key: cord-0824586-o6gvs9we authors: Sharma, Arun; Bowman, Ryan; Ettema, Sandra L.; Gregory, Stacie R.; Javadi, Pardis; Johnson, Matthew D.; Butcher, Marissa L.; Mutua, Evans; Stack, Brendan C.; Crosby, Dana L. title: Rapid telehealth implementation into an otolaryngology practice during the COVID‐19 pandemic date: 2021-05-04 journal: Laryngoscope Investig Otolaryngol DOI: 10.1002/lio2.552 sha: db88fb5a39cccdcbc70cf1ee79b8885ef9013cf8 doc_id: 824586 cord_uid: o6gvs9we OBJECTIVE: Report outcomes of rapid implementation of telehealth across an academic otolaryngology‐head and neck surgery department during the COVID‐19 pandemic. METHODS: This is a retrospective, single‐institution study of rapid deployment of telehealth during the COVID‐19 pandemic. Characteristics of patients were compared between those who agreed and those who declined telehealth care. Reasons for declining telehealth visits were ascertained. Characteristics of telehealth visits were collected and patients were asked to complete a post‐visit satisfaction survey. RESULTS: There was a 68% acceptance rate for telehealth visits. In multivariable analysis, patients were more likely to accept telehealth if they were being seen in the facial plastics subspecialty clinic (odds ratio [OR] 59.55, 95% confidence interval [CI] 2.21‐1607.52; P = .015) compared to the general otolaryngology clinic. Patients with Medicare (compared to commercial insurance) as their primary insurance were less likely to accept telehealth visits (OR 0.10, 95% CI 0.01‐0.77; P = .027). Two hundred and thirty one patients underwent telehealth visits; most visits (69%) were for established patients and residents were involved in 38% of visits. There was an 85% response rate to the post‐visit survey. On a scale of one to ten, the median satisfaction score was 10 and 99% of patients gave a score of 8 or higher. Satisfaction scores were higher for new patient visits than established patient visits (P = .020). CONCLUSION: Rapid implementation of telehealth in an academic otolaryngology‐head and neck surgery department is feasible. There was high acceptance of and satisfaction scores with telehealth. LEVEL OF EVIDENCE: 3. Telehealth is a scalable technology which allows for remote delivery of healthcare by using audio and video interaction between healthcare providers and patients. 1 Even prior to the coronavirus disease 2019 pandemic, multiple evolving trends in telehealth usage were noted; these include increasing access (while reducing costs), expansion of conditions and situations deemed appropriate for telehealth usage, and migration of telehealth to patient's homes and mobile devices. 1 Telehealth has been shown to reduce travel costs for patients 2 while allowing for delivery of care with high levels of patient satisfaction. 1, 3, 4 COVID-19 is a novel respiratory illness caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which has spread rapidly around the world and has been designated as a pandemic by the World Health Organization (WHO). 5 Since the primary mode of transmission is thought to be through respiratory droplets and transmission can occur by asymptomatic patients, there is high potential for human-to-human transmission, especially in situations where people are in close proximity. [6] [7] [8] [9] For those reasons, there was widespread implementation of social distancing measures and "stay at home" orders throughout the United States. 10 This resulted in decreased patient access and utilization of healthcare for non-COVID-19 reasons, including non-urgent outpatient clinic visits and surgical procedures, especially early in the COVID-19 pandemic. [11] [12] [13] [14] In outpatient clinic settings, social distancing was achieved by reducing providers, decreasing clinical schedules, and reducing personnel in clinic rooms, all of which result in fewer possible episodes of human-to-human contact and subsequent risk of viral transmission. In addition to these measures, there has been increasing interest and utilization of telehealth given social distancing recommendations and "stay at home" restrictions during the COVID-19 pandemic. 15, 16 Telehealth availability has been expanded by the Centers for Medicare & Medicaid Services (CMS), Medicaid in many states, and several private insurers during the COVID-19 pandemic to allow patients to access the healthcare system via telehealth from home. 17 This allows preservation of social distancing measures while allowing for continued clinical care as prior telehealth regulations required patients to present to a local clinic or other facility to access telehealth. In this study, we report outcomes of rapid adoption and implementation of telehealth across an academic otolaryngology-head and neck surgery department to demonstrate provider acceptance and relatively rapid learning curve. The outcomes of interest were patient acceptance of telehealth as a substitute for in-person clinic visits, characteristics of telehealth visits, and