: We present the results of multiple studies aiming to explain patient and family perception towards satisfaction of telehealth visits.We collected and analyzed responses for a telehealth patient satisfaction survey from 5,144 respondents,followed by a retrospective analysis 200 medical records to understand reasons for cancellation and rescheduling of televisits.

Abstract: The COVID‐19 pandemic has ushered a new era of health care delivery by hastening the adoption of telehealth, which led to a growing interest in understanding the quality and experience of telehealth services from the perspectives of patients and families.

Nationwide Childrens Hospital, one of the largest pediatric hospitals in the U.S. with 1.5 million visits per year, designed and rolled out an organization‐wide telehealth patient satisfaction survey (TPSS) in July 2020. Patients completing video visits are automatically identified through EHR and sent a unique survey link to the HIPAA‐compliant REDCap platform via their patient portal. The survey asks the patients or families to reflect on their experience of a specific encounter. Behind the scenes, survey result is linked to the encounter in EHR, reducing survey burden on the respondents. The 5‐minutes survey consists of 23 items with the majority being Likert‐scale responses.

To further understand the challenges telehealth imposes to patients and families, in addition to TPSS collected on completed visits, we qualitatively investigated the EHR documented reasons for telehealth visit cancellations and rescheduling (C/R). We reviewed EHR notes (n = 200) to analyze and understand the reasons for C/R in the most frequently tele‐visited departments (Behavioral Health, Speech Pathology).

Method: Survey/Qualitative

Classification of Research: Patient Experience

Results: 5,144 survey responses received from July 2020 to January 2021 showed most patients had a positive telehealth experience (95.7%), and health care needs were met with telehealth (96.8%). However, only 76.3% indicated they would use telehealth in the future if given the option. Our survey revealed the top telehealth challenges for patients were finding a suitable place to conduct visit, concerns regarding care quality, and technical issues. Chart review analysis revealed that the top reasons for C/R were “technical problems” (36%), “scheduling conflicts” (24%), and “engagement issues”, which is the inability to engage a patient to complete the telehealth session (25%).

Conclusions: This large telehealth patient/family satisfaction survey study indicates that patients in general are highly satisfied with telehealth services, but patient engagement is a new type of challenge that healthcare providers must overcome. The linkage to patient and visit information enabled in‐depth analysis of the survey responses, such as patient characteristics, condition, or specialty‐specific challenges. Importantly, the patient comments and the clinical notes on reasons for C/R offered a wealth of insights into the patient experience. Our study revealed several drivers and challenges for telehealth adoption for pediatric patients and their families.

20. RACIAL DIFFERENCES IN THE POSSIBLE DRIVERS OF DTC TELEHEALTH USAGE AND POTENTIAL IMPLICATIONS FOR IMPROVING HEALTH OUTCOMES/REDUCING DISPARITIES: AN OBSERVATIONAL STUDY

Veroneque Ignace

Ro

Description: Proponents of direct‐to‐consumer (DTC) telehealth platforms often view them as a tool to reduce health disparities, yet little research exists on if and how these platforms might accomplish this. Insight into racial differences in motivation for seeking virtual treatment can inform future outreach efforts and equity‐centered initiatives.

Abstract: The COVID‐19 pandemic exacerbated racial health disparities and created pathways for telehealth to democratize health care, thus producing a need for research at the intersection of disparities and virtual care. Understanding what role race plays in patients motivation for seeking virtual treatment can inform efforts to facilitate telehealths ability to reduce disparities.

We compared white and nonwhite DTC telehealth patient survey data across five measures: whether they used telehealth before, whether they had a primary care physician, whether receiving in‐person is a hassle, whether they had any insurance and whether they had some form of private insurance.

We found most respondents were first time telehealth users regardless of race, but white patients were significantly more likely to report having a PCP, less likely to be uninsured, more likely to have some form of private insurance, and less likely to report experiencing hassle receiving in‐peron care.

Findings suggest that nonwhite patients first‐time motivation for seeking an alternative to in‐person care might be more closely linked to access and cost challenges with the in‐person system than for white patients. Findings have implications for how telehealth can create pathways for disparities reduction.

Method: Survey/Qualitative

Classification of Research: Patient Experience

Results: Thirty five percent of survey respondents self‐identified as nonwhite. The majority (>90%) of all patients were first time telehealth users regardless of race. Compared to nonwhite patients, white patients were almost twice as likely (OR = 1.88, p < 0.01) to report having a PCP, were half as likely to be uninsured (OR = 0.61, p < 0.10), were more than 1.5 times more likely to have some form of private insurance (OR = 1.60, p < 0.05), and were half as likely to report that receiving in person care is a hassle (OR = 0.55, p < 0.10).

Conclusions: Findings suggest that nonwhite patients’ motivations in trying DTC telehealth might be more closely linked to access and cost challenges with in‐person care than for white patients. As such, DTC platforms might help reduce disparities provided they promote inclusivity and equitable access. By leveraging scale to reduce cash pay prices, DTC platforms might also impact racial disparities associated with inequitable rates of insurance coverage. Should they succeed, DTC platforms may be well‐positioned to reduce disparities in health outcomes, particularly if they expand their services to include treatment for chronic conditions with disproportionate prevalence in communities of color in the future.

21. SCHOOL BASED TELEMEDICINE AS A NOVEL SOLUTION TO IMPROVING STUDENT CHRONIC ABSENTEEISM IN CALIFORNIA

Robert Darzynkiewicz

Hazel Health Services

Description: In California, chronic absenteeism is defined as students missing 10% or more school days. Acute medical conditions contribute to school absences. Students who are chronically absent are at higher risk of not completing high school. Students who do not complete high school are a risk for poor health outcomes.

Abstract:Purpose: To analyze the effect of in‐school telehealth support on chronic attendance of K‐8 schools. Especially those that may have lack of access to proper care.

Methods: Health Insurance Portability and Accountability Act (HIPAA) and Federal Educational Rights and Privacy Act (FERPA) compliant consent was obtained. 21 schools were enrolled over 17 months. Acute medical visits and health screens were selected by the school health staff after training. Students were assessed via video by licensed health care professionals (HCP). Care and disposition, over the counter medication, and follow up care were determined by the HCP and in concordance to the school district health policy. Chronic absenteeism data in California was obtained from the state website. Chronic absenteeism was collected after half a year, one full year and 2 years of service. Schools were identified at title 1 and districts in medically underserved through national databases.

Method: Observational

Classification of Research: Clinical Effectiveness

Results: Schools with telemedicine services for half a school year (90 school days) reported a reduction in the relative rate of chronic absenteeism of 0.7 percentage points [15.3% to 14.6%], a 4.6% year‐over‐year decrease. Schools with telemedicine services for at least one school year (180 school days) reported a reduction in the relative rate of chronic absenteeism of 1.5 percentage points [12.6% to 11.1%], a 12.9% year‐over‐year decrease. Schools with telemedicine for at least 2 full school years (360 school days) reported a reduction of 2.4 percentage points [11.6% to 9.2%], a 21.3% year‐over‐year decrease from the year before program’s launch.

Conclusions: Providing access to quality health care via telemedicine appears to affect chronic absenteeism in title one schools where resources are limited and social determinants of health are more prevalent. In a time after COVID‐19 where many inequities have been discovered, leveraging technology may help to improve health both by helping medical conditions and also allowing children a better chance at graduating from high school.

22. SURGE TELEMEDICINE COVERAGE FOR ICU COVID‐19 PATIENTS

Michael Marquez, Bryan Ludwig, P. William Ludwig, Ray Morales, Samir Peshimam

NuView Health

Description: NuView Health provides on‐site/telemedicine support to ICUs of various sizes and patient acuity. The COVID‐19 pandemic has caused strain on ICU staffing. NuView developed a surge model of daytime telemedicine support for on‐site Intensivist staff. We report the results of this model of care in two of our ICU programs.

Abstract:Introduction: NuView Health provides on‐site/telemedicine support to ICUs of various sizes and patient acuity. The COVID‐19 pandemic has caused strain on ICU staffing. NuView developed a surge model of daytime telemedicine support for on‐site Intensivist staff. We report the results of this model of care in 2 of our ICU programs.

Methods: During the COVID‐19 pandemic, the on‐site Intensivist could activate telemedicine support depending on patient volume. The Intensivist would designate COVID‐19 patients for telemedicine evaluation. The TeleIntensivist completed work rounds, MDR rounds, enter notes, orders in the EMR, and provide family discussion.

Method: Observational

Classification of Research: Clinical Effectiveness

Results: During a 9‐month period, there were 730 telemedicine encounters,153 total patients seen, during daytime rounds. In hospital A, 456 encounters, 104 patients seen, 63% ventilated. In hospital B, 274 encounters, 49 patients seen, 59% ventilated. The average daily census seen was 5.2 patients, reducing the on‐site intensivists daily tasks. Overall mortality rate for these patients was 30.7%. This was not significantly different than patients seen by the on‐site Intensivist.

Conclusions: Daytime surge telemedicine support provided a significant reduction in workload for daytime intensivists during the COVID‐19 pandemic. The TeleIntensivist provided comprehensive care for COVID‐19 patients with outcomes not significantly different from those achieved by the on‐site Intensivist.

