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Assessing patient safety in a pediatric telemedicine setting: a multi-methods study.

ABSTRACT: BACKGROUND:Telemedicine and telephone-triage may compromise patient safety, particularly if urgency is underestimated. We aimed to explore the level of safety of a pediatric telemedicine service, with particular reference to the appropriateness of the medical diagnoses made by the online physicians and the reasonableness of their decisions. METHODS:This retrospective multi-method study investigated the decision-making process of physicians in a pediatric tele-triage service provided in Israel. The first section of the study investigates several measures relating to patient safety in the telemedicine setting. Two physicians reviewed a random sample of 339 parent-physician consultations conducted via a pediatric telemedicine service provided by a healthcare organization during 2014-2017. The consultations were analyzed for factors that may have affected the online physicians' decisions, with an emphasis on the appropriateness of the diagnoses and the reasonableness of the decisions. The online physicians' decisions were also compared to the subsequent outcomes (i.e., parental compliance with the recommendations and medical follow-ups within the healthcare system) after each consultation. The second section of the study (using a qualitative approach) consisted of interviews with 15 physicians who work in the pediatric telemedicine service, in order to explore their subjective experiences and efforts for assuring patient safety. The physicians were asked about factors that may have affected their reaching an appropriate diagnosis and a reasonable decision while maintaining patient safety. RESULTS:The first section of the study demonstrates high levels of diagnosis appropriateness (98.5%) and decision reasonableness (92%), as well as low levels of false-positive (2.65%) and false-negative (5.3%), good sensitivity (82.85%), and high specificity (96.15%). A high association between the online decisions and the subsequent outcomes was also observed. The second section of the study presents physicians' means for ensuring high patient safety - by implementing a range of factors that helped them reach appropriate diagnoses and reasonable decisions. CONCLUSIONS:The results show overall high patient safety in the pediatric tele-triage service that was examined. However, decision makers must strive to implement additional means for further enhancing the clinicians' ability to reach accurate diagnoses and provide optimal treatments within the tele-triage settings - with the aim of ensuring patient safety.

SUBMITTER: Haimi M

PROVIDER: S-EPMC7126468 | biostudies-literature | 2020 Apr

REPOSITORIES: biostudies-literature

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Assessing patient safety in a pediatric telemedicine setting: a multi-methods study.

Haimi Motti M Brammli-Greenberg Shuli S Baron-Epel Orna O Waisman Yehezkel Y

BMC medical informatics and decision making 20200403 1

<h4>Background</h4>Telemedicine and telephone-triage may compromise patient safety, particularly if urgency is underestimated. We aimed to explore the level of safety of a pediatric telemedicine service, with particular reference to the appropriateness of the medical diagnoses made by the online physicians and the reasonableness of their decisions.<h4>Methods</h4>This retrospective multi-method study investigated the decision-making process of physicians in a pediatric tele-triage service provid ...[more]

PMID: 32245469

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Project description:BackgroundTo characterize telemedicine use among pediatric subspecialties with respect to clinical uses of telemedicine, provider experience, and patient perceptions during the COVID-19 pandemic.MethodsWe performed a mixed-methods study of telemedicine visits across pediatric endocrinology, nephrology, orthopedic surgery, and rheumatology at a large children's hospital. We used deductive analysis to review observational data from 40 video visits. Providers and patients/caregivers were surveyed around areas of satisfaction and communication.ResultsWe found adaptations of telemedicine including shared-screen use and provider-guided parent procedures among others. All providers felt that it was safest for their patients to conduct visits by video, and 72.7% reported completing some component of a clinical exam. Patients rated the areas of being respected by the clinical staff/provider and showing care and concern highly, and the mean overall satisfaction was 86.7 ± 19.3%.ConclusionsTelemedicine has been used to deliver care to pediatric patients during the pandemic, and we found that patients were satisfied with the telemedicine visits during this stressful time and that providers were able to innovate during visits. Telemedicine is a tool that can be successfully adapted to patient and provider needs, but further studies are needed to fully explore its integration in pediatric subspecialty care.ImpactThis study describes telemedicine use at the height of the COVID-19 pandemic from both a provider and patient perspective, in four different pediatric subspecialties. Prior to COVID-19, pediatric telehealth landscape analysis suggested that many pediatric specialty practices had pilot telehealth programs, but there are few published studies evaluating telemedicine performance through the simultaneous patient and provider experience as part of standard care. We describe novel uses and adaptations of telemedicine during a time of rapid deployment in pediatric specialty care.

