key: cord-1003394-it17prv8
authors: Hakim, Amin; Gaviria-Agudelo, Claudia; Edwards, Kathryn; Olson, Daniel
title: Pre-Coronavirus Disease 2019 Telehealth Practices Among Pediatric Infectious Diseases Specialists in the United States
date: 2020-11-16
journal: J Pediatric Infect Dis Soc
DOI: 10.1093/jpids/piaa146
sha: 40cab858578b8be260ab6198c9a6fc16bd726c98
doc_id: 1003394
cord_uid: it17prv8

BACKGROUND: Telehealth (TH) practices among pediatric infectious disease specialists prior to the coronavirus disease 2019 (COVID-19) pandemic are largely unknown. METHODS: In 2019, the Pediatric Infectious Diseases Society (PIDS) Telehealth Working Group surveyed PIDS members to collect data on the use of TH modalities, adoption barriers, interest, extent of curbside consultations (CC), and reimbursement. RESULTS: Of 1,213 PIDS members, 161 (13.3%) completed the survey, and the responses of 154 (12.7%) from the US were included in our report. Medical school (63.6%) and hospital (44.8%) were the commonest work settings with 16.9% practicing in both of them. The most common TH modalities used were synchronous provider-patient virtual visits (20.8%) and synchronous provider-provider consultations (13.6%). TH services included outpatient consultations (48.1%), vaccine recommendations (43.5%), inpatient consultations (39.6%) and travel advice (39.6%). Barriers perceived by respondents included reimbursement (55.8%), lack of experience with TH (55.2%), lack of institutional support (52.6%), lack of administrative support (50%), and cost of implementation (48.7%). Most respondents (144, 93.5%) were interested in implementing a wide range of TH modalities. CCs accounted for 1-20 hours/week among 148 respondents. CONCLUSIONS: Most of the PIDS survey respondents reported low utilization of TH and several perceived barriers to TH adoption before the COVID-19 pandemic. Nonetheless, they expressed a strong interest in adopting different TH modalities. They also reported spending considerable time on non-reimbursed CCs from within and outside their institutions. Results of this survey provide baseline information that will allow comparisons with post-COVID-19 changes in the adoption of TH in PID.

American Telemedicine Association (ATA) definitions are utilized by many. 1, 2 Telehealth refers often to virtual communication between a patient and a clinician, but usually includes telemedicine which entails communications between providers. Physicians in many specialties use TH to provide services to colleagues and patients. The American Medical Association's 2016 Physician Practice Survey reported that 15.4% of US physicians had adopted virtual care modalities including audio-visual e-visits (a term often indicating virtual visits) for patients and inter-professional interactions, and 11.2% of the physicians reported working in settings that used provider-to-provider communications such as subspecialty consultations. 3 It should be noted that " telemedicine" was defined in that report as "the use of technology as a substitute for an in-person encounter with a health care professional" to avoid Medicare's definition at the time which limited telehealth to twoway, audiovisual, real-time interactions. The Health Resources Services Administration (HRSA) currently defines TH as the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional healthrelated education, public health and health administration. 4 HRSA notes that TH is different from telemedicine because TH refers to a broader scope of remote healthcare services than telemedicine, and the latter refers specifically to remote clinical services.

A 2018 survey regarding trends in the TH industry reported that 22% of 800 US physicians in various specialties used TH, a four-fold increase from 5% in 2015. 5 Specialists accounted for 37.5% of survey participants. The Given the limited data about practices and attitudes of individual clinicians in our field, the Pediatric Infectious Diseases Society (PIDS) Telehealth Working Group (TWG) sought to understand the TH landscape along with perceptions of barriers to adoption among its members. The results of its first TH survey form the basis of this report.