23. SYNCHRONOUS TELEMEDICINE APPROACH TO INTERNATIONAL ZIKA CHILD RESEARCH DURING THE COVID‐19 PANDEMIC

Sarah Mulkey, Margarita Arroyave‐Wessel

Children’s National Hospital

Description: We previously studied Colombian children with antenatal Zika‐virus exposure who did not have Congenital Zika Syndrome but had lower neurodevelopmental scores. The COVID‐19 pandemic occurred during planned in‐person neurodevelopmental follow‐up of this cohort when the children were 3–4 years old in addition to needing recruitment and assessment of study controls

Abstract: We performed a prospective study of child neurodevelopment in a rural town inColombia using synchronous telemedicine. Children with Zika‐virus exposure previously studied were eligible. An observational motor and conceptional standardized tool kit (Movement‐ABC and Bracken School Readiness) was mailed to Colombia; other materials were translated and emailed; team training was done virtually over 3 days by Zoom. Each assessment was demonstrated, and Spanish interpretation provided. The Colombian team practiced and demonstrated learned skills to our team virtually over 2 days. Children werescheduled by team on the ground. Synchronous activities were video recorded directly to two laptops, each with a telehealth Zoom link to allow simultaneous evaluation of “table” and “standing” activities. Back‐up recordings were captured by team on the ground. The U.S. team attended live over Zoom from 3 states and 5 distinct locations, made observational notes, and provided real‐time feedback in Spanish and English. Additionally, a non‐Zika exposed control group was successfully recruited by team on the ground and the children were assessed using the same synchronous methodology as the cases. The team in Colombia wore masks, handwashed, and cleaned items between children.

Method: Observational

Classification of Research: Clinical Outcomes

Results: Fifty‐seven, 3‐4‐year‐old children were studied during 5 day trips. Day 1 did not have an internet connection. Day 2 (community center) and days 3–5 (school) had an internet connection for live telemedicine Zoom but had multiple brief outages despite conducting prior connectivity testing. Direct laptop recording was necessary to ensure complete record of child activities. A total of 70 controls were added to the study during 5 days of remote, synchronous enrollment. The U.S. team was able to provide important feedback and adjusted the exclusion criteria based on live assessment observations of the control group.

Conclusions: Telemedicine infrastructure successfully enabled synchronous international research collaboration to train a research team, evaluate child outcomes, and enroll study controls during the COVID‐19 pandemic. Adequate internet connection should be tested prior to research activities and direct video recording should be available as a backup. Satellite internet capabilities, especially in rural research sites, could potentially improve the quality and experience. Telemedicine is a powerful tool to accomplish remote research activities in a collaborative and efficient manner enabling clinical research to help children across the globe.

24. TELEHEALTH IMPLEMENTATION IN A WOMEN’S CLINIC USING NORMALIZATION PROCESS THEORY AND INDUCTIVE CONTENT ANALYSIS

Nicholas Wagner

University of Alabama

Description: Programs don’t always work the way you expect them to in a given setting, but what do you do to move forward a stalled implementation process? This presentation discusses a recently stalled telehealth implementation and a mixed‐methods approach to regain traction using normalization process theory and inductive content analysis.

Abstract: This quality improvement project facilitated the integration of telehealth services in a womens clinic. Normalization Process Theory (NPT) and the Normalization Measures Development (NoMAD) instrument were identified as tools. The NoMAD survey was augmented with a request for 2–3 sentences of explanation for each item. This data was then evaluated using inductive content analysis to identify specific facilitators and barriers. Results were presented to an interdisciplinary team charged with the responsibility of making modifications to the existing telehealth workflow and the resultant workflow was piloted for 30 encounters. Statistically significant improvement in average NoMAD score was demonstrated on repeat survey.

Method: Implementation Science

Classification of Research: Quality Improvement

Results: The revised workflow was piloted for 30 patient encounters (11 Pre‐Visits, 14 Follow‐up, 2 Educational, 2 New Patient, and 1 New Complaint). Statistically significant improvement in mean scores for NoMAD items were demonstrated at a 95 % confidence interval with both the Mann‐Whitney test (U = 138, z = ‐1.66, p = 0.04846) and the Paired T‐test (t = 2.41, p = 0.01297, mean difference 0.34). Improvement was demonstrated in three of the four NPT core constructs with a slight reduction noted in the core construct of collective action.

Conclusions: This mixed methods approach provided an effective means to engage an interdisciplinary team and begin a cycle of continuous quality improvement. The free text explanations provided direct insight into facilitators and barriers specific to the clinical setting. Although no role specific details were included in text samples, the discussion of themes and representative texts fostered a deeper understanding of role specific difficulties across the team and enabled solution oriented thinking.

25. TELEHEALTH TRIAGE AND INJURY PREVENTION IN EMPLOYEE WORKPLACE HEALTH; RESULTS OF A 2 YEAR STUDY

Tammy Richmond

Go2Care

Description: Work‐related musculoskeletal disorders (MSDs)are the most frequently reported causes of lost or restricted work time. This session will discuss the results of a 2‐year study of MSD triage and prevention telehealth services in a steel manufacturing company.

Abstract: Work‐related musculoskeletal disorders (MSDs) are among the most frequently reported causes of lost or restricted work time. According to the Bureau of Labor Statistics (BLS) in 2013, MSD cases accounted for 33% of all worker injury and illness cases. Studies show that MSDs can be prevented with ergonomics, early symptom reporting, and education and training of employees and safety management. Currently, national MSD programs require OT or PTs to travel to the worksite to provide services. We deployed a telehealth triage and MSD prevention program within a remote, major steel manufacturing plant to decrease MSD injuries, extend the lifespan of employees and to show cost savings. This course will discuss the results of technology and service deployment, integration of telehealth and cost savings to meet these goals during a 2 year program.

Method: Cost Analysis

Classification of Research: Clinical Outcomes

Results: The average cost per person per MSD is $7,800; $1,000 for Physical therapy. Prevention telehealth cost per employee in study was $330. No workers comp case during the 2‐year period. Average less then 10 prevention visits per 500 employees. Overall cost savings was tremendous. Employee satisfaction was high. Employer expanded telehealth services to include hire training and wellness.

Conclusions: Evidence supports the use of therapeutic interventions to improve occupational performance for workers to reduce job loss and sick leave. Web‐based musculoskeletal discomfort monitoring, triage and prevention interventions at a remote steel manufacturing plant had a positive effect and cost savings. Early reporting of musculoskeletal discomforts can help prevent or reduce the progression of symptoms, the development of serious injuries, and subsequent lost‐time claims.

26. TELEMEDICINE USE AMONG GERIATRIC OUTPATIENTS DURING THE COVID PANDEMIC

Edith Burns

Northwell Health; Anita Szerszen, Staten Island University Hospital, Northwell Health

Description: This is an evaluation of the utilization of telemedicine, defined as audio‐video and audio‐only communications, by community‐based older adults, across age, gender, race, and insurance provider. We discuss potential factors affectingtelemedicine use such as technology preference or caregiver presence during telemedicine visits.

Abstract: Although technology adoption among seniors is growing, ethnic/racial minorities and those with socioeconomic disadvantages may have lower utilization of telemedicine. We evaluated uptake of telemedicine amongst community‐based older adults during the first COVID‐19 surge across demographic characteristics. We discuss potential factors affecting use such as technology platform and caregiver presence during telemedicine visits.

EMR data were examined for documentation of telemedicine use among patients ≥ 65 years at 2 New York geriatric ambulatory practices and one home visit program from January‐November 2020. 712 patients engaged in 1,005 telemedicine visits. Telemedicine use reached 80% of all visits during April and averaged 11.8% after June. While telemedicine use was similar across age, gender, race and insurance, Black patients were 30% more likely to utilize telemedicine. Non‐English speakers, those 85+, and with more comorbidities used telemedicine more. 25.8% of patients had both in‐person and telemedicine visits. 37.8% of video visits included an additional person at the patient end.

Telemedicine augmented access to health care for older individuals during the peak of the COVID pandemic and continues to be utilized. Given the preference for telemedicine among Black patients, it has potential to serve as a tool to reduce enduring health care disparities beyond the pandemic.

Method: Observational

Classification of Research: Access to Care

Results: A total of 712 patients (32.3%) engaged in 1,005 telemedicine visits. Telemedicine represented 80% and 66% of all encounters during April and May respectively, and averaged 11.8% June‐November. Use was similar across age groups (65–74,75–84, 85+), gender, race and insurance between telemedicine utilizers and in‐person visitors. Black/African‐Americans were 30% more likely to use telemedicine vs in‐person visits. Patients with primary language other than English, those 85+ and more comorbidities had greater telemedicine use. Among those engaging in video visits, 20% had more than one visit. 37.8% of video visits had documented the presence of an additional person with a patient.

Conclusions: Telemedicine augmented access to health care for older individuals during the peak of the COVID pandemic and continues to be utilized to improve access to care for older Americans. Given the observation that Black patients were over‐represented among telemedicine users, this technology may potentially serve as a tool to reduce enduring health care disparities beyond the pandemic. Patients with Medicaid had similar utilization rates of telemedicine and in‐person visits suggesting the technology was equally likely to be accessed by lower income adults as those with Medicare alone or private insurance.

27. THE FEASIBILITY AND EFFICACY OF TELE‐MUSIC THERAPY FOR CHILDREN WITH AUTISM

Yue Wu

University of Minnesota

Description: his is the topic of my dissertation study. Currently the study is undergoing recruitment and intervention phases. I will explain the study design as well as present some priliminary data.

