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The American Journal of Managed Care January 2019
The Gamification of Healthcare: Emergence of the Digital Practitioner?
Eli G. Phillips Jr, PharmD, JD; Chadi Nabhan, MD, MBA; and Bruce A. Feinberg, DO
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Patient and Clinician Experiences With Telehealth for Patient Follow-up Care
Karen Donelan, ScD, EdM; Esteban A. Barreto, MA; Sarah Sossong, MPH; Carie Michael, SM; Juan J. Estrada, MSc, MBA; Adam B. Cohen, MD; Janet Wozniak, MD; and Lee H. Schwamm, MD
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Paul T. Norton, MPH, MBA; Hector P. Rodriguez, PhD, MPH; Stephen M. Shortell, PhD, MPH, MBA; and Valerie A. Lewis, PhD, MA
Alternative Payment Models and Hospital Engagement in Health Information Exchange
Sunny C. Lin, MS; John M. Hollingsworth, MD, MS; and Julia Adler-Milstein, PhD
Drivers of Health Information Exchange Use During Postacute Care Transitions
Dori A. Cross, PhD; Jeffrey S. McCullough, PhD; and Julia Adler-Milstein, PhD

Patient and Clinician Experiences With Telehealth for Patient Follow-up Care

Karen Donelan, ScD, EdM; Esteban A. Barreto, MA; Sarah Sossong, MPH; Carie Michael, SM; Juan J. Estrada, MSc, MBA; Adam B. Cohen, MD; Janet Wozniak, MD; and Lee H. Schwamm, MD
Telemedicine visits may be used with established patients for follow-up care without a loss of patient satisfaction with communication with providers and with enhanced convenience and reduced travel time; a majority may be willing to pay standard co-pays or more for this convenience. Clinicians see value in this new mode of care to enhance connections with patients.
RESULTS

Patient characteristics are shown in the eAppendix Table (eAppendix available at ajmc.com). VVV patients were diverse in age and gender and were predominantly white and non-Hispanic, consistent with patient demographics in our system. Patients receiving behavioral health care are overrepresented due to the rapid uptake of VVV by those clinicians and patients. No significant differences were measured in characteristics of respondents and nonrespondents. Clinician respondents were psychologists and psychiatrists (34%), neurologists (38%), cardiologists (10%), oncologists (2%), and primary care clinicians (16%).

Patient Experience of VVVs

Patient experience with a VVV was measured in multiple items. Responses are shown in the Table by specialty, comparing neurology and cardiology patient responses with those of the psychiatry patients (referent). We used 4 measures from the CAHPS Clinician Group visit to assess patient experience with efficiency and communication during VVVs. Overall, 80% or more respondents answered “yes, definitely” to these items; 82.3% responded “yes, definitely” to whether they would recommend VVV to their family and friends. On a scale of 0 to 10, where 0 is the worst possible visit and 10 is the best visit, 68.5% rated the visit a 9 or 10.

We asked patients to consider whether the care provided during their recent VVV could have been provided in another way and still met their needs, asking “Do you think the health issues you discussed with clinicians today could just as easily have been addressed by [insert visit mode]?” Nearly 90% of patients agreed that their issues could also have been addressed in an office visit (definitely, 70.8%; somewhat, 17.8%) and nearly 60% by telephone calls (definitely, 23.2%; somewhat, 36.7%). The results for secure email (definitely, 7.2%; somewhat, 23.5%) and text messaging (definitely, 3.6%; somewhat, 12.7%) suggest that they are less often appropriate substitutes (data not shown).

Patient and Clinician Comparisons of Office Visits and VVVs

The Figure shows patient and clinician responses to a series of comparative questions about office visits and VVVs that were asked of both groups. Expanded data are shown in eAppendix Figures 1 and 2—one with patient data, one with clinician data—and include several items that were directed only to one group or the other.

Most patients (62.6%) and clinicians (59.0%) reported “no difference” between virtual and office visits on “the overall quality of the visit.” When rating “the personal connection felt during the visit,” 32.7% of patients and 45.9% of clinicians reported that the “office visit is better,” but more than half of the respondents (patients, 59.1%; clinicians, 50.8%) said that there was “no difference.”

Patient Willingness to Pay for VVV

eAppendix Figure 3 shows data on patient willingness to pay for VVV out of pocket. Patients were not initially charged co-payments. However, the majority of patients expressed a willingness to pay a co-payment of up to $50. Among those willing to bear the full cost of the VVV, more than one-third had no current co-payment and all had private (vs public) insurance. We conducted bivariate analyses of the willingness to make co-payments for VVV by both self-reported travel time and cost of attending office visits. Among those who traveled more than 90 minutes to an office visit, 51.5% indicated they would pay a co-payment of more than $50 for a VVV compared with 30.4% of those who traveled less than 30 minutes. Among patients who spent $25 or more on travel to attend an office visit, 73.2% would pay a co-payment of $26 to $50 for a VVV and 97.6% would pay a co-payment of $10 to $25 (travel data not shown).