The PIDS TWG was established in 2018 to understand and facilitate the implementation of TH in PID. The group's first task was to understand current TH practices. The PIDS TWG outlined areas within TH that were considered important in understanding existing practices and would be relevant to the adoption of TH in PID. We focused on the specialist in the A c c e p t e d M a n u s c r i p t 6 care-team subdomain of domain 3 (the experience of TH by its users) of the National Quality Forum framework for measuring the use of TH. 7 The other domains are access to care, financial impact/cost and effectiveness. The survey included the following areas: (1) current TH practices in the US, (2) perceived barriers to implementing telehealth, and (3) practical topics relevant to using telehealth (e.g. reimbursement, liability, etc.). We included questions about the respondents' geographic location, specialty/subspecialty training and practice, practice setting and size, the use of synchronous and asynchronous modalities, and TH applications. We queried respondents about the services provided via TH, the modalities used, adoption barriers, reimbursement, whether extramural credentialing (i.e. credentials at outside organizations other than the primary one) was required, professional practice liability, methods and estimated number of curbside consultations (CCs) per week, and the estimated time spent providing CCs per week. The survey did not collect data about remote monitoring, tele-education of patients or * https://www.idsociety.org/idsa-newsletter/may-9-2018/how-is-tech-used-in-id-clinical-practice-work-grouplaunches-member-survey/ 

We used TH terms for the purpose of this report primarily as defined by the American Telemedicine Association; it should be noted that its definitions, which resided originally on one webpage, were split among two sources as of September 2020. 1,2 Asynchronous telecommunication is store-and-forward transmission of medical images and/or data typically in separate time frames; synchronous telecommunication is live simultaneous transmission. Both methods may be used among providers, or between providers and patients. Telehealth and telemedicine have been used interchangeably in the literature; the latter is considered a type of TH. 4 We use TH to refer to interactions outside the interclinical-site scenario such as provider-patient asynchronous or asynchronous virtual or evisits. Virtual visits refer to asynchronous or synchronous communications between patients and providers, and is often used, as is "e-visits," in the industry's vernacular to mean synchronous audiovisual telecommunication between them. Telemedicine in the discussion section refers to communications between clinical sites, e.g. consultations, regardless of the transmission type. We use the terms teleID and telePID to refer to TH usage by ID and PID specialists, respectively. When we cite terms from references, we use them per the original sources. Curbside consultations (CCs) were defined as any informal advice, suggestion, or A c c e p t e d M a n u s c r i p t 8 opinion provided to a health care worker (HCW) concerning infectious diseases for which a formal consultation was not performed by the FAHC infectious diseases service, and as such is non-reimbursed service. 8

We used descriptive statistics to characterize each question with a focus on practice settings, types of services rendered by the respondents, and reimbursement. We did not perform comparative statistics. Respondents were excluded from the analysis if their responses indicated locations outside the US or not practicing PID. When questions were skipped, the number of respondents who answered the question were reported accordingly.

One hundred sixty-one PIDS members (13.3% of 1,213) completed the survey; seven (4.3%)

were excluded because they practiced outside the US (four), were retired at the time of the survey for an unknown period of time (two) or did not practice in the specialty (one). The remaining 154 respondents were all PID physicians, including two who also see adults and two fellows in training. The respondents were located in 34 states with 1-15 respondents per state. The states with the most respondents were California (15), New York (14) 

There were 86 (55.8%) respondents who cited "no reimbursement" and/or "insufficient reimbursement" as barriers to TH adoption. Other barriers included lack of experience with the technology (n=85, 55.2%), lack of institutional support (81, 52.6%), lack of administrative support (77, 50%), cost of implementation (75, 48.7%), and insufficient provider time (72, 46.8%) (Figure 3) . Individually, "no reimbursement" and "insufficient reimbursement" accounted for 59 (38.3%) and 56 (36.4%) of responses, respectively, and different 29 respondents of each group cited the other reimbursement concern, too. Other barriers were less frequently reported.

The majority of respondents did not know if there was a requirement for extramural credentialing (n=88, 57.1%) or liability coverage (68, 47%) for TH. Notably, many did not answer these two questions resulting in a significantly lower number of responses. It is worth noting that 56 (36.4%) respondents cited fear of medical liability as a barrier to using TH.

Only 44 (28.6%) of the 154 respondents reported any type of reimbursement for TH, and 16 of them (36.4%) did not know the TH payment source or reimbursement arrangements.