Project description:BackgroundEarly efforts to incorporate telemedicine into Emergency Medicine focused on connecting remote treatment clinics to larger emergency departments (EDs) and providing remote consultation services to EDs with limited resources. Owing to continued ED overcrowding, some EDs have used telemedicine to increase the number of providers during surges of patient visits and offer scheduled "home" face-to-face, on-screen encounters. In this study, we used remote on-screen telemedicine providers in the "screening-in-triage" role.ObjectiveThis study aimed to compare the efficiency and patient safety of in-person screening and telescreening.MethodsThis cohort study, matched for days and proximate hours, compared the performance of real-time remote telescreening and in-person screening at a single urban academic ED over 22 weeks in the spring and summer of 2016. The study involved 337 standard screening hours and 315 telescreening hours. The primary outcome measure was patients screened per hour. Additional outcomes were rates of patients who left without being seen, rates of analgesia ordered by the screener, and proportion of patients with chest pain receiving or prescribed a standard set of tests and medications.ResultsIn-person screeners evaluated 1933 patients over 337 hours (5.7 patients per hour), whereas telescreeners evaluated 1497 patients over 315 hours (4.9 patients per hour; difference=0.8; 95% CI 0.5-1.2). Split analysis revealed that for the final 3 weeks of the evaluation, the patient-per-hour rate differential was neither clinically relevant nor statistically discernable (difference=0.2; 95% CI -0.7 to 1.2). There were fewer patients who left without being seen during in-person screening than during telescreening (2.6% vs 3.8%; difference=-1.2; 95% CI -2.4 to 0.0). However, compared to prior year-, date-, and time-matched data on weekdays from 1 am to 3 am, a period previously void of provider screening, telescreening decreased the rate of patients LWBS from 25.1% to 4.5% (difference=20.7%; 95% CI 10.1-31.2). Analgesia was ordered more frequently by telescreeners than by in-person screeners (51.2% vs 31.6%; difference=19.6%; 95% CI 12.1-27.1). There was no difference in standard care received by patients with chest pain between telescreening and in-person screening (29.4% vs 22.4%; difference=7.0%; 95% CI -3.4 to 17.4).ConclusionsAlthough the efficiency of telescreening, as measured by the rate of patients seen per hour, was lower early in the study period, telescreening achieved the same level of efficiency as in-person screening by the end of the pilot study. Adding telescreening during 1-3 am on weekdays dramatically decreased the number of patients who left without being seen compared to historic data. Telescreening was an effective and safe way for this ED to expand the hours in which patients were screened by a health care provider in triage.

Project description:BackgroundPatient safety research has lagged within academic settings, including chiropractic teaching institutions. To develop a robust patient safety culture, the Institute of Medicine emphasized the need for employee's attitudes to be understanding and positive. To initiate the assessment of the current culture and future needs, this study evaluated patient safety attitudes among chiropractic teaching clinic stakeholders (supervising clinicians, student interns, and administrative staff) and compared their standardized survey scores to established medical survey databases.MethodsWe conducted a cross-sectional, mixed methods survey design with quantitative analytic priority. Chiropractic interns, clinical faculty, and clinic staff of 5 international chiropractic educational programs completed a modified version of the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Culture for Medical Offices Survey with open-ended comment fields between 2014 and 2016. Composite means of positive responses were calculated and compared to patient safety, quality of care, and overall self-ratings benchmarks from Canadian providers and academic settings in the AHRQ database. Qualitative responses were thematically categorized for a convergent analysis of quantitative results for the chiropractic sample.ResultsChiropractic survey response rate was 45.3% (n = 645). Quantitative survey results indicated moderate scores and ranges (57-85%) on all patient safety dimensions for the chiropractic samples. Academic medicine and chiropractic providers' benchmarks scored higher positive responses than chiropractic teaching clinics on most quantitative dimensions, except for work pressure/pace. Teamwork, organizational learning, and patient tracking/follow-up were the most positively endorsed quantitative dimensions, with communication, staff training, office standardization, and leadership support considered areas for improvement in both settings. Qualitative responses for the chiropractic clinics identified a need for open communication; additional staff training and student involvement in creating safety cultures; standardization of office processes including information exchange, scheduling, and equipment maintenance; and leadership support that focused on decreasing work pressure/pace and setting safety priorities.ConclusionAs the first report of patient safety attitudes from stakeholders in chiropractic teaching clinics, specific areas of improvement were identified. Chiropractic teaching programs might consider incorporating these and related patient safety concepts into their formal curricula. Mixed methods approach offers teaching clinics opportunities to assess stakeholders' insights and enhance safe delivery of chiropractic care.

