key: cord-0682343-o5pcfzgs
authors: Serino-Cipoletta, Jessica; Dempsey, Catherine; Goldberg, Nancy; Marinaccio, Barbara; O'Malley, Kimberli; Dolan, Caitlin; Parker-Hartigan, Lori; Williams, Lucinda; Vessey, Judith A.
title: Telemedicine and Health Equity During COVID-19 in Pediatric Gastroenterology
date: 2021-06-23
journal: J Pediatr Health Care
DOI: 10.1016/j.pedhc.2021.01.007
sha: 0c09a3b9356ed1542e22bb4df2088d54cf3864b0
doc_id: 682343
cord_uid: o5pcfzgs

INTRODUCTION: Telehealth (TH) services rapidly expanded during the COVID-19 pandemic. This rapid deployment precluded the opportunity for initial planning of implementation strategies. The purpose of the quality improvement project was to understand the needs of nurse practitioners and examine TH procedures and interventions designed to promote high-quality, equitable health care for pediatric patients with gastrointestinal concerns. METHOD: The Plan-Do-Study-Act model was used. Survey data from providers and families were collected and analyzed. They were further illuminated through iterative dialog across the research team to determine the quality and efficiency of TH. RESULTS: A toolkit of strategies for promoting the quality and efficiency of TH was created according to the three domains of health equity: availability, accessibility, and acceptability. DISCUSSION: TH will be used in the postpandemic era. Institutions need to implement evidence-based strategies that ensure health equity across TH platforms to ensure excellent patient care.

Telehealth, health equity, nurse practitioner, quality improvement, pediatrics Although telehealth (TH) began in the late 1800s, these practices have grown exponentially during the COVID-19 pandemic (Bestsennyy, Gilbert, Harris, & Rost, 2020 ; Board on Health Care Services, Institute of Medicine, 2012). TH platforms and other digital health innovations present a viable option to efficiently and safely provide some forms of patient care (Crawford & Serhal, 2020) , but widespread usage by many health care organizations was previously uncommon. Such was the case for one quaternary freestanding children's hospital in the northeast United States. The capacity of their pediatric clinics to see patients in-person was sharply curtailed during the COVID-19 pandemic when state-wide guidance and organizational decisions required that all nonemergent care be delivered electronically. The gastroenterology (GI) nurse practitioner (NP) team immediately shifted their clinical practices to TH, but its rapid deployment precluded the opportunity for initial planning and design of virtual clinic visits (Health IT.gov, 2017) . Initially, parental anxieties surrounding their child's health and provider concerns on providing quality patient care were paramount. As a part of implementing robust TH practices, promoting health equity for all patients and families was of primary importance. It could not be assumed that every family had access to the necessary digital technologies or the wherewithal to meaningfully engage in TH. In addition, it could not be assumed that the GI NPs and larger health care systems were positioned to deliver care in this manner. Of particular concern to the team was how to provide highquality care to their patients whose families were underresourced or had low health literacy.

This quality improvement project (QIP) was designed to determine the feasibility and efficiency of TH visits for patients, parents, and providers. Emphasis was on assessing whether care was equitable for all families and, where barriers were identified, to determine how best to address them. The Institute for Healthcare Improvement's (n.d.) Plan-Do-Study-Act model for conducting quality initiatives provided the structure for designing and operationalizing this project. The revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0; SQUIRE, 2020) guidelines provide the systematic framework for reporting this project's findings (Ogrinc et al., 2016) .

Telehealth TH takes many forms; for this, QIP TH refers to NPpatient/parent communication using live (synchronous) audio-video conferencing, or in the absence of video capability, audioconferencing. TH uses the electronic transmission of health care data to consult new patients, provide diagnoses, conduct follow-up visits, and recommend treatment plans (Crawford & Serhal, 2020; Olson, 2018) . It was originally designed to increase access for basic acute care to select populations, including the military, prisons, and rural locations. As the digital divide has narrowed, varied clinical applications are now widely used across diverse populations and settings (Dorsey & Topol, 2016; Park, Erikson, Han, & Iyer, 2018) . Patient enthusiasm for TH is much higher in younger populations, making it a popular care platform with unlimited potential for pediatric patients and their families (Park et al., 2018) .

TH has distinct advantages. Health care providers can be more available to geographically diverse populations and allocate their time more efficiently to care for patients needing the most attention. TH also allows for greater multidisciplinary team involvement, creating a more patient-centric approach that is associated with improved patient outcomes (Kvedar, Coye, & Everett, 2014) . Patients have generally reported high satisfaction with TH; it is convenient, reduces travel time and costs, and limits time away from their jobs (Kruse et al., 2017) . During the pandemic, TH proved to enhance infection control by eliminating patients' and families' potential exposure to COVID-19 associated with onsite visits and conserve limited resources such as reducing the usage of personal protective equipment by hospital personal (Berg et al., 2020) .