Payer types included Medicaid/Medicare (29.5%), private payers (27.3%), internal institutional payments (18.2%), and inter-hospital contracts (11.4%). The remaining 13.6%

were split among fee-for-service arrangements with public health or other organizations 

There was high interest among PID respondents to implement one or more TH modalities in their practices (n=144, 93.5%), particularly those entailing provider-to-provider interactions, including synchronous (108, 70.1%) and asynchronous (88, 57.1%) consultations ( Figure 4 ).

They were also interested in patient-provider synchronous (n=81, 52.6%) and asynchronous (68, 44.1%) e-visits. Interest in adopting TH was indicated by TH users and nonusers, e.g. 49 (74.2%) of 66 nonusers reported such interest. The adoption of additional modalities varied among users due to the different ones already in use.

This report is the first, to our knowledge, to describe the use of, barriers to implementation and attitudes towards TH among individual PID specialists, and it provides a useful baseline of PID TH practices in the pre-COVID-19 era. Overall, the PIDS survey respondents reported low usage but high interest in TH. Synchronous consultation with patient examination and A c c e p t e d M a n u s c r i p t 12 synchronous/asynchronous provider-to-provider consultations were the most commonly used modalities. Respondents identified significant barriers to implementing TH services at their institutions, which reflected the need for support in navigating technical, payer, legal and credentialing issues. The top three barriers to implementing TH were reimbursement, lack of experience, and lack of support. Yet interest in implementing various TH modalities, especially synchronous provider-to-provider consultations was high prior to the COVID-19 pandemic.

Our survey found that CCs accounted for a significant amount of PID specialist time. Nonreimbursable CCs accounted for 17% of the clinical-work reimbursable value of an adult ID service obtained in a prospective one-year study conducted in 2005. 8 The estimated oneyear revenues if this work was compensated were $93,979 using 2005 CMS reimbursement for a six-specialist group, but it was not reported if all the clinicians or some of them provided the CCs. An analysis of 197 asynchronous PID "e-consult" CCs estimated their value to be equivalent to 70 level 4 outpatient consultations, but only 10.5% were converted to inperson evaluations. 9 About half of the respondents to our survey reported only 0%-10% conversion, underscoring the importance of reimbursement as an adoption barrier before the pandemic.

Our findings are similar to results of a large multi-specialty survey conducted before the pandemic. The survey focused primarily on video visits, a core service of the survey sponsor, and reported an increase in their usage from 5% in 2015 to 22% in 2019. That survey showed low utilization and high interest in TH among pediatric providers (7% and 79%) and infectious disease specialists (17% and 83%). 5 It is unclear if the latter group included PID specialists or not. The top adoption barriers among all respondents were uncertainty of A c c e p t e d M a n u s c r i p t 13 reimbursement (77%), doubt about clinical appropriateness (72%), lack of physician buy-in (60%) and poor leadership support (44%).

There are limited data about outcomes in teleID, and particularly in telePID. Some studies of TH in managing infectious diseases report on practices of primary care clinicians, not ID subspecialists. One study of outpatient claims for children and adults with six common infections found that virtual visits had lower rates of laboratory testing and imaging, a similar rate of follow-up visits versus most other care settings, but higher rates of antibiotic prescribing and broad spectrum antibiotic usage. 10 Previously, the increased rates of antibiotic usage during e-visits were observed in some studies, 11 while in not in others. 12 Some methodologic differences may explain these discrepancies.