Abstract: In light of the current COVID‐19 pandemic, in‐person services have often been suspended. This presentation introduces the use of real‐time video‐conferencing platforms to provide music therapy to serve children with autism. A robust and reliable alternative method of music therapy creates a service delivery option while addressing an acute need caused by the pandemic.

Method: Randomized Controlled Trial

Classification of Research: Clinical Effectiveness

Results: This study is ongoing. Preliminary quantitative data and feedback from the participants and their family members will be shared at the presentation.

Conclusions: This is the first study using a RCT model to test the feasibility and efficacy of tele‐music therapy.

28. THE IMPACT OF COVID‐19 ON TELEHEALTH USAGE IN RURAL TEXAS

Chris McGovern

Connected Nation, Inc.

Description: This study, based on a survey of health care providers and households in rural Texas, examines the use of multiple online tools for patient treatment and communication and how these usage rates changed after Governor Abbott declared of a state of emergency due to climbing rates of COVID‐19.

Abstract: COVID‐19 radically changed the way health care is practiced and perceived. As travel restrictions mounted and facilities sought out new ways to treat patients remotely, the use of telehealth tools expanded rapidly, particularly in rural areas where such innovations had been less common in the past. The extent to which these services will continue to grow remains to be fully determined. Pockets of evidence are emerging, though, that show that the use of these applications is still growing and will continue to be part of medical treatment for years to come.

As part of its Connected Communities program, Connected Nation Texas (CN Texas) conducts surveys of households and health care facilities in primarily rural communities to identify trends in telehealth usage and demand. Data from these surveys indicate that telehealth and the use of online communication tools has increased since March 2020, when Texas Governor Greg Abbott declared a state of emergency due to COVID‐19. These trends also highlight the growing demand for fast, reliable internet service both to health care providers as well as the public at large.

Method: Survey/Qualitative

Classification of Research: Information Technology

Results: This study finds that as the COVID‐19 pandemic continues to threaten the well‐being of patients, particularly those who are older or have underlying medical conditions, telehealth usage demand is growing faster than current rural internet service can provide to health care facilities and the public.

Conclusions: The need for telehealth applications will only continue to grow, along with the need for concomitant training, infrastructure, and resources for households and health care providers alike. Telehealth usage has already spiked during this short time frame and will continue to grow as patients become more comfortable with these tools that were once deemed “science fiction.” Knowing what services are growing fastest and how quickly these applications are growing in use and popularity will be necessary to identify steps that will be needed to close the current gaps.

29. THE ROLE OF TELEHEALTH IN PROVIDING SERVICES TO INDIVIDUALS WITH DISABILITIES

Cheryl Austein Casnoff

MITRE

Description: The purpose of this panel is to explore the opportunities and challenges in using telehealth and remote technologies to serve the health care needs of persons with disabilities. This panel will showcase hands on experience of providers, persons with disabilities and policymakers.

Abstract: The purpose of this panel is to explore the opportunities and challenges in using telehealth and remote technologies to serve the health care needs of persons with disabilities. Telehealth use expanded dramatically during the pandemic but also identified barriers to care for individuals with connectivity and other challenges. This panel will showcase hands on experience of providers, persons with disabilities and policymakers to talk about real life experiences in applying telehealth widely during the pandemic. The panel will discuss current experiences and future implications for the expanded use of telehealth to assure that all individuals can benefit from these new technologies and delivery care without a digital divide and other barriers. The panel will also discuss how these new technologies can support families of children with special health care needs and other vulnerable populations.

Method: Panel discussion

Classification of Research: Clinician Experience

Results: This session will showcase how telehealth is serving the needs of persons with disabilities and children with special health needs. Those with special needs and those who provide services will participate in this unique panel session. Each panelist will talk from a personal and professional perspective about their experiences providing and receiving services during the pandemic and the panel discussion will focus on how to assure that these services serve the needs of all populations going forward.

Conclusions: The panel will showcase individuals who are prominent in the area of healthcare for individuals with special health care needs The panel will discuss how new technologies can support families of children with special health care needs and other vulnerable populations.

30. USE OF PAIN INTENSITY AND PERCEIVED EXERTION SCORES TO MODULATE EXERCISE DIFFICULTY IN A DIGITALLY‐DELIVERED PROGRAM FOR PERSISTENT MUSCULOSKELETAL PAIN: AN OBSERVATIONAL STUDY

Jackie Mendelsohn, Malcolm Hess, Meredith Christiansen, Naomi Yudanin, Christina Nadaskay

Fern Health, Inc.

Description: Exercise is an effective, though underutilized, treatment for mitigating musculoskeletal (MSK) pain. Digitally‐delivered exercise therapy is a promising solution, but modulating exercises for safety, e.g., increasing or decreasing difficulty, remains challenging. Here we detail the use of post‐exercise pain intensity and perceived exertion scores to guide digital exercise modulation.

Abstract: Fern Health delivers an 8‐week app‐based program that includes exercise therapy, pain neuroscience and cognitive behavioral therapy education with 1:1 health coaching. Study data were collected from participants that had back, neck, shoulder(s), knee(s) or hip(s) pain for at least 12 weeks, had a smartphone, were 18 to 75 years of age, passed a medical screen, and consented to participate in a data research study. The 8‐week exercise program was designed by physical therapists and consisted of 20‐minute daily “workouts” comprising 6‐9 body region‐specific, non‐aerobic exercises that increased in difficulty weekly. Participants were asked to complete workouts 3‐5 times per week. After completing a workout, participants were asked to self‐report pain intensity (PI) and perceived exertion (PE) using a numeric scale (0‐10), with lower scores indicating less PI or PE, respectively. Scores were then used to modulate exercise difficulty as follows: increased (PI = 0 and PE ≤2), decreased (PI ≥9 and PE ≥5), no change (PI ≤5 and 3≤PE ≤8). Study outcomes included descriptive statistics about participants, baseline pain, total modulation count and direction, and weekly average PI and PE scores.

Method: Observational

Classification of Research: Clinical Outcomes

Results: The study included 89 participants (75% female), 46 ± 13 (mean±SD) years of age, 6.0 ± 2 baseline pain, and 9 ± 9 years of pain. The average weekly PI was 4.8 ± 2.3, 4.1 ± 2.0, 4.3 ± 2.1, 3.2 ± 2.6, 2.5 ± 2.2, 3.8 ± 1.4, 4.3 ± 1.9, 4.2 ± 2.5, at 1 to 8 weeks, respectively. The average weekly PE was 4.8 ± 1.5, 3.8 ± 1.7, 3.5 ± 2.1, 3.3 ± 2.4, 2.8 ± 2.2, 4.5 ± 1.3, 5.4 ± 0.9, 6.0 ± 1.2, at 1 to 8 weeks, respectively. Exercise modulations increasing difficulty occurred in 3% of participants.

Conclusions: Few participants triggered exercise modulation, and none required decreasing difficulty. Average weekly PI and PE scores of ≤5 and ≤8, respectively, indicated that digitally‐delivered exercises were safe to perform and remained at light‐to‐moderate difficulty. As such, using weekly pain intensity and perceived exertion scores may effectively guide remote exercise modulation to ensure safety and maintain appropriate difficulty throughout the therapeutic program.

31. USING TELEUTI TO INCREASE ACCESS TO MULTIDISCIPLINARY TEAM DURING THE SARS‐COV‐2 PANDEMIC IN BRAZIL

Eloiza Andrade Almeida Rodrigues, Renato Oliveira Santos, Health Ministry; Andrea Francisco, Leonardo Tomé da Silva, Nídia Cristina de Souza, Bruno de Melo Tavares, Daniela Laranja Gomes Rodrigues, Leonardo Lima Rocha, Lívia Muller Bernz, Wladimir Garcia Silva, Guilherme Cesar Silva Dias Santos, Karen Cristina da Conceição Dias Silva, Luciana Gouvêa de Albuquerque Souza

Hospital Alemão Oswaldo Cruz

Description: Due to the SARS‐CoV‐ 2pandemic, strategies increasing access to specialists, especially in intensive care units, were created with the aim of improving assistance to users of the public Unified Health System in Brazil (SUS).

Abstract: Due to the SARS‐CoV‐2 pandemic, strategies increasing access to specialists, especially in intensive care units (ICU), were created with the aim of improving assistance to users of the public Health System in Brazil (SUS).

Objective: describe the TELEUTI project, developed through a partnership between the Brazilian Ministry of Health and private hospital, to implement national clinical protocols and multidisciplinary teams support to adopt best clinical practices.

Methodology: a multidisciplinary team located at Hospital Alemao Oswaldo Cruz and composed by intensivists, nurses, physiotherapists and infectologists, performed, via the Webex^®; platform, daily monitoring of patients admitted to public ICUs with confirmed or suspected diagnosis of SARS‐CoV‐2, using a structured checklist involving screening for delirium, sedation and analgesia, parameters in mechanical ventilation, among others.

Results: from March to November 2020, 1,197 multidisciplinary rounds were carried out on 325 patients distributed in 9 hospitals in three Brazilian regions. In addition to the implementation of quality indicators, the hub teams reported greater support in critical patient decision‐making.

Conclusion: the use of eHealth strategies has the potential to increase the access of specialists, in addition to enabling the implementation of a multidisciplinary visit with monitoring of daily goals and qualification of care practices through knowledge transfer.