DISCUSSION

Increased interest in new strategies for managing population health and episodic specialty care, coupled with the widespread availability of communications technologies, have encouraged the exploration of the appropriate roles of different modes of clinical encounters or visits.16,17 Our data—gathered from patients and clinicians during and following an initial full year of experience with the MGH Center for TeleHealth’s VVV implementation—show a high degree of patient and clinician satisfaction, as measured by both ratings of overall visit quality and willingness to recommend the visits.

VVVs are perceived by the majority of patients as the same as or better than office visits in convenience and cost, at the same level of quality and personal connection. Patients appear to value the face-to-face interactive nature of VVVs; they perceive office or telephone encounters as the main alternatives to this new type of visit, rather than email or structured questionnaires, likely because they maintain a real-time personal connection. Even though VVVs represent a great convenience, our data reinforce that they are unlikely to be a useful substitute for an in-office visit in some clinical situations—for example, those with more complexity and need for physical examination or observation. More research is needed to study the association of the care delivery modality (in-person vs telehealth) with total cost and clinical outcomes and to understand settings in which telehealth affects healthcare value.14,18 The regulatory, administrative, and legal environment related to the conduct of telehealth visits is in constant flux; delivery of care to established patients across state lines adds further complexity. The Chronic Care Act of 2017, enacted in 2018, takes some small steps toward relaxing reimbursement and regulatory restrictions in selected diseases and insurance markets; hopefully, this trend will continue.

Limitations

Patient participants were selected for these visits by their clinicians based on their suitability, as determined during prior office visits as established patients. This was not a controlled study. These data were gathered in the first full year of VVV implementation in our system and are primarily from VVVs for a specialty, so they very likely do not fully reflect the challenges or opportunities of using VVVs in primary care settings. Surveys are subject to sources of error and bias; we attempted to minimize these with high-quality methods and response rate enhancement methods. Lastly, Massachusetts is not among the 31 states that now routinely require third-party reimbursement for telehealth visits; our health system chose to support reimbursement to clinicians. It is unknown if the level of reimbursement created positive or negative incentives. Further study is needed, including improved models to compensate clinicians, to measure and define the appropriate mix of virtual and office visits, and to understand the role of other modes of care.

CONCLUSIONS

With the inexorable adoption of digital offerings to meet many of the needs of today’s consumers, it is likely that telehealth will increasingly be adopted over the next several years. Our data suggest that initial experiences for patients and clinicians were positive and that, for most encounters, these VVVs are just as clinically effective and less expensive for both patient and provider compared with in-person visits. The fears of distracted, overwhelmed providers and a loss of human connection between patient and provider have been raised repeatedly with the rising use of computers in the doctor’s office. Interestingly, this issue was not a central concern to participants in our VVV program, perhaps due to the use of VVVs with established patients. These visits are not just replacements for in-office visits; they hold the possibility of new avenues for care delivery, more frequent but shorter encounters, and opportunity for earlier intervention. Further studies are needed to test different provider compensation models to measure and define the appropriate mix of virtual, office, and other modes of care and to establish appropriateness criteria for the use of telehealth encounters. These issues are all important in the further use of this technology as part of effective and efficient patient-centered care and population management.19 Telehealth should further the aims of improving the quality of healthcare and addressing the Institute of Medicine domains of quality, with special attention to overcoming existing barriers in access to care, including the burden of time and financial costs that patients and families bear in attending traditional office visits.

Author Affiliations: Mongan Institute Health Policy Center (KD, EAB, CM), MGH Center for TeleHealth (JJE, LHS), Department of Neurology (JJE, LHS), and Department of Psychiatry (JW), Massachusetts General Hospital, Boston, MA; Flare Capital Partners (SS), Boston, MA; Applied Physics Laboratory, Johns Hopkins University (ABC), Laurel, MD; Department of Neurology, Johns Hopkins Hospital and Health System (ABC), Baltimore, MD.

Source of Funding: Massachusetts General Hospital Institutional Funds.

Author Disclosures: Dr Cohen is employed with and provided expert testimony for Johns Hopkins University Applied Physics Laboratory, which develops health technology, including telemedicine-related technology. Dr Wozniak’s spouse has received royalties from UpToDate; consultation fees from Advance Medical, FlexPharma, Merck, Otsuka, and Gerson Lehman Group; and research support from RLS Foundation. Dr Schwamm has received a Patient-Centered Outcomes Research Institute grant on tele–palliative care and is the director of the MGH Center for TeleHealth. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (KD, SS, CM, JJE, ABC, JW, LHS); acquisition of data (KD, EAB, SS, CM, JJE, ABC, JW, LHS); analysis and interpretation of data (KD, EAB, SS, CM, JJE, ABC, JW, LHS); drafting of the manuscript (KD, EAB, CM, LHS); critical revision of the manuscript for important intellectual content (KD, SS, CM, JJE, ABC, JW, LHS); statistical analysis (KD, EAB, CM, JJE, ABC, JW, LHS); provision of patients or study materials (KD, SS, CM, JJE, ABC, JW, LHS); obtaining funding (KD, SS, CM, JJE, ABC, JW, LHS); administrative, technical, or logistic support (KD, SS, CM, JJE, ABC, JW, LHS); and supervision (KD, SS, CM, JJE, ABC, JW, LHS).