TH's major disadvantages for both the providers and the patients are a potentially less robust therapeutic relationship, inability to conduct a thorough physical examination, and incompatibility of available digital technologies (Dorsey & Topol, 2016) . When a physical examination is needed, TH is not a preferred option as basic examination techniquesauscultation, palpation, and percussion-are not possible, and inspection is limited (Chaet, Clearfield, Sabin, Skimming, & Council on Ethical and Judicial Affairs American Medical Association, 2017) . Health care providers must convey precise instructions and rely on the patients to follow their directions for some examination techniques and interpret findings despite not knowing what is normal; when important information is not captured, it imposes risks that can lead to further problems such as missed or incorrect diagnoses. Incompatibility between institutional software and patient digital devices, difficulty establishing or maintaining an electronic connection, and breaches in privacy are also common issues (Alverson et al., 2008) .

Many organizations, such as the American Medical Association, American Academy of Pediatrics, and adult gastroenterology societies, have provided pediatric gastroenterology provider guidelines on implementing TH into their practice (Berg et al., 2020) . However, across these guidelines was the failure to address specific considerations in conducting TH with under-resourced patients and families or those that have low levels of health or technological literacy.

Providing high-quality care requires that principles for achieving health equity are used in its planning and delivery. The U.S. Centers for Disease Control and Prevention (Centers for Disease Control and Prevention, 2020) defines health equity as "achieved when every person has the opportunity to attain his or her full health potential and no one is disadvantaged from achieving this potential because of social position or other socially determined circumstances." The three central domains of health equity are accessibility, availability, and acceptability (see Figure) . Health inequities are reflected in differences in length and quality of life, rates and severity of the disease, disability and death, and access to treatment. These will result in poor patient outcomes (Crawford & Serhal, 2020) .

TH is generally viewed as an equalizer to providing care to diverse pediatric populations (Brophy, 2017; Utidjian & Abramson, 2016) . However, TH creates specific health equity concerns for patients from families with fewer technological resources or poorer health literacy. Underserved populations have not historically used synchronous video communication as widely as other socioeconomic groups (Park et al., 2018) . Providers must be prepared to address all aspects of the cultural, social, and economic barriers that come with TH.

The gastroenterology department schedules approximately 56,000 patients annually and has 11 clinic sites across eastern Massachusetts. The NPs are experts in managing GI issues, with an average of 15 years of experience working as advanced practitioners (range: 5−30). Their caseloads include patients from birth through young adulthood and span a wide array of acute and chronic conditions of varying levels of complexity. Most of these conditions are chronic; many are exacerbated by stress and require expensive treatments. Carefully tracking their clinical course and proactive management of emerging issues is critically important.

The pandemic created an environment that allowed the symptomology of many GI disorders to flourish, hindering patients' health-related quality of life. Most patients seen in the GI Department are followed on a regular basis and have a long-term relationship with their NP. TH visits with their GI NP provided a lifeline for patients and families; without these visits and early intervention, patients would need to resort to seeking care in the emergency department with the potential for the hospital admission. The result would be a worsening clinical course, more expensive care, and, unfortunately, an increased risk of community or hospital exposure to COVID-19.

Shortly after the rapid deployment of TH, NP anecdotal impressions supported that quality care for selected visit types could be rendered through TH, and these encounters are generally well-received by families. However, with a lack of objective data, it was not possible to clearly delineate strengths and weaknesses and thus limited the development of best practices for the use of TH across diverse populations. Specific aims of this QIP were as follows:

1. determine variables important to quality telehealth interactions (NP experience, "known" patient, the FIGURE. Health equity framework reason for visit, the sophistication of telehealth platform, NP's comfort with technology, working relationship with the supervising attending); 2. codify specific elements identified by NPs that impact the efficiency and effectiveness of TH interactions with families from diverse backgrounds; 3. identify potential issues of health disparity when using TH as a primary method of health care delivery with children and their parents; and 4. design a patient/family-centric toolkit for NP TH visits, with individual strategies appropriate for further testing.