Method: Descriptive

Classification of Research: Regulatory & Policy Research

Results: From March to November 2020, 1,197 multidisciplinary visits were carried out on 325 patients distributed in 9 hospitals in three Brazilian regions. In addition to the implementation of quality indicators, the hub teams reported greater support in critical patient decision‐making.

Conclusions: The use of eHealth strategies has the potential to increase the access of specialists to areas in need of them, in addition to enabling the implementation of a multidisciplinary visit with monitoring of daily goals and qualification of care practices through knowledge transfer.

Poster Presentations

32. A FEASIBILITY STUDY ON PATIENT USE OF DIGITAL VIDEOSCOPES AND SMARTPHONES FOR REMOTE SKIN EXAMINATIONS

Yixuan Zheng

University of California, San Francisco

Description: Existing direct‐to‐consumer technologies such as smartphones and digital videoscopes may have the potential to facilitate remote skin examination. This study pilots patient use of these devices for simulated remote skin examinations and assesses the usefulness of acquired images. Patient satisfaction, willingness to purchase, and ease of use are also examined.

Abstract: The current pandemic has necessitated telehealth visits from patients homes and active patient participation in obtaining remote physical examinations. In recent years, store‐and‐forward images transmitted to dermatologists have become commonplace with the ubiquity of smartphones and other image capture devices. However, there is a dearth of literature describing the effectiveness of patient self‐image capture for skin examinations. In this study, we examine the feasibility of patient use of smartphone and a commercially available low‐cost digital videoscope in acquiring remote examination images. Subjects used these devices to capture images of a benign facial skin lesion and completed a survey about their experience. A blinded dermatologist reviewed all images for clinical usefulness. Among seventeen participants (ages 21–83 years), 88% and 59% of subjects felt the digital videoscope and smartphone were easy to use, respectively. 65% of patients were able to obtain at least one clinically acceptable image between the image sources. These data indicate digital videoscopes and smartphones for image capture may provide benefits in triaging patients with skin complaints during virtual visits. Improving the quality of telehealth physical examination may decrease the number of non‐essential in person visits, which is beneficial for social distancing efforts and patient convenience.

Method: Descriptive

Classification of Research: Quality Improvement

Results: Among 17 subjects, 88% rated the digital videoscope as easy to use for capturing images of the skin while 59% of subjects rated the smartphone as such. The average time for digital videoscope image capture (45 ± 20 seconds) was shorter than for smartphone photo capture (101 ± 53 seconds, p < 0.001). Difficulties patients faced include determining optimal focal distance for image capture (n = 10). The reviewer rated 25% of videoscope images, 47% of smartphone photos, and 33% of smartphone videos as acceptable for clinical examination purposes (p = 0.74); 65% of patients were able to obtain at least one acceptable image between the three image sources.

Conclusions: During the current pandemic, it is important to be able to offer appointments over telehealth and other secure electronic means while being able to optimize physical examination for skin findings. The convenience and affordability of the digital videoscope combined with the ubiquity of smartphones make these tools feasible as part of the patient’s home telehealth toolbox. Additionally, these devices are easy to use for patients and may provide useful information in remote patient triage between continued observation, specialist referral, or urgent in‐person visit.

33. ANALYSIS OF PRIVATE PAYER TELEHEALTH COVERAGE DURING THE COVID‐19 PANDEMIC

Samuel Taylor

Center for Connected Health Policy

Description: This report builds on the Center for Connected Health Policys COVID‐19 research and resources by detailing the efforts that major U.S. health insurance carriers took to expand telehealth access in response to the pandemic.

Abstract: Private health insurance covers 68% of all Americans andis the primary source of health coverage for health care consumers in the U.S.As such, the health insurance industry was expected to play a larger role in ensuringaccess to telehealth services.Almost overnight, the nations largest commercial health insurancecarriers made an unprecedented number of coverage changes to their telehealth policies in response to COVID‐19. There has been little policy research focusing on temporary telehealth coverage expansion among private payers, with most available resources or studies examining public payers (e.g., Medicaid). Center for Connected Health Policy researchersanalyzed telehealth coverage policies for the largest U.S‐based health insurers and private payer laws and regulations developed in response to the pandemic in all 50 states and D.C. We focused our analysis on private payer policies implemented from the outset of the public health emergency (PHE) declaration through November 25, 2020. Most payers implemented largecoverage expansions from business as usual. The most common changes includedblanket cost sharing waivers, coverage for out‐of‐network telehealth services, and pay parity. Findings underscore the historic momentum behind private payer telehealth coverage prompted by the PHE.

Method: Policy Analysis

Classification of Research: Regulatory & Policy Research

Results:

1. All of the national insurance carriers voluntarily expanded telehealth coverage for their commercial health plans on a temporary basis.

2. Nearly all major insurers (6 of 7) waived cost‐sharing for COVID‐19 telehealth treatment services.

3. Most private payers (6 of 7) extended cost share waivers to non‐COVID telehealth services, typically for primary or urgent care or behavioral health visits.

4. Four major insurers covered limited out‐of‐network telehealth services. At least 1 major payer (Anthem Blue Cross Blue Shield) waived cost share obligations for out‐of‐network telemedicine visits through Spring 2020.

5. Most private payers (6 of 7) reimbursed telehealth services at the in‐person rate.

Conclusions: While many of the more expansive telehealth benefits expired in mid‐ or late 2020, some coverage features extended into 2021 and a few will become permanent. In particular, CMS recommendations around audio‐only coverage and expanding the originating site to include the home, are likely to become a fixture of major private payer telehealth policies in 2021 and beyond. The COVID‐19 pandemic presented private payers with a unique opportunity to reassess their telehealth coverage policies in light of emerging utilization trends and consumer preferences.

34. COMPLEXITIES OF IMPLEMENTING TELEHEALTH IN SKILLED NURSING FACILITIES ACROSS THE UNITED STATES

Aimee Perron

Patricia Larkin‐Upton, Genesis Rehab Services

Description: During the pandemic, skilled nursing facilities (SNF) had to incorporate isolation restrictions including limiting clinician access to facilities and even from floor to floor, to minimize infection transmission. These restrictions, along with compliance to state requirements, necessitated the incorporation of telehealth into therapy practice to allow residents to receive care.

Abstract: Clinical Directors of a large national rehabilitation company were charged with determining regulations for telehealth in order to implement it across the United States to support safe and effective patient access to care. State practice acts, state and federal laws for telehealth, and payer allowances needed to be researched. Unfortunately, telehealth in SNF was not straightforward. Finding the exact allowances for the provision of telehealth in the SNF became more and more complex due to varying state practice acts, licensure requirements, limitations for therapist as authorized providers and essential workers, state executive or Governing Board waivers, and significant variations in definitions and allowances by payers. All of these areas continued to evolve throughout the research process. Prior to implementing telehealth, updates to clinician education, company policies, and electronic medical records was required. We developed a step by step clinical orientation to telehealth and clinical documentation which included the rules and regulations for state requirements and allowances and ensuring HIPAA compliance. Clinical guidelines additionally supported person centered interventions to facilitate patient independence with using telehealth technology. Audit tools were developed and utilized in order to ensure compliance.

Method: Prospective and Retrospective Analysis

Classification of Research: Access to Care

Results: Our qualitative and quantitative analysis are currently being collected and under review, however some outcomes we have affected so far include:

• Advocacy efforts resulting in policy change: 16 states

• Improved employee engagement through education to over 1000 clinicians

• Improved patient access to care with telehealth services in over 100 sites in 29 states

• Positive patient outcomes identified by quarterly clinical reports

• Advocacy efforts through use of company database case reviews

• Increased recognition of therapists as essential healthcare workers reducing staff furloughs

• Effective and efficient interprofessional team approach through use of telehealth

Conclusions: The rapidly changing laws and policies, and threatened patient access to physical therapy, occupational therapy, and speech and language pathology, due to the pandemic forced us to research alternative opportunities for providing patient care. The complexities of state practice acts, state and federal laws, executive orders, payer policies, and clinician inexperience necessitated a comprehensive approach prior to implementation of telehealth in skilled nursing facilities. Lessons learned have provided material for strong advocacy efforts that are much needed to support full implementation of telehealth into practice following the pandemic.

35. CREATING TELEMEDICINE EDUCATIONAL OPPORTUNITIES FOR FAMILY MEDICINE STUDENTS, RESIDENTS AND PHYSICIANS

Jeetinder Gujral¹, Keasha Guerrier², and Tochi Iroku‐Malize³

¹Northwell Health System, ²Northwell Health; Zucker School of Medicine at Hofstra/Northwell, and ³Northwell Health; Zucker School of Medicine at Hofstra/Northwell

Description: The family medicine chair decided to create a telemedicine curriculum. It had been used in the ICU and ED for neurology specialists to consult from a distant site. The rollout began with education for residents then expanded to medical students and practicing physicians. The COVID 19 pandemic accelerated the project.

Abstract: The department of family medicine at the Zucker School of Medicine at Hofstra/Northwell and Northwell Health had been using telemedicine for inpatient management of acute stroke patients in the Emergency Department and the ICU. Neurologists would be consulted and would evaluate the patient from a distant site. In 2015, the chair of the department decided to create a mechanism to pilot telemedicine in the ambulatory setting. It took several years to get started during which time a telemedicine elective and 12 week track was created for the residents interested in pursuing added knowledge and skills. Ambulatory sites were set up but the physicians in practice needed education to be competent in using this new tool. Telemedicine includes diagnostics, treatment, monitoring, consultation, and education. The department set up educational sessions for students, residents and practicing physicians. With the onset of the COVID‐19 pandemic, the pace of setting up telemedicine services, especially in the ambulatory setting, increased. Virtual didactic sessions were added for all levels of practicing physicians and as a steady state is approached with regards to the pandemic, the strategy to continue to incorporate telemedicine in all health care settings is being formulated.