patient satisfaction after telehealth visits. This information is relevant to other otolaryngologyhead and neck surgery practices as they incorporate telehealth as an option for their patients. Individual providers decided which conditions and patients they would consider seeing via telehealth based on their clinical judgment. Departmental nursing staff contacted potential patients to assess whether they would be willing to use telehealth. During this telephone call, patients were asked about whether they had access to a computer and/or smartphone, internet or data access, an email address, and interest in receiving care through telehealth. Those who met all of the above criteria were offered telehealth appointments. Those who were unable to participate in telehealth or declined telehealth visits were offered an in-person clinic appointment within 1-2 weeks (if they had an urgent clinical need) or an in-person clinic appointment at a later time (if the provider felt that the visit could be safely delayed). Characteristics of all patients who were contacted from April 6-10, 2020 for possible involvement in a telehealth visit were recorded. Patients who declined involvement in telehealth were asked specifically why they were not interested or able to use telehealth. The goal was to conduct all telehealth visits with audio and video May 29, 2020 . This included demographic data on patients, reasons for the visits, billing data, and any technical problems that occurred. After telehealth visits that occurred from March 31, 2020 to April 28, 2020, patients were contacted via telephone to provide an overall satisfaction score (from 1 to 10) for the visit. They were also asked whether there was anything that would have made the visit better and whether they would continue using telehealth for their healthcare. The Shapiro-Wilk W test and Shapiro-Francia W' test were used to assess for normal distribution among the continuous variables (patient age and satisfaction scores). These tests showed that these variables were not normally distributed. Therefore, the continuous variables were described using median and interquartile range (IQR); comparisons between groups were made using Wilcoxon ranksum Eighty-two patients who were deemed appropriate for telehealth visits were contacted between April 6-10, 2020 to assess whether they would accept a telehealth visit with an otolaryngologist-head and neck surgeon. Of these patients, 56 (68%) agreed to have a telehealth visit. Characteristics of patients who were screened for telehealth are shown in Table 1 . Medicare as primary insurance was associated with higher chance of refusing a telehealth visit (P = .049). None of the other characteristics were associated with accepting or refusing telehealth visits in the univariate analyses (see Table 1 ). A multivariable regression model was fit with telehealth acceptance as the outcomes of interest (see Table 2 ). Patients were more likely to accept telehealth if they were being seen in the facial plastics Table 3 . The age distribution was bimodal and shown in (Table 3) . Patients being seen for new telehealth visits were younger than patients being seen for established telehealth visits (median age: 35 vs 48, respectively, P = .016). Patients seen in the head and neck subspecialty clinic were more likely to be established patients (compared to the general otolaryngology clinic; P = .013). Physicians utilized telehealth more often for established patients compared to advanced practice providers (P = .038). Of the 89 patients who successfully completed telehealth visits and were asked to provide feedback on the telehealth visit via a post-visit phone call, 76 responded (85% response rate). On a scale of one to ten, with ten being the highest satisfaction, the median satisfaction score was ten (n = 75, since one patient refused to provide a satisfaction score, but provided qualitative feedback) and 99% of patients gave a score of eight or higher (Figure 2 ). Satisfaction scores were compared among patient and visit characteristics (Table 4 ). Satisfaction scores were higher for new patient visits (88% had a score of 10) than established patient visits (59% had a score of 10) (P = .020) ( Note: Characteristics that were statistically significant (P < .05) or showed a trend toward significant (P < .10) are shown in bold. Abbreviations: CI, confidence interval; OR, odds ratio. Prior studies have demonstrated feasibility of telehealth integration into otolaryngology-head and neck surgery. 