A modified participatory action research (PAR) approach was adopted for this QIP. The PAR methodology addresses complex phenomena by intentionally engaging participants in sharing local knowledge while engaging them in obtaining relevant solutions for the community of interest (Fardi, Grunbaum, Gray, Franks, & Simoes, 2007; Jones, 2009) . A specific goal of PAR is to improve health and reduce health inequities (Baum, MacDougall, & Smith, 2006) . The team was composed of GI NPs (n = 4), a nurse scientist, nursing leadership (n = 2), and registered research nurses (n = 2). The team met weekly via Zoom (Zoom, 2020) to design, conduct, and evaluate this project. Every week, team members reflected on components of the TH rollout, adjusting their practices when possible. Each step is described later.

Joint Commission regulations and published evidence describing the use of TH with children with chronic/complex conditions were reviewed. Using this information and expert opinion, two data collection tools were designed for this project-the Provider GI TH Data form and the Parent/ Patient GI TH Data form. Both instruments were adapted, incorporating new items specific to TH and GI care, from approved quality improvement forms already used by the hospital. The Provider form contains six separate domains: (1) encounter characteristics (including International Classification of Disease, Tenth Revision, and current procedural terminology codes), (2) consultations, (3) electronic communication strategies employed, (4) visit complexity level, (5) call disposition, and (6) time involvement. Operational definitions for variables in each domain helped standardize data collection (Vessey, McCrave, Curro-Harrington, & DiFazio, 2015) . The Parent/Patient form consisted of 10 Likert-style items specific to the patient experience and another three items comparing TH and onsite visit familyincurred costs; these items were adapted on the basis of published recommendations (D avalos, French, Burdick, & Simmons, 2009; Henderson, Davis, Smith, & King, 2014) . Iterative drafts of both instruments were trialed, evaluated, and modified; final drafts were formatted into REDCap (Vanderbilt University, Nashville, TN), a secure web application for data management.

Before data collection and in consultation with a statistician, it was determined a priori sample of 100 visits would provide sufficient descriptive data collected on the Provider GI TH Data form regarding the overall TH visit, and a sample size of 80 (two-sided 95% confidence interval with a width equal to 0.186 when the sample proportion was 0.800) would be adequate for the parent/patient survey. Before the initiation of data collection, the GI NPs trialed the Provider GI TH Data form to help ensure interrater reliability. Data were then collected on consecutive TH visits. The NP's recorded time spent on (1) preparing for the visit, (2) seeing the patient, (3) developing the management plan, (4) ordering medications and diagnostic tests, and (5) recording key information in the patient's electronic medical record. Finally, they recorded the TH platform used (e.g., Zoom [Zoom, 2020] , SBR Health [SBR Health, 2020], Doximity [Doximity, 2020] ) and the quality of the video and sound.

Parents/patients were asked at the visit's conclusion if they would be willing to be contacted regarding their TH experience by a research nurse. Families who agreed completed the Parent/Patient form over the phone within several days of the visit; data were later transcribed into REDCap. The GI NPs' then forwarded their completed tool to the research nurses. The GI NPs engaged in regular, unstructured discussions with the full QIP team about the challenges or barriers they faced while providing care with TH over the prior week. Key information from these discussions was captured for later analysis.

Data garnered from the Provider (n = 169) and Parent/ Patient (n = 80) GI TH Data forms were downloaded from REDCap into SPSS (IBM, Armonk, NY) for analysis. Descriptive statistics were calculated and are presented in Tables 1 and 2. To better understand the socioeconomic composition of this sample and look for differences in TH patterns, median household income was estimated using zip code status (University of Michigan, Population Studies Center, Institute for Social Research, & Morenoff, 2011) . In the sample captured in the Parent/Patient follow-up interviews, 38.8% had an estimated median household income below the 50th percentile for this New England catchment area. Finally, the weekly information collected from the GI NPs illuminated these findings. The data from these three sources were triangulated to help create relevant solutions for the community of interest.

Using the results from the Provider and Parent/Patient Data forms and information from the weekly QIP team debriefing sessions, specific health equity issues were identified and categorized according to the domain: availability, accessibility, and acceptability. A toolkit was then developed (see Table 3 ). Strategies for some issues were deemed ready for immediate deployment, such as the flashcards to use with technological difficulties or working with schedulers to improve care coordination. Other concerns were outside of the GI NPs' immediate scope of practice, such as connectivity issues with the TH platforms. Meetings were held with the respective personnel from other divisions in the hospital to share QIP data while suggesting potential solutions. Finally, other strategies will be further tested in future QIP or formal research studies on the basis of urgency, complexity, and feasibility. For example, anecdotal information suggested that some families encountered extra expenses when trialing different formulas or copays associated with obtaining laboratory work or unanticipated patient emergency department visits and/or hospital admissions; additional data are needed to better understand the scope of the problem before positing solutions.