Method: Descriptive

Classification of Research: Information Technology

Results: At the end of 2020, over 150 students, residents and practicing physicians from the family medicine department had received training and begun implementing telemedicine in both the inpatient and outpatient setting. In response to the increased need for health care workers who were versed in telemedicine, the department created delineation of privileges for the members. Currently, the physicians are going through the process of adding these privileges to their credentials. The residents who have done the electives and tracks are being encouraged to take the certification examination.

Conclusions: Telemedicine education is a relevant component of medical training for medical students, residents and practicing physicians as it is a tool by which greater patient access to health care can be achieved. Creating an educational process for all levels of physicians is a mechanism to ensure standardized management of patients in a variety of health care settings. The future of health care will include telemedicine and other technologies, so it is important to provide the education now.

36. FEASIBILITY, ACCEPTABILITY AND UTILIZATION OF A SMOKING CESSATION E‐VISIT FOR PEOPLE EXPERIENCING HOMELESSNESS

Cristin Adams

Medical University of South Carolina

Description: Key informant interviews and single arm pilot study investigating the feasibility, acceptability and utilization of a smoking cessation e‐visit for people experiencing homelessness at a homeless shelter in Charleston, SC.

Abstract:Introduction: Tobacco‐related mortality is high among people experiencing homelessness (PEH), a population that lacks access to evidence‐based smoking cessation treatment. Electronic visits (e‐visits) reduce barriers but implementation studies for smoking cessation treatment among PEH are limited.

Methods: Feasibility, acceptability, and utilization of smoking cessation e‐visits at a homeless shelter were evaluated via structured interviews with homeless smokers, shelter staff, and medical providers and a single arm pilot study with homeless smokers.

Results: Interviewed smokers (n = 10) felt the e‐visit could be incorporated into their routine, shelter staff (n = 3) felt it could be incorporated into their workflow, and providers (n = 3) felt comfortable prescribing recommended treatments. Pilot study participants (n = 15) smoked an average of 13.8 cigarettes daily and over a quarter (26.6%) reported a chronic respiratory condition. The majority (80.0%) had previously tried to quit but only one (6.7%) had used a prescription medication. Most (86.7%) accepted the recommended treatment of either varenicline (46.7%) or nicotine replacement therapy (53.3%). Two participants (13.3%) completed the 1‐month e‐visit.

Conclusion: E‐visits are a feasible and acceptable modality to initiate smoking cessation treatment for PEH. Investigation is needed to enhance treatment follow up.

Method: Qualitative interviews and single arm feasibility trial

Classification of Research: Patient Experience

Results: Interviewed smokers (n = 10) felt the e‐visit could be incorporated into their routine, shelter staff (n = 3) felt it could be incorporated into their workflow, and providers (n = 3) felt comfortable prescribing recommended treatments. Pilot study participants (n = 15) smoked an average of 13.8 cigarettes daily and over a quarter (26.6%) reported a chronic respiratory condition. The majority (80.0%) had previously tried to quit but only one (6.7%) had used a prescription medication. Most (86.7%) accepted the recommended treatment of either varenicline (46.7%) or nicotine replacement therapy (53.3%). Two participants (13.3%) completed the one‐month e‐visit.

Conclusions: E‐visits are a feasible and acceptable modality to initiate evidence‐based smoking cessation treatment for people experiencing homelessness. Further investigation is needed to enhance treatment follow up.

37. FOLLOW‐UP TO EYE CARE FOR DIABETIC PATIENTS WITH VISUALLY SIGNIFICANT FINDINGS IN A POPULATION‐BASED TELEOPHTHALMOLOGY SCREENING PROGRAM

Hamza Sadhra

University of Rochester School of Medicine and Dentistry

Description: Teleopthalmology programs improve annual screening rates for diabetic retinopathy in safety‐net primary care clinics but timely follow‐up to eye care after screening is a consistent challenge. Health insurance plan type may alter the likelihood of following up after screening.

Abstract:Importance: Tele‐ophthalmology screening programs are effective if patients adhere to follow‐up recommendations. Follow‐up rates after tele‐eye screens remain low and research examining why is limited.

Objective: To determine factors influencing adherence to follow‐up after an initial tele‐ophthalmology screen in diabetic patients attending low‐income urban primary care clinics. Changes in metrics gauging diabetic eye screen rates and the type of ocular pathologies found since program implementation were also assessed.

Design: A prospective quality improvement study of low‐income patients with visually significant findings determined by a store and forward teleophthalmology program, “Tele‐I‐Care” was conducted from program implementation in July 2018 to the end of December 2019. Non‐mydriatic fundus cameras were used to evaluate patients for retinopathy and other ocular pathologies, and visual acuity testing was used to assess vision. Patients were triaged for follow‐up according to findings. Factors associated with follow‐up adherence were assessed using Chi² test.

Main Outcome/Measure: Detail the presence and severity of DR, and other ocular pathologies including cataracts and suspected glaucoma, in relation to visual acuities of screened patients. Examine follow‐up rates after tele‐eye screen, and factors that influence adherence to follow‐up.

Method: Observational

Classification of Research: Quality Improvement

Results: 558 patients (median age 55 years, 56% women, 53% African American) were screened; 15% (85) showed positive findings for diabetic retinopathy. Of patients without DR, other pathologies were found including cataracts for 7% (39) and suspected glaucoma for 4% (20). Of the 292 patients that were instructed to follow up within a 1–3 month time frame due to vision threatening pathology or an unreadable screening image, 134 scheduled and attended their appointment, whereas 67 (50%) scheduled but did not attend. Individuals with a Medicaid Managed Care or Medicare Advantage Plan were most likely to be adherent to follow up.

Conclusions: Tele‐ophthalmology can be used to increase annual screening rates among diabetic patients in low‐income settings. In combination with visual acuity testing, a tele‐ophthalmology program can be used to identify and triage potential vision threatening pathology. Adherence to follow‐up is an essential yet challenging component of the program which was found to vary based on insurance plan. Studying the specialty eye care referral process by insurance plan type is a potential avenue of research.

38. GLOBAL EXPERIENCES OF TELECONSULTATION TRAINING IN UNDERGRADUATE HEALTH CARE AND SOCIAL WORK EDUCATION – A SYSTEMATIC REVIEW

Lisa‐Christin Wetzlmair

University of St Andrews

Description: Previous studies and the COVID‐19 pandemic stressed the importance of teleconsultation in health care. Educating the workforce is essential to continue with safe, high‐quality delivery of services and increases the likelihood of implementing teleconsultations in health care. While training for the workforce is encouraged, teleconsultation education in health care and social work programmes are seldom documented. Therefore, the present review aims to investigate global experiences of teleconsultation training in undergraduate health care and social work education.

Abstract: A systematic review of peer‐reviewed literature was undertaken. Electronic databases were searched for eligible evidence. Grey literature was excluded. Studies had to describe or evaluate education in teleconsultation of undergraduate health care and social work students. It was not intended to analyse digital learning in health care and social work education. The search identified 586 articles published between 2010 and 2020.

Method: Observational

Classification of Research: Clinician Experience

Results: After screening the articles, 17 cross‐sectional, non‐randomized interventional, and interview studies were included. The mode of delivery of training sessions included practical experiences with simulated patients or experiences during clinical placements. The majority of courses were not mandatory and focused on videoconsultation as opposed to telephone consultation and email correspondence. Overall, health care students felt more confident in offering and using teleconsultation and their knowledge increased after training. Feedback on courses was genuinely positive; students valued the relevance of the topic, real‐life experiences, immediate feedback and supervision. Qualitative studies, in particular, lacked reporting on data analyses and did not represent the participants adequately.

Conclusions: The review shows that mandatory learning in telecommunication and teleconsultation is rare in undergraduate health care education. Even though educators and students advocate for training being offered in health care curricula, only few regions worldwide report on learning about teleconsultation in undergraduate education. International guidelines to regulate telemedicine in educational settings lack clarity, and little focus is given on special training in teleconsultations. Training sessions in teleconsultation are a legitimate way to expose students to telemedicine. High satisfaction rates, increased knowledge and confidence in use indicate that students welcome this education. Nevertheless, further high‐quality research and guidelines are warranted.

39. INTEGRATING TELEHEALTH VISIT IN THE POST‐OPERATIVE CARE OF A SUBSET OF PLASTIC SURGERY PATIENTS: AN EXPERIENCE DURING COVID‐19 PANDEMIC

Saurabh Chandra, Peter Arnold, Christie Henderson

University of Mississippi Medical Center

Description: Telehealth visits have become an integral part of ambulatory practices during the current pandemic and we demonstrate the valueof telehealth in a subset of plastic surgery patients in the provision of post‐operative care.