Address Correspondence to: Karen Donelan, ScD, EdM, Mongan Institute Health Policy Center, Massachusetts General Hospital, 100 Cambridge St, Ste 1600, Boston, MA 02114. Email: kdonelan@mgh.harvard.edu.
REFERENCES

1. Güler NF, Übeyli ED. Theory and applications of telemedicine. J Med Syst. 2002;26(3):199-220.

2. Mehrotra A, Jena AB, Busch AB, Souza J, Uscher-Pines L, Landon BE. Utilization of telemedicine among rural Medicare beneficiaries. JAMA. 2016;315(18):2015-2016. doi: 10.1001/jama.2016.2186.

3. Perrin A, Jiang J. About a quarter of U.S. adults say they are ‘almost constantly’ online. Pew Research Center website. pewresearch.org/fact-tank/2018/03/14/about-a-quarter-of-americans-report-going-online-almost-constantly. Published March 14, 2018. Accessed July 12, 2018.

4. Perrin A, Duggan M. Americans’ internet access: 2000-2015. Pew Research Center website. pewinternet.org/2015/06/26/americans-internet-access-2000-2015. Published June 26, 2015. Accessed December 21, 2018.

5. Agha Z, Schapira RM, Laud PW, McNutt G, Roter DL. Patient satisfaction with physician-patient communication during telemedicine. Telemed J E Health. 2009;15(9):830-839. doi: 10.1089/tmj.2009.0030.

6. Perle JG, Langsam LC, Randel A, et al. Attitudes toward psychological telehealth: current and future clinical psychologists’ opinions of internet-based interventions. J Clin Psychol. 2013;69(1):100-113. doi: 10.1002/jclp.21912.

7. Polinski JM, Barker T, Gagliano N, Sussman A, Brennan TA, Shrank WH. Patients’ satisfaction with and preference for telehealth visits. J Gen Intern Med. 2015;31(3):269-275. doi: 10.1007/s11606-015-3489-x.

8. Viers BR, Pruthi S, Rivera ME, et al. Are patients willing to engage in telemedicine for their care: a survey of preuse perceptions and acceptance of remote video visits in a urological patient population. Urology. 2015;85(6):1233-1240. doi: 10.1016/j.urology.2014.12.064.

9. LeRouge CM, Garfield MJ, Hevner AR. Patient perspectives of telemedicine quality. Patient Prefer Adherence. 2015;9:25-40. doi: 10.2147/PPA.S67506.

10. LeRouge C, Hevner A, Collins R, Garfield M, Law D. Telemedicine encounter quality: comparing patient and provider perspectives of a socio-technical system. Presented at: 37th Annual Hawaii International Conference on System Sciences; January 5-8, 2004; Big Island, HI. doi: 10.1109/HICSS.2004.1265375.

11. Weinstein RS, Lopez AM, Krupinski EA, et al. Integrating telemedicine and telehealth: putting it all together. Stud Health Technol Inform. 2008;131:23-38.

12. Meyers D, Peikes D, Genevro J, et al. The roles of patient-centered medical homes and accountable care organizations in coordinating patient care [AHRQ publication no. 11-M0005-EF]. Agency for Healthcare Research and Quality website. pcmh.ahrq.gov/sites/default/files/attachments/Roles%20of%20PCMHs%20And%20ACOs%20in%20Coordinating%20Patient%20Care.pdf. Published December 2010. Accessed December 21, 2018.

13. Bao Y, Casalino LP, Pincus HA. Behavioral health and health care reform models: patient-centered medical home, health home, and accountable care organization. J Behav Health Serv Res. 2013;40(1):121-132. doi: 10.1007/s11414-012-9306-y.

14. Adler-Milstein J, Kvedar J, Bates DW. Telehealth among US hospitals: several factors, including state reimbursement and licensure policies, influence adoption. Health Aff (Millwood). 2014;33(2):207-215. doi: 10.1377/hlthaff.2013.1054.

15. An overview of version 3.0 of the CAHPS Clinician & Group Survey. Agency for Healthcare Research and Quality website. ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/cg/about/cg_3-0_overview.pdf. Published June 17, 2015. Accessed December 21, 2018.

16. Kvedar J, Coye MJ, Everett W. Connected health: a review of technologies and strategies to improve patient care with telemedicine and telehealth. Health Aff (Millwood). 2014;33(2):194-199.

17. Kim YS. Telemedicine in the USA with focus on clinical applications and issues. Yonsei Med J. 2004;45(5):761-775. doi: 10.3349/ymj.2004.45.5.761.

18. Health policy brief: telehealth parity laws. Health Affairs Blog website. healthaffairs.org/do/10.1377/hblog20160815.056155/full. Published August 15, 2016. Accessed December 21, 2018.

19. Schwamm LH. Telehealth: seven strategies to successfully implement disruptive technology and transform health care. Health Aff (Millwood). 2014;33(2):200-206. doi: 10.1377/hlthaff.2013.1021.
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