Every indication was that TH would become fully integrated into health organizations' care delivery. In a recent survey, McKinsey & Company reported that 76% of consumers want to use TH services moving forward, 57% of providers view TH more favorably, and 67% were comfortable with TH, and regulatory requirements have been widely expanded (Bestsennyy et al., 2020) . For TH to reach its potential in providing equitable, high-quality care to patients and families, prioritization must be given to addressing the impact of social determinants of health on implementation strategies (Park et al., 2018) .

In this QIP, connectivity and communication were the major issues encountered. Our hospital uses a variety of technological interfaces. Synchronous video-based conferencing programs such as Zoom (Zoom, 2020), Doximity (Doximity, 2020) , and SBR (SBR Health, 2020) were used for actual clinic visits. SBR (SBR Health, 2020) is designed specifically for TH and is Health Insurance Portability and Accountability Act (HIPAA) compliant. Unfortunately, in this project, it was associated with connectivity issues, primarily lower socioeconomic families who had technology with minimal capacity (i.e., chrome books). It also did not allow more than two parties (patient and provider) to participate at a time, limiting real-time care coordination. Doximity (Doximity, 2020 ) is a network for health care professionals used for calling patients using their office phone number, video conferencing, and faxing HIPAA compliant patient documents such as instructions, prescriptions, and clinic notes to sharing providers. These can occur while not disrupting personal cell phone information to conduct TH practices. Zoom (Zoom, 2020) is a video communication program that allows for HIPAA compliant video conferencing across all professional domains. For nonurgent issues, asynchronous platforms such as the patient portal, secure email, and telephone calls were used to communicate with patients.

Patient/family failure to successfully download apps, insufficient bandwidth, and interrupted transmission were all encountered, although the immediate five-state geographic area has some of the best broadband connectivity in the country (Cooper, 2018) . Difficulty accessing an interpreter and maintaining interpreter services if technological difficulties occurred was also a concern. Although a technology helpdesk was available to all patients, families, and providers, delayed response times and the complexity of the issue often required that the visit be rescheduled.

Diverse platform options are recommended to meet the needs of different patient subgroups to improve TH adoption and use (Armbruster et al., 2020) . Although multiple technologies can enhance communication, they also require that families are capable of using and monitoring multiple electronic information sources. When families failed to see electronic visit planning messages or successfully download connectivity software, visits were interrupted, canceled, or missed altogether. Ensuring that families were fully prepared for the TH visit was a challenge if all the visit preparation emails were not read or followed. For example, a common problem was that the child was not weighed before the visit. Another surprising issue was parents who did not include their child in the TH visit.

An organizational-wide plan is essential for TH to be both efficient and efficacious (Alverson et al., 2008) ; ideally, it should be designed for multiple family members (i.e., both parents, adolescent patients) to synchronously receive the same messages and participate in the calls when prudent. Examples include divorced families with shared custody or when the patient was at college, but their parent was at home. Prompts for families in which English is not the preferred language, standardized symbols, quick response codes, and other prompts on all materials will alert families regarding translation services.

Limited Internet and mobile band access and data fees sustain the digital divide across socioeconomic groups (Anderson & Kumar, 2019; Steele, 2016) . As new, more sophisticated modalities are adopted by an organization, attention must be paid to their compatibility with basic technological devices and the amount of data time they use so as Assess Wi-Fi ability before TH visits, include information in introductory e-mails (emphasize privacy concerns) Connectivity (providers): Audio failure during the call For organizations and providers: Develop organizational-specific written procedures/algorithms for switching across platforms Work with the agency's virtual visit team to create a robust platform for integrating the electronic medical record, visit coding (billing system), and scheduling system Confirm uniform resource locators monthly to ensure that the guidance is up to date Provide providers with a laminated copy of key agency uniform resource locators and phone numbers useful in case of electronic failure Provide laminated connectivity flashcards to providers Useful materials: Downloadable and printable Connectivity Flashcards are located in the Supplementary Materials Financial barriers Economic well-being: Loss of employment affecting insurance coverage, ability to pay prescription copays, purchase formula, etc.