Abstract: The current COVID‐19 pandemic has seen an unprecedented rise in the growth of telehealth visits in the ambulatory setting. Spurred by relaxation in the regulatory requirements, Telehealth helped offset the decline in face to face visits (JAMA Intern Med, 2021;181(3)). However, overtime there has been a gradual decline in the number of telehealth visits. To sustain the enormous value brought by telehealth during the current pandemic, many health systems are investing in defining provider and patient preferences, appropriate use cases for telehealth and associated reimbursement in an effort to create a hybrid model that maximizes good clinical outcomes with both patient and provider satisfaction.

At the brink of the COVID‐19 pandemic, we in the Department of Plastic Surgery began to brainstorm safe alternatives for pre and post‐operative appointments via telehealth. Our surgeons were allowed to perform low‐risk ambulatory surgeries during the pandemic such as breast reduction surgeries. We utilized telehealth for their first follow‐up to limit their exposure to COVID‐19. The following visit was completed in‐person and telehealth was offered for subsequent visits for any patients who did not live in this area or were concerned about being exposed to COVID‐19.

Method: Descriptive

Classification of Research: Patient Experience

Results: Post‐operative evaluation via Telehealth has proven to be very beneficial not only in limiting exposure to COVID‐19, but patients no longer have to rely on someone to help them return to campus while on post‐operative pain medications resulting in enhanced patient experience and satisfaction. It has allowed us to avoid a back log of breast reduction surgeries adding to patient satisfaction. We have now integrated telehealth visits as a standard practice in the care of breast reduction surgery patients.

Conclusions: The value of telehealth in pre‐ and post‐operative care of plastic surgery patients has been examined by several studies even before the current pandemic. However most of these studies either performed telehealth evaluation of patients in community based clinics or sent a nurse to facilitate visits from patient’s home. With the relaxation in originating site requirements during the current pandemic we were able to successfully conduct telehealth visits in patient’s homes and identified a subset of patients that accrue significant benefits like avoiding driving to a physical location when on pain medication in the early post‐operative period.

40. IT’S TIME: TELEHEALTH SHOULD BE AN INTEGRAL PART OF THE UNDERGRADUATE MEDICAL EDUCATION CURRICULUM

Gino Farina, Jeetinder Gujral, Martin Doerfler, Saurabh Chandra

Northwell Health

Description: To sustain the rapid growth of telehealth and realize its true potential, we need to develop a structured curriculum for the incorporation of telehealth in the undergraduate medical education. This should encompass education of best use case scenarios and proper etiquette for conducting a telehealth visit.

Abstract: The current COVID‐19 pandemic has seen an unprecedented rise in the growth of telehealth visits.According to a report by McKinsey and Company 76% of consumers are now interested in telehealth as compared to 11% before the pandemic. In addition, 57% of providers have a more favorable view of telehealth than before. The continued growth of telehealth is dependent on providing education and exposure to telehealth to medical students by developing a formal structured curriculum.

In this report, we provide results of a surveyr eceived from 4^th year students of The Donald and Barbara Zucker School of Medicine at Hofstra University/Northwell Health in Long Island, New York. Northwell Health has an established Telehealth Center that is staffed 24/7 by board certified critical care and hospitalist physicians that provide critical care services to the ICUs and admit non‐ICU patients in the EDs respectively. The students spent one afternoon in the telehealth center in small batches of 4–5 students. A didactic lecture on a broad overview of telehealth was followed by observing and interacting withcritical care and Hospitalist physicians providingservices via telehealth. Since 2016, approximately 400 students have visited the dtelehealth center.

Method: Survey/Qualitative

Classification of Research: Information Technology

Results: From 2016–2020, a total of 257 surveys were collected. 85% of the respondents either agreed or strongly agreed that the experience had made them interested in learning about new telehealth programs in the future. 95% of the respondents either agreed or strongly agreed that the experience increased their understanding of the role of telehealth in health care.

Conclusions: We demonstrate that a structured curriculum can enhance the knowledge of telehealth for medical students. One of the biggest barriers to the wide spread adoption of telehealth is the familiarity, comfort and knowledge of the scope of telehealth services. Engaging patients on camera is an art that requires acquiring of new skills that are honed over time with practice. For realizing the full potential of the benefits of telehealth, inclusion of telehealth in the medical school curriculum should become mandatory.

41. LESSONS LEARNED FROM AN AHRQ ECHO NATIONAL NURSING HOME COVID‐19 ACTION NETWORK TRAINING CENTER

Bhagyashri Navalkele, Kim Tarver, Jason Parham, Svenja Albrecht, Morgan Davis

University of Mississippi Medical Center

Description: University of Mississippi Medical Center, an established Project ECHO hub, became a training center for the National Nursing Home COVID‐19 Action Network (NNHCAN) to address the profound impact of COVID‐19 on nursing homes. The following presentation discusses the factors that resulted in a rapid and successful implementation of this ECHO.

Abstract: COVID‐19 has devastated skilled nursing facilities, accounting for 5% of diagnosed infections and a stunning one third of America’s deaths. In August 2020, the Agency for Healthcare Research (AHRQ) announced a partnership with the ECHO Project at the University of New Mexico (UNM) to create a network to provide tele‐education for nursing homes across the country. Project ECHO was founded Dr. Sanjeev Arora in 2003 to treat patients with chronic hepatitis C in rural New Mexico and cover many diseases worldwide. This tele‐mentoring model focused on case‐based learning has now been utilized to support long term care facilities in the prevention and management of COVID‐19 in both their residents and staff. The University of Mississippi Medical Center became a training center in November and launched its collaborative cohorts shortly after. The UMMC hub team consists of a geriatrician with expertise in dementia, an infection prevention and infectious disease (ID) specialist, two general ID specialists, and a telehealth program coordinator in addition to a quality improvement coach supplied by Institute for Healthcare Improvement (IHI). The decentralized spoke and hub nature of the Project ECHO is adaptable to emergent public crises like the COVID‐19 pandemic.

Method: Descriptive

Classification of Research: Access to Care

Results: Due to the rapid escalation of COVID‐19 and short timeline for planning, the UMMC training center relied on established protocols developed by UNM ECHO hub and its project partner IHI. The UMMC training center recruited partners (“spokes”) from the hundreds of long term care facilities in Mississippi and neighboring states; we have now successfully completed phase one of the project where we shared content expertise and quality improvement techniques with nursing home staff, and in turn allowed the nursing home staff to instruct others in the cohorts from their firsthand experiences.

Conclusions: Given the fluid nature of the pandemic and this project, the UMMC hub learned the following lessons: (1) Rapid collaboration and development of an interdisciplinary team were key to successful implementation of this project in a very short timeframe; (2) Funding for the time of both the hub and spokes helped remove participation barriers: (3) Both a collegial rapport and a guided exchange of ideas between the hub and spokes were keys to successful training sessions.; and (4) The degree of outreach and rapid access to expert knowledge and opinion could not be accomplished without the expanded use of tele‐education. This project was funded under Contract No. 75Q80120C00003 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services (HHS). The authors of this document are responsible for its content. The content does not necessarily represent the official views of or imply endorsement by AHRQ or HHS.

42. MEDICAID TELEDENTISTRY COVERAGE: ARE LOW‐INCOME RURAL ADULTS BEING LEFT BEHIND?

Jason Semprini

University of Iowa

Description: This study aims to better understand the reach of Medicaid teledentistry from a rural perspective by comparing the proportion of rural and non‐rural low‐income adults living in states covering Medicaid teledentistry services.

Abstract:Purpose: Compared to metro and urban populations, low‐income adults in rural regions are disproportionately confronted by barriers to improving oral health outcomes. A recent approach to overcome rural professional shortages is teledentistry. This study aims to better understand the reach of Medicaid teledentistry from a rural perspective by comparing the proportion of rural and non‐rural low‐income adults living in states covering Medicaid teledentistry services.

Methods: Publicly available data from the Centers for Medicare and Medicaid Services and the Center for Connected Health Policy were used to construct a state‐level Medicaid dental benefit policy dataset. Using county‐level U.S. Census data, the proportion of low‐income (<1,100% FPL) rural adults living in states with various Medicaid dental policies were compared with the proportion of non‐rural counterparts. Rurality was defined by U.S. ERS Rural‐Urban Continuum Codes (7–9).

Findings: Low‐income rural adults were less likely to live in states with Medicaid teledentistry coverage (R = 17%; NR = 34%).

Conclusions: Comparing policies across states, low‐income rural adults were less likely to live in states with teledentistry Medicaid benefits. This study highlights the disconnect between the need for teledentistry and policies accommodating the reality of rural dental shortage areas.

Method: Secondary Data Analysis

Classification of Research: Access to Care

Results: Nine state Medicaid programs reimburse teledentistry services. Low‐income rural adults were less likely to live in states with Medicaid teledentistry coverage (R = 17%; NR = 34%). Within states covering comprehensive Medicaid dental services, rural low‐income adults are still underrepresented by Medicaid teledentistry coverage (R = 18.3%, NR = 35.6%).

Conclusions: Comparing policies across states, low‐income rural adults were less likely to live in states with teledentistry Medicaid benefits. This study highlights the disconnect between the need for teledentistry and policies accommodating the reality of rural dental shortage areas.

43. PREDICTING FAVORABLE OUTCOMES AFTER RURAL PEDIATRIC OUT‐OF‐HOSPITAL CARDIAC ARREST (OOHCA)

Katie DeJong

Avera McKennan Hospital & University Health Center, eCARE Emergency Medicine; Kevin Curtis, Connected Care & Center for Telehealth, Dartmouth‐Hitchcock Health GraniteOne

Description: Determining the impact of telemedicine on outcomes after pediatric out‐of‐hospital cardiac arrest is an important area for new research which has the potential to improve resuscitation practice and reduce morbidity and mortality. Utilizing emergency services and its associated databases offered an opportunity to begin to understand OOHCA in rural regions.