18 Medicare (n = 16) 10 (10-10) .268 Self-pay/uninsured (n = 5) 10 (9-10) .809 Unknown (n = 2) 10 (10-10) .361 No (n = 60) 10 (9-10) Yes (n = 15) 10 (8-10) visits. Now that these goals have been met, one of the subsequent goals will be to increase the level of resident involvement. Patient satisfaction was very high in our study. The only statistically significant predictor of satisfaction scores was visit type, with new patient encounters having higher satisfaction than established patient encounters. However, the scoring system seemed to have a ceiling effect (as shown in Figure 2 ) with scores skewed to the top of the scale. Further research could employ a different scoring system to avoid this ceiling effect and subsequent limitations on statistical analyses. Physicians and advanced practice providers reported multiple limitations with telehealth during this rapid implementation period. These included technical difficulties experienced by patients, which resulted in delayed appointments, need for alternative applications if patients were unable to access or use Cisco Webex Meetings, or an audio-only appointment. Furthermore, limited physical examination and difficulty communicating, especially with patients who had auditory, speech, or airway impairment, were additional limitations of telehealth. The current report is a single-institution report of feasibility and outcomes of telehealth implementation. Our findings are likely representative of an academic otolaryngology-head and neck surgery department with a large proportion of fellowship-trained subspecialists. However, differing results and outcomes may be seen in other practice settings. Implementation of telehealth requires support from a multitude of professionals beyond physicians and advanced practice providers. Involvement of administrators, nursing staff, information technology and telehealth support staff, and compliance/billing support are critical. At our institution, all of these key players were supportive and able to facilitate rapid implementation. Local and institutional factors in other settings may limit the applicability of telehealth elsewhere. In this study, we demonstrate the successful and rapid adoption of telehealth services for a broad range of patients requiring otolaryngologic care. The majority of patients (68%) agreed to use telehealth for their healthcare needs and satisfaction scores were high. Further studies could demonstrate the utility and limitations of telehealth in delivery of care, both during and after the COVID-19 pandemic. Although many uncertainties regarding the exact long-term role of telehealth remain, we anticipate that it will likely be used to a greater and broader extent than in the pre-COVID-19 era. State of telehealth VA telemedicine: an analysis of cost and time savings Telehealth and patient satisfaction: a systematic review and narrative analysis Patients' satisfaction with and preference for telehealth visits COVID-19) events as they happen Potential presymptomatic transmission of SARS-CoV-2 Pattern of early human-to-human transmission of Wuhan The origin, transmission and clinical therapies on coronavirus disease 2019 (COVID-19) outbreak -an update on the status Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia Delayed access or provision of care in Italy resulting from fear of COVID-19 COVID-19: UKcould delay non-urgent care and call doctors back from leave and retirement Global guidance for surgical care during the COVID-19 pandemic COVID-19: Guidance for Triage of Non-Emergent Surgical Procedures Prioritizing Novel Approaches to Telehealth for All Practitioners Telehealth for global emergencies: implications for coronavirus disease Medicare Telemedicine Health Care Provider Fact Sheet Where does telemedicine fit into otolaryngology? An assessment of telemedicine eligibility among otolaryngology diagnoses Telemedicine in otolaryngology outpatient setting-single center head and neck surgery experience AMA quick guide to telemedicine in practice Embracing telemedicine into your otolaryngology practice amid the COVID-19 crisis: an invited commentary Is telehealth effective in managing malnutrition in community-dwelling older adults? A systematic review and meta-analysis Ten Have T. Outcomes of a telehealth intervention for homebound older adults with heart or chronic respiratory failure: a randomized controlled trial Ten Have T. Integrated telehealth care for chronic illness and depression in geriatric home care patients: the integrated telehealth education and activation of mood (I-TEAM) study Estimates of the severity of coronavirus disease 2019: a model-based analysis statements/statement-older-people-are-athighest-risk-from-covid-19,-but-all-must-act-to-prevent-communityspread eHealth literacy in otolaryngology patients Rural-urban differences in the association between individual, facility, and clinical characteristics and travel time for cancer treatment Rural-urban disparities in otolaryngology: the state of Illinois VA evidencebased synthesis program reports. Rural vs. Urban Ambulatory Health Care: A Systematic Review Insights on otolaryngology residency training during the COVID-19 pandemic Rapid telehealth implementation into an otolaryngology practice during the COVID-19 pandemic The authors would like to acknowledge the efforts and support of Michelle Lynn, RN, BSN and Sarah Stout, RN, BSN. The authors declare no conflicts of interest.