Project description:This study sought to understand patient experiences, benefits, and challenges to osteoporosis care delivered virtually by telemedicine. Telemedicine bridges the access gap to specialized osteoporosis care in remote areas. Improving coordination of investigations, access to allied health members, and future initiatives may improve osteoporosis-related morbidity and mortality in this population.IntroductionThere is limited research on the role of telemedicine (TM) in the management of osteoporosis (OP). We previously reported that OP patients assessed by TM had a higher prevalence of fragility fractures, co-morbidities, and need for allied health resources than those serviced by the outpatient clinic. The purpose of this study is to understand the experiences, benefits, and challenges associated with receiving OP care by TM from the patient perspective.MethodsWe adopted a convergent, mixed methods study design whereby both a quantitative component (mailed survey) and qualitative component (30-min telephone interviews) were conducted simultaneously. In addition to reporting survey data, thematic analysis was applied to interview data.ResultsParticipants were comfortable with virtual technology and perceived that their quality of care by TM was comparable to in-person visits. Expressed benefits included the convenience of timely care close to home, reduced burden of travel and costs, and enhanced sense of confidence with being assessed by an osteoporosis specialist. Perceived barriers included poor follow-up with allied health professionals in the TM program (e.g., physiotherapist) and coordination of tests and investigations. Many participants indicated interest in an OP self-management program, with content focusing on diet and lifestyle factors.ConclusionThe TM program bridges the access gap for those living with OP in underserviced and remote areas. However, we identified the need to improve the existing processes to better coordinate access to allied health team members and arrangements for investigations. Participants also expressed interest for a virtual osteoporosis self-management program.

Project description:BackgroundThe capacity to deliver essential health services has been negatively impacted by the COVID-19 pandemic, particularly due to lockdown restrictions. Telemedicine provides a safe, efficient, and effective alternative that addresses the needs of patients and the health system. However, there remain implementation challenges and barriers to patient adoption in resource-limited settings as in the Philippines. This mixed methods study aimed to describe patient perspectives and experiences with telemedicine services, and explore the factors that influence telemedicine use and satisfaction.MethodsAn online survey consisting of items adapted from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Clinician & Group Adult Visit Survey 4.0 (beta) and the Telehealth Usability Questionnaire (TUQ) was completed by 200 participants aged 18 to 65 years residing in the Philippines. A subsample of 16 participants was interviewed to provide further insights on their experiences. We used descriptive statistics to analyze survey data and thematically analyzed data from interviews guided by the principles of grounded theory.ResultsParticipants were generally satisfied with telemedicine, and found it to be an efficient and convenient means of receiving healthcare. About 3 in 5 perceived telemedicine as affordable, with some finding telemedicine costs to be high and comparable to in-person consultations. Our results suggest that participants preferred telemedicine services, especially in cases where they feel that their condition is not urgent and does not need extensive physical examination. Safety against COVID-19, privacy, accessibility, and availability of multiple communication platforms contributed to patient satisfaction with telemedicine. Negative perceptions of patients on quality of care and service related to their telemedicine provider, inherent limitations of telemedicine in the diagnosis and management of patients, perceived high costs especially for mental health conditions, and poor connectivity and other technological issues were barriers to telemedicine use and satisfaction.ConclusionTelemedicine is viewed as a safe, efficient, and affordable alternative to receiving care. Expectations of patients on costs and outcomes need to be managed by providers to increase satisfaction. Continued adoption of telemedicine will require improvements in technology infrastructure and technical support for patients, training and performance evaluation of providers to ensure quality of care and service, better patient communication to meet patient needs, and integration of telemedicine services in remote areas that have limited access to medical services. Telemedicine, to realize its full potential, should be centered in health equity - addressing patient barriers and needs, reducing health disparities across population groups and settings, and providing quality services to all.

Project description:BackgroundBedside manner describes how clinicians relate to patients in person. Telemedicine allows clinicians to connect virtually with patients using digital tools. Effective virtual communication or webside manner may require modifications to traditional bedside manner.ObjectiveThis study aims to understand the experiences of telemedicine providers with patient-to-provider virtual visits and communication with families at a single large-volume children's hospital to inform program development and training for future clinicians.MethodsA total of 2 focus groups of pediatric clinicians (N=11) performing virtual visits before the COVID-19 pandemic, with a range of experiences and specialties, were engaged to discuss experiential, implementation, and practice-related issues. Focus groups were facilitated using a semistructured guide covering general experience, preparedness, rapport strategies, and suggestions. Sessions were digitally recorded, and the corresponding transcripts were reviewed for data analysis. The transcripts were coded based on the identified main themes and subthemes. On the basis of a higher-level analysis of these codes, the study authors generated a final set of key themes to describe the collected data.ResultsTheme consistency was identified across diverse participants, although individual clinician experiences were influenced by their specialties and practices. A total of 3 key themes emerged regarding the development of best practices, barriers to scalability, and establishing patient rapport. Issues and concerns related to privacy were salient across all themes. Clinicians felt that telemedicine required new skills for patient interaction, and not all were comfortable with their training.ConclusionsTelemedicine provides benefits as well as challenges to health care delivery. In interprofessional focus groups, pediatric clinicians emphasized the importance of considering safety and privacy to promote rapport and webside manner when conducting virtual visits. The inclusion of webside manner instructions within training curricula is crucial as telemedicine becomes an established modality for providing health care.

Dataset Information

Assessing patient safety in a pediatric telemedicine setting: a multi-methods study.

Publications

Assessing patient safety in a pediatric telemedicine setting: a multi-methods study.

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