Abstract: There is no accepted estimate of survival after rural pediatric OOHCA. Most relevant research involves EMS registries or retrospective data from urban settings.This research initiative sought to use the Avera and Dartmouth telemedicine experience and database to (1) determine the incidence of return of spontaneous circulation (ROSC) among pediatric patients in a rural setting who suffered out‐of‐hospital cardiac arrest and received Avera or Dartmouth‐Hitchcock eEmergency services and (2) for this population, determine: (a) The rate of survival to transfer out of the originating hospital ED, (b) The rate of survival to discharge from the hospital receiving the child in transfer, (c) The rate of survival to discharge with normal neurologic function; and (d) Characteristics associated with ROSC and survival to transfer and/or discharge.

A retrospective medical chart review of children <18 yoa who had an OOHCA between January 1, 2016 and December 31, 2019 and received eCARE or DH telemedicine emergency services. Univariate analysis was performed using Students t‐test for continuous variables and Fischers exact test for categorical variables. To assess the risk factors for the various outcomes, a multivariable analysis was performed. Independent variables were identified using a threshold of <0.10 on univariate analysis.

Method: Secondary Data Analysis

Classification of Research: Clinical Outcomes

Results: The incidence of ROSC among rural pediatric patients was 36.7%. The presence of a witness was a predictor of both ROSC in the ED (witness = 61.5%; no witness = 16.0%, p = 0.009) and of survival to transfer (68.8% vs. 0%, p = 0.03). Although not statistically significant, there was a trend toward benefit in survival to transfer for placement of an advanced airway in the ED, (81.3% vs. 25.0%, p = 0.06) vs. toward harm if placed in the prehospital setting (6.3% vs. 50.0%, p = 0.16). No impact on outcome was observed due to initial rhythm, AED use, ROSC in the field, or administration of prehospital medications.

Conclusions: This novel research found that the rate of ROSC among rural pediatric OOHCA patients may not be lower than in urban settings and the impact of being witnessed might be even greater. This benefit of a witness could be due to longer response and transport times in rural areas. The differing association between placement of an advanced airway in the prehospital setting vs. in the ED could reflect a negative impact of prehospital procedures on transport time vs. a selection bias in the ED to place an airway only for children with ROSC and/or who show signs of possible survival.

44. PROVIDERS’ PERCEPTION OF TELEHEALTH AMIDST COVID‐19

Mayra Sainz

Emory University, Rollins School of Public Health

Description: This study exploresproviders perception towards telehealth practices and sustainability, the differences in clinic structure and population served between safety‐net and hospital‐associated clinics, benefits and barriers to telehealth, and the impact of COVID‐19 on telehealth practices.

Abstract: It is crucial for practice leadership and management to understand the perceptions of and barriers to using telehealth to improve provider experience with this care modality. The purpose of this mixed‐methods study is to understand the experiences and satisfaction among healthcare providers towards telehealth practices, both in safety‐net and hospital‐associated clinics in Atlanta, Georgia. Online quantitative surveys were administered to healthcare providers (n = 22). The survey, adopted from the User Satisfaction with Telehealth Survey (Becevic et al., 2015), is a 13‐item scale utilizing a 5‐point Likert Scale. Semi‐structured interviews (n = 7) were conducted to explore providers perception towards telehealth practices and sustainability. Providers reported having ambivalent experiences towards telehealth. Participants reported an item mean score of 2.05 and a scale mean score of 26.67. Four central themes emerged from participants descriptions of telehealth experiences: (1) satisfaction with patient safety and convenience, (2) lack of patient engagement, (3) increased access to care among rural residents and low‐income individuals, and (4) technology and financial challenges among providers. Understanding providers perceptions and satisfaction regarding telehealth is crucial to improving the existing telehealth framework and supporting vulnerable populations access to new methods of care, particularly in diverse metropolitan locations within the United States.

Method: Survey/Qualitative

Classification of Research: Clinician Experience

Results: Providers reported having ambivalent experiences towards telehealth. Participants reported an item mean score of 2.05 and a scale mean score of 26.67. Four central themes emerged from participants’ descriptions of telehealth experiences: (1) satisfaction with patient safety and convenience, (2) lack of patient engagement, (3) increased access to care among rural residents and low‐income individuals, and (4) technology and financial challenges among providers.

Conclusions: While the use of telehealth practices by providers is increasing, the COVID‐19 pandemic has largely catalyzed this adoption. Understanding providers’ perceptions and satisfaction regarding telehealth is crucial to improving the existing telehealth framework and supporting vulnerable populations’ access to new methods of care, particularly in diverse metropolitan locations within the United States.

45. PROVIDERS’ VIEWS ON TELEMEDICINE WITHIN THE DEPARTMENT OF PHYSICAL MEDICINE AND REHABILITATION SERVICES DURING THE COVID‐19 PANDEMIC

Andrew Hill, Christina Crawford, Nandita Keole

Department of Veteran Affairs

Description: An online survey aimed at understanding providers opinion about telemedicine services across the Department of Physical Medicine and Rehabilitation Services at the Phoenix VA Medical Center after the abrupt implementation of telemedicine services in response to COVID. Participants included physiatrist, physical, occupational, recreational and kinesiotherapists.

Abstract: Physical Medicine and Rehabilitation providers were forcedto stop in‐person visits with immediate implementation of telemedicine services in response to COVID‐19 in 2020. This presentation provides the perceptions of physiatrists, physical therapists, occupational therapists, recrational therapists, and kinesiotherapists. Aanonymous retrospective survey was issued to the providers after the implementation of telemedicine to understand their views and challenges. Quantitative and qualitative feedback give guidance for future implementation of telemedicine services for physical medicine providers.

Method: Descriptive (Survey quantitative and qualitative)

Classification of Research: Clinician Experience

Results: Providers used telemedicine for new and follow up appointments. Prior to COVID‐19, 55% of the providers had completed a telemedicine appointment. 85% of providers attended the VA training sessions and of those 59% sought additional outside education. 97% at least somewhat agree that that the clinical exam provided sufficient information to make clinical decisions. 54% of respondents preferred to see the patients in person however 33% of providers felt telemedicine improved clinic efficiency. Qualitative feedback suggested a need for more education to the patient prior to the virtual appointment. Additional data available on poster.

Conclusions: Physical medicine providers were able to have effective telemedicine encounters. Many expressed satisfaction and felt patients were also satisfied. Telemedicine was a mean to gather information for clinical decision making and did not interfere with visualizing the body part of interest. Three quarters of participants would have preferred to see their patient in person, yet many did not agree that technology was a distraction. Many providers sought additional telemedicine education. Our providers experiences potentially varied from other environments given that over half had prior telemedicine experience. Additional details on poster.

46. RAPID RESPONSE: LEVERAGING STATEWIDE TELEHEALTH INFRASTRUCTURE TO RESPOND TO THE COVID19 PANDEMIC

King Kathryn, James McElligott, Jillian Harvey, Ryan Kruis

Medical University of South Carolina

Description: The challenges of leveraging our telehealth infrastructure to meet the healthcare needs during COVID‐19 included anticipating the changing telehealth needs and offering flexible surge capacity.

Abstract: The Medical University of South Carolina utilizes a “learning telehealth system’s” approach, building on community networks, and informatics infrastructure to develop and implement telehealth services. Two of the service domains include Virtual Urgent Care (VUC) and Ambulatory Video Visits. These services have experienced steady growth, with the volume of consults more than doubling each year between 2015 and 2019.

MUSC experienced a drop in in‐person ambulatory care visits of over 70% in March 2020. At the same time, our primary care providers, of whom only 20% had some prior experience performing telehealth visits, converted the in‐person outpatient clinics to tele‐visits.

On March 17, 2020 VUC consultations were offered at no‐charge to anyone in SC experiencing COVID19‐like symptoms.

This session will describe the changes and lessons learned from our efforts to leverage existing telehealth infrastructure to meet the statewide care needs during the pandemic. Within the initial weeks of the pandemic over 100 advance practice providers were trained, credentialed, and privileged. Scope of practices and compensation plans for the providers were developed. New protocols offering Spanish‐speaking patients online access to the COVID‐19 services were developed. Telephone options were developed to ensure access to those in rural or remote locations.

Method: Descriptive

Classification of Research: Access to Care

Results: In 2020, 162,603 VUC visit were completed, a 1074.3% increase from the prior year. Patient populations using this service were consistent with telehealth trends, with the majority being female (71.7%) and the majority (71.1%) were between ages 24–54.

In 2020, 289,370 ambulatory visits were conducted via telehealth video platforms. Through the transition to telehealth video visits, compared to the national average, MUSC saw an even more substantial use of telehealth visits in mid‐April with the MUSC rate of 68% conducted via telehealth vs national rate of 14%.

Conclusions: Within a single health system connected to a state‐wide telehealth network, the impact of COVID‐19 put a significant strain on healthcare delivery. Due to telehealth infrastructure in place across the state, we rapidly found process changes and transformed the healthcare system from in‐person delivery to digital platforms that enabled us to screen, and refer patients for testing, and continue to provide medical care for non‐COVID pediatric preventive care and adult acute and chronic conditions. Even with the substantial existing infrastructure, the increase in telehealth visits offered challenges and lessons learned in provider training, and technical difficulties with audio and video.