Include required assessment questions at each visit: Specific to changes in living situations, employment, and insurance coverage Ability to pay copays and others related to managing child's condition Refer to the social-work department to assist with insurance eligibility/coverage/redeterminations or new applications Copays: Extra copays associated with obtaining laboratory work, unanticipated patient emergency department visits, and/or hospital admissions Use future Plan-Do-Study-Act cycles to complete chart audits to determine the scope of the problem and possible solutions not to shut out lower socioeconomic populations. Formalized backup plans for poor Internet-based connectivity are essential (Brophy, 2017) . During the data collection for this QIP, TH visits were the only option for nonemergent visits for either new or continuing patients. Generally, the GI NPs thought that TH was an excellent platform for most follow-up visits but establishing therapeutic relationships with some new patients was more difficult than when initial visits were conducted in-person. Social capital factors such as trust and engagement with the provider and organization are known to significantly positively affect patients' perceived ease of use of, the usefulness of, and intention to use TH (Tsai, 2014) . Incorporating these into TH protocols, using in-clinic visits for new patients, and maintaining the same provider are strategies that should be considered (Dorsey & Topol, 2016; Orlando, Beard, & Kumar, 2019) . This QIP was not designed to capture routine follow-up visits that went unscheduled or those that were missed despite being scheduled. However, the GI NPs' anecdotal impressions were that the patients and families might have lacked knowledge on how to use the technology or had health literacy concerns. Auditing missed visits and determining associated factors would help illuminate this issue and lead to better care coordination.

The inability to conduct a physical examination for some patients was problematic. Even with inspection, assessment capabilities were limited by the quality of the patient's and provider's cameras. When a physical examination was essential, TH alone was insufficient and may have contributed to health inequalities.

TH also prevented seamless transitions in care. When laboratory tests or other simple diagnostic procedures were ordered, they could not be completed at the time of the visit. The GI NPs reported that patients and families had to schedule separate appointments for diagnostic examinations, laboratory studies, or x-rays. Access to free formula samples and timely consultation with the attending were also not always available. These follow-up visits required families to assume the cost and time burdens associated with travel, parental leave time, extra copays, and others. Delayed care could also be an issue. All contribute to excess health care use (Dorsey & Topol, 2016) .

The literature supports that additional training in TH procedures is needed by experienced clinicians (Brophy, 2017; Clay-Williams et al., 2017) . For example, in this QIP, the GI NPs had to modify their practices to match available technology. Preplanning and record review was essential. Having only a small laptop screen to use when conducting the visit, visual contact with parents and patients was interrupted when the GI NPs had to switch among screens to review information in the electronic medical record, consult formularies, order laboratory tests, and others. Including audio cues were necessary so that patients remain engaged. Interruptions in visual engagement interfere with the therapeutic relationship, critically important in advancing health equity for all families (Kemery & Goldschmidt, 2020) . The GI NPs also needed to provide additional instruction not needed in in-clinic settings. For example, parents needed to be reminded that their child needed to be present for the TH visit. Documentation and coding strategies needed to be modified to capture total visit time, not just time "on camera." Training specific to Children's Online Privacy Protection Act regulations that place parents in control of providing personal information from children under the age of 13 years and the need for providers to share with parents/guardians about how such information will be used needed to be provided (Federal Trade Commission, 2017) .

Finally, health care organizations must heed human factors and ergonomics principles when implementing TH (Carayon, 2017) . For NPs conducting TH from their homes, computers configured with high-quality visual and audio capabilities, embedded decision support systems, and dual screens will maximize patient assessment and communication while meeting patient privacy concerns. Ergonomically correct workstations will help prevent provider injury.

Albeit the information gleaned from this QIP is enlightening and useful, this project included only a small number of NPs from a single pediatric subspecialty outpatient clinic where Note. NP, nurse practioner; TH, telehealth; HIPAA, Health Insurance Portability and Accountability Act; COPPA, Children's Online Privacy Protection Act. Selected items were also reported by Armbruster et al. (2020) , Berg et al. (2020) , Dorsey & Topol (2016) , Orlando, Beard, & Kumar (2019) , and Kemery and Goldschmidt (2020).

customarily the visits are conducted in-person. The model of care is highly interdisciplinary, typically including not only NPs but clinical nurses, physicians and physician trainees, social workers, dieticians, and professional personnel such as pharmacists. Administrative staff also are part of the care delivery model. Although all these individuals contribute to the work of the GI ambulatory clinic, they were not included in this exploratory project. The parent/family sample size (n = 80) was adequate but modest. In addition, the data collection tools used for the project were not validated instruments. Securing financial information such as comparing family expenses when conducting TH visits with in-person visits, rates of reimbursement for NP TH with in-person visits would all have added value to this project. Finally, families were not part of the team that planned this initiative, given the project emerged in the setting of a pandemic.

All indications are that TH will remain fully integrated into care delivery in the postpandemic era. Strategic planning, implementation, and evaluation were required to ensure that delivery strategies are designed to be "value added" by enhancing health equity for the children and families for whom we care.

Supplementary material associated with this article can be found in the online version at https://doi.org/10.1016/j. pedhc.2021.01.007.

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