TH studies published between January 2015 and March 2019 also assessed the impact on clinical outcomes from various infections. These studies demonstrated more appropriate antibiotic prescribing and significant reductions in isolating multi-drug resistant bacteria following a telemedicine antimicrobial stewardship program; similar outcomes to on-site consultation in appropriate management, mortality and readmission for S. aureus bacteremia; effective use of HIV pre-exposure prophylaxis; and equivalent response to hepatitis C virus therapy. 13 Synchronous multispecialty telemedicine and/or teleconference including ID was associated with sustained virologic response similar to in-clinic management for hepatitis C regardless of genotype. 14 A systematic review of teleID studies, involving mostly adult patients, found that clinical outcomes seemed comparable to inperson consultations with high patient satisfaction, although the studies were deemed to be of poor quality. 15 TeleID has demonstrated high patient satisfaction for general ID, hepatitis C and HIV. 13 A recent systematic review found several benefits from using telehealth, such A c c e p t e d M a n u s c r i p t 14 as ease of use, trends for improved outcomes and communication, increased access to care and fewer missed appointments. 16 Our findings must be viewed in the context of the COVID-19 pandemic, which impacted the US 10 months after completion of the survey. The pandemic has transformed the use of TH in the US and elsewhere with higher TH utilization by patients and clinicians. Primary care providers were already eager to take advantage of telePID before the pandemic. 17 Data from other countries highlight their TH usage, too. Vilendrer et al 20 described rapid deployment of telemedicine at a children's hospital but did not report utilization trends. An Italian team described a new telePID program that was activated in response to the pandemic relying on synchronous consultation with limited examination. 21 In a two-month period, 55 of 61 (90.2%) children avoided visits to the emergency room. TH played a valuable role in reducing potential exposure to pathogens and improving contact tracing and monitoring of large numbers of individuals during epidemics, 22 and telemedicine A c c e p t e d M a n u s c r i p t 15 reduced the use of personal protective equipment during care for newborns. 23 A report from China described asynchronous and synchronous provider-patient COVID-19

consultations which included ID and other specialists. 24 The level of TH adoption in PID in the US during the pandemic is unknown, but would almost certainly be higher than before it.

Our survey had several strengths and limitations. It was the first to assess TH practices among PID specialists from a geographically diverse sample in the US. It was limited by the small sample size due to the low response rate, and the preponderance of respondents from university and hospital settings. It is unclear if inexperience with TH caused the survey's low response rate, though the latter is typical for most online surveys.

In summary, our survey of PID providers documented low usage and high interest in telehealth before the COVID-19 pandemic. It identified barriers to implementing telePID that existed before the pandemic and found that PID providers dedicated a significant amount of time to non-reimbursable curbside consultations. The survey provides baseline data of telePID practices which surely underwent a dramatic change in 2020. The PIDS Telehealth Working Group will conduct another survey to assess the extent of new telePID adoption since the pandemic has started. M a n u s c r i p t 

Telehealth: Defining 21st Century Care

ATA's Standardized Telehealth Terminology and Policy Language for States on Medical Practice

The Use of Telemedicine by Physicians: Still The Exception Rather Than The Rule

Office of the National Coordinator for Health Information Technology. What is telehealth? How is telehealth different from telemedicine

Telehealth Index: 2019 Physician Survey

The Current Pediatric Telehealth Landscape

Creating a Framework to Support Measure Development for Telehealth

Physicianto-Physician Electronic Consultation: A Tool for the Pediatric Infectious Diseases Specialist to Document Encounters and Quantify Effort

Virtual Visits for Acute, Nonurgent Care: A Claims Analysis of Episode-Level Utilization

Antibiotic Prescribing for Respiratory Tract Infections and Encounter Length: An Observational Study of Telemedicine

Antibiotic Prescribing for Acute Respiratory Infections in Direct-to-Consumer Telemedicine Visits

The Role of Telemedicine in Infectious Diseases

Outcomes of Treatment for Hepatitis C Virus Infection by Primary Care Providers

Telemedicine Infectious Diseases Consultations and Clinical Outcomes: A Systematic Review. Open Forum Infectious Diseases

Telehealth and Patient Satisfaction: A Systematic Review and Narrative Analysis

Optimizing Telehealth Strategies for Subspecialty Care: Recommendations from Rural Pediatricians

Policy Changes During The COVID-19 Public Health Emergency

Population-Level Interest and Telehealth Capacity of US Hospitals in Response to COVID-19: Cross-Sectional Analysis of Google Search and National Hospital Survey Data

Rapid Deployment of Inpatient Telemedicine in Response to COVID-19 Across Three Health Systems

Telemedicine for Management of Paediatric Infectious Diseases During COVID-19 Outbreak

Role of Telehealth in the Management of COVID-19: Lessons Learned from Previous SARS, MERS, and Ebola Outbreaks

In-Hospital Telehealth Supports Care for Neonatal Patients in Strict Isolation

Application and Preliminary Outcomes of Remote Diagnosis and Treatment During the COVID-19 Outbreak: Retrospective Cohort Study

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