47. READY AND WILLING: ONE TELEHEALTH CENTER’S RESPONSE TO THE PUBLIC HEALTH EMERGENCY (PHE)

Tearsanee Davis

University of Mississippi Medical Center

Description: The University of Mississippi Medical Center Center for Telehealth has been long recognized for its commitment to the advancement of telehealth in its plight to improve access to care for all people. This presenation will highlight the efforts of the center during the COVID‐19 pandemic in Mississippi.

Abstract: Prior to March 2020, Telehealth activity outside of UMMCs Center for Telehealth was very low. Within a matter of weeks, Telehealth activity soared and grew over 200%. Not only was the Center ready to assist the Mississippi State Department of Health with screenings and scheduling for COVID‐19 testing, the Center was able to leverage the exisiting platform to meet the needs of the many patients needing care and providers who wanted to continue to serve them. The insititutions transition to virtual visits allowed clinical operations to continue in a way that not only protected patients from all over the state, but that allowed for maximization of the existing workforce who otherwise would not have been available. As a result, telehealth utlization is now an expectation in all departments at the University of Mississippi Medical Center. Not only are providers using it, patients are expecting it.

Method: Other

Classification of Research: Access to Care

Results: The public health emergency (PHE) created a need for urgent expansion of telehealth activity at the University of Mississippi Medical Center. Completed telehealth visits grew from 12,551 from April‐ Dec 2019 to 131,803 visits from April 2020‐December 2020.

Conclusions: The PHE created disruptions in health care delivery all over the world. Not only was there a need to protect patients from COVID‐19, there was a need to equip providers to be able to continue to care for those who needed them. Telehealth has proven to be a valuable solution to creating better access to care in a safe and efficient manner. Telehealth is a vital part of the growth of any health care organization.

48. Staving off the Healthcare “Blue Blur”

Brendan Smith

The MITRE Corp

Description: With the exponential growth of personal health data from remote patient monitoring (RPM) devices including wearables, the healthcare industry is heading towards a “blue blur”, a term which means that there is too much data or information to properly assess the medical situation and make proper clinical decisions.

Abstract: When the military began a major transformation to digitize their forces to aid decision makers, they inadvertently created a situation called the “blue blur”; too much data for the commanders to process. We contend that the healthcare industry is heading towards its own version of the “blue blur”. Personal remote monitoring devices, or wearables, are growing in popularity and can collect heart rate, blood oxygen levels, and fitness/activity tracking. Other RPM devices are available for home use including blood pressure monitor, thermometer, and many others. While all these devices and automation are designed to help people monitor their own health (self‐care), these devices can also provide valuable information to care teams and providers. However, the large volume of data can overwhelm a care team if they do not have the tools and technology to aggregate and correlate all of the data. And many factors will affect the data value including the users and care teams trust in the data based on type of sensor, certification, latency of the transmission, and accuracy of the data.

Method: Descriptive

Classification of Research: Information Technology

Results: We are heading towards a healthcare “blue blur” due to large amounts of healthcare being collected by RPM devices including wearables. This data is an excellent source of information for a user to take control of their own health and monitor their activity. For the healthcare teams and providers, the type and amount of data can be a challenge. Healthcare teams must answer these questions: do they trust the data; what is the data provenance; was the data timely and accurate; will they be reimbursed for processing the data; are they liable if they do not act on the data?

Conclusions: The proliferation of RPM devices, wearables and activity monitors are providing users with the technology to monitor and take ownership of their own health. However, there are many challenges that need to be addressed. Artificial Intelligence and machine learning algorithms can be used to process the large amount of health data being generated, enhance diagnosis and assist in clinical decision making. Open standards can aid with device integration and interoperability. Health care teams need to trust the data so devices need to be regulated and approved by trustworthy organizations. Reimbursement and liability must be established.

49. TELEHEALTH HOME PHYSICAL THERAPY VISITS FOLLOWING DISCHARGE AFTER TOTAL JOINT ARTHROPLASTY: TRENDS AND PATIENT CHARACTERISTICS

Charles Fisher, Elizabeth Biehl, Erica Fritz Eannucci, JeMe Cioppa‐Mosca, Jodi Lewis, Joshua Elias, M. Jake Grundstein, Laura Jasphy, Joseph Nguyen

Hospital for Special Surgery

Description: This study set out to explore the utilization of telehalth and characteristics of CJR patients s/p discharge from a hospital after arthroplasty. Review of RAPT scores and other characteristics may help to redefine the scope of patients who are appropriate for telehealth PT, thereby having implications for future practice.

Abstract: This study set out to explore the utilization and characteristics of CJR patients enrolled in HSS @ Home pre and during pandemic. Patients enrolled in HSS @ Home have virtual visits with HSS physical therapists from our institutionduring the immediate post‐acute stage (0–30 days) following a total joint arthroplasty. A total of 448 patients were analyzed, 227 met inclusion criteria for the pre‐pandemic cohort, as did 221 patients for the pandemic cohort. The research question posed is whether trends have been merely in volume increase or if the characteristics of patients utilizing PT telehealth has changed in any way from prior to during the pandemic.

Study findings show that during the pandemic, patients hadsignificantly lower RAPT scores and significantly lower levels of caregiver support than the pre‐pandemic cohort. Though not planned, the impact of Covid‐19 has demonstrated that more patients with lower functional levels and less caregiver support benefit from telehealth programs than what was occurring pre‐pandemic. This provides the opportunity to continue to study telehealth in more widespread patient populations to meet patient treatment needs.

Method: Descriptive

Classification of Research: Clinical Effectiveness

Results: A total of 448 CJR patients having had single total joint replacements were included in the study results. Average age of the pre‐pandemic cohort was 69.71 ± 5.8 years, and average age of the Pandemic Cohort was 70.63 ± 6.20 years. There was a higher percentage of females in post ‐pandemic (66%) versus pre (53%) (P = 0.005), and a higher percentage of caregiver support in pre‐pandemic (97%) versus post (92%) (P = 0.011)

RAPT score was significantly higher in pre‐pandemic patients (mean: 10.1) versus post (9.3) (P10 in pre‐pandemic (79%) versus post (54%) ({P<0.001).

Conclusions: Our results demonstrate that post‐pandemic, patients had a significantly lower RAPT score than prior indicating that more patients with lower functional statuses were now participating in telehealth. Similarly, patients with significantly lower levels of caregiver support participated post‐pandemic. Though not planned, the impact of Covid‐19 has demonstrated that more patients with lower functional levels and caregiver support levels benefit from telehealth programs than what was occurring pre‐pandemic. This provides the opportunity to continue to study telehealth in more widespread patient populations to meet patient treatment needs.

50. TELEHOSPITALIST ‐ EXTENDING HIGH VALUE CARE

Mihir Patel

Ballad Health

Description: Rural hospitals are facing difficulties with recruitment and retention of permanent hospitalistphysicians.In Ballad Health, telehospitalist model where hospitalist working in larger facilities at night covered rural hospitals using telemedicine while supporting onsite APP which prevented unnecessary transfers and helped to retain and recruit daytime ruralhospitalist.

Abstract: Rural hospitals are facing difficulties with recruitment and retention of permanent hospitalistphysicians.Telemedicine can help to resolve many problems related to rural hospitalist nighttime staffing by removing geographical barriers and reducing physician burnout.Telehospitalists can cover a multiple of hospitals simultaneously.Both physicians and nurse practitioners (NP) can remotely participate in the telehospitalists workflow.

In Ballad health,nocturnist tele hospitalist cross coverage pilot for rural hospital provided efficient, high quality and low‐cost solution. I thelped to remove a burden of nighttime supervision from the daytime hospitalist and provide support to onsite nurse practitioners by telehospitalist without any significant increase in the cost.

Night hospitalist working in tertiary carehospitalsuprevised APP in rural hospitals using telemedicine. Telehospitalists received only an average of 4.25 calls per night from rural hospital APP/emergency room physicians but it prevented an average of 0.36 avoidable patient transfers per night from rural hospitals to surrounding larger health care facilities.

This new workflow can help to reduce physician burnout, especially for rural hospitalists, boosting recruitment and retention of a permanen thospitalist workforce and minimizing dependence on locum or temporary hospitalist physicians, saving a rural hospital an average $271,000 per permanent hospitalist recruitment with long‐term retention.

Method: Observational

Classification of Research: Quality Improvement

Results: Telehospitalists received only an average of 4.25 calls per night from rural hospital APP/emergency room physicians but it prevented an average of 0.36 avoidable patient transfers per night from rural hospitals to surrounding larger healthcare facilities. It also showed potential to recruit and retain permanent daytime rural hospitalist by not requiring them to provide nighttime supervision thus reducing burnout and saving annual cost on of temporary labor of around $271,000.

Conclusions: Based on the results, it was apparent that the nocturnist tele hospitalist cross coverage model for rural hospital can provide efficient, high quality and low‐cost solution. It can help to remove a burden of nighttime supervision from the daytime hospitalist and provide support to onsite nurse practitioners without any significant increase in the cost. Healthcare industry has been charged with transforming to a value‐based business model and telemedicine tools and workflows within hospital medicine will aid in that evolution while showing great promise to increase consumer access to high‐value care while remaining close to home.