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Certified Examination Assistants in the Age of Telemedicine: A Blueprint Through Neurology.

ABSTRACT: The optimal approach to a clinical physical examination via telemedicine is still being explored. The medical community has no standardized or widely followed criteria for telemedicine examinations, so a broad spectrum of approaches is used. Unfortunately, the need for telemedicine is outpacing physical examination validation research. Given that certain specialties have been using telemedicine longer than others, lessons from those specialties might aid in developing standardized protocols for telemedicine. Neurology has been at the forefront of telemedicine use, initially through stroke care and later in multiple subspecialties. We present a framework for optimizing the history taking and physical examination process via telemedicine based on our experience in neurology. This mainly includes remotely examining a patient unassisted or with an untrained assistant present on the patient side of the connection. We also discuss the need for trained, certified assistants to assist the off-site physician in history taking and physical examination. These certified assistants would be allied health professionals who perform high-quality cued patient examinations under direct physician supervision with no responsibility to diagnose or treat. This contrasts with the approach seen in advanced practice providers such as physician assistants and nurse practitioners who undergo years of training to diagnose and treat patients under supervision. This training process would serve as a stepping stone for the development of dedicated certification programs for neurology and other medical specialties; however, assessments of practical training, costs, implementation, and longitudinal quality are warranted.

SUBMITTER: Bragin I

PROVIDER: S-EPMC8529478 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:AimTo characterize child neurology telemedicine visits flagged as requiring in-person evaluation during the COVID-19 pandemic.MethodWe analyzed 7130 audio-video telemedicine visits between March and November 2020. Visits of concern (VOCs) were defined as telemedicine visits where the clinical scenario necessitated in-person follow-up evaluation sooner than if the visit had been conducted in-person.ResultsVOCs occurred in 5% (333/7130) of visits for 292 individuals (148 females, 144 males). Providers noted technical challenges more often in VOCs (40%; 133/333) than visits without concern (non-VOCs) (28%; 1922/6797) (p < 0.05). The median age was younger in VOCs (9 years 3 months, interquartile range [IQR] 2 years 0 months-14 years 3 months) than non-VOCs (11 years 3 months, IQR 5 years 10 months-15 years 10 months) (p < 0.05). Median household income was lower for patients with VOCs ($74 K, IQR $55 K-$97 K) compared to non-VOCs ($80 K, IQR $61 K-$100 K) (p < 0.05). Compared with all other race categories, families who self-identified as Black were more likely to have a VOC (odds ratio 1.53, 95% confidence interval 1.21-2.06). Epilepsy and headache represented the highest percentages of VOCs, while neuromuscular disorders and developmental delay had a higher proportion of VOCs than other neurological disorders.InterpretationThese findings suggest that telemedicine is an effective platform for most child neurology visits. Younger children and those with neuromuscular disorders or developmental delays are more likely to require in-person evaluation.What this paper addsIt is possible to successfully flag patients who need in-person assessment. Providers can manage issues arising during telemedicine in 95% of visits. Visits flagged as concerning were likely unrelated to modality of patient care. Provider concern was independent of technical difficulties for most telehealth visits. Younger age may be correlated with need for in-person assessment.

Project description:Objectives:Growing prevalence of chronic diseases and limited resources are the key challenges for future healthcare. As a promising approach to maintain high-quality primary care, non-physician healthcare professionals have been trained to broaden qualifications and responsibilities. This study aimed to assess the influence of involving certified healthcare assistants (HCAs, German: Versorgungsassistent/in in der Hausarztpraxis) on quality and efficacy of primary care in Germany.Design:Cross-sectional study.Setting:Primary care.Participants:Patients insured by the Allgemeine Ortskrankenkasse (AOK) statutory health insurer (AOK, Baden-Wuerttemberg, Germany).Interventions:Since 2008 practice assistants in Germany can enhance their professional education to become certified HCAs.Primary and secondary outcome measures:Claims data related to patients treated in practices employing at least one HCA were compared with data from practices not employing HCAs to determine frequency of consultations, hospital admissions and readmissions. Economic analysis comprised hospitalisation costs, prescriptions of follow-on drugs and outpatient medication costs.Results:A total of 397 493 patients were treated in HCA practices, 463 730 patients attended to non-HCA practices. Patients in HCA practices had an 8.2% lower rate of specialist consultations (p<0.0001), a 4.0% lower rate of hospitalisations (p<0.0001), a 3.5% lower rate of readmissions (p=0.0463), a 14.2% lower rate of follow-on drug prescriptions (p<0.0001) and 4.7% lower costs of total medication (p<0.0001). No difference was found regarding the consultation rate of general practitioners and hospital costs.Conclusions:For the first time, this high-volume claims data analysis showed that involving HCAs in primary care in Germany is associated with a reduction in hospital admissions, specialist consultations and medication costs. Consequently, broadening qualifications may be a successful strategy not only to share physicians' work load but to improve quality and efficacy in primary care to meet future challenges. Future studies may explore specific tasks to be shared with non-physician workforces and standardisation of the professional role.

Project description:ImportanceTelemedicine is increasingly used to provide outpatient pediatric neurology consultations in underserved communities. Although telemedicine clinics have been shown to improve access, little is known about how they alter patients' utilization of hospital services.ObjectiveTo evaluate the association between access to telemedicine clinics and hospital utilization among underserved children with neurologic conditions.Design, setting, and participantsThis retrospective cross-sectional study included 4169 patients who received outpatient care from pediatric neurologists affiliated with an academic children's hospital in California between January 1, 2009, and July 31, 2017, either in person or using telemedicine.ExposuresConsultation modality (telemedicine or in person) in the outpatient neurology clinics.Main outcomes and measuresDemographic and clinical variables were abstracted from the hospital's electronic medical records. The association between the modality of outpatient neurology care and patients' utilization of the emergency department and hospitalizations was evaluated. Both all-cause and neurologic condition-related hospital utilization were analyzed using multivariable negative binomial regression in overall and matched samples.ResultsThe telemedicine cohort comprised 378 patients (211 [55.8%] male), and the in-person cohort comprised 3791 patients (2090 [55.1%] male). The mean (SD) age at the first encounter was 7.4 (5.4) years for the telemedicine cohort and 7.8 (5.1) years for the in-person cohort. The telemedicine cohort was more likely than the in-person cohort to have nonprivate insurance (public insurance, self-pay, or uninsured), lower education, and lower household income. The rates of all-cause and neurologic hospital encounters were lower among children who received pediatric neurology consultations over telemedicine compared with children who received care in the in-person clinics (5.7 [95% CI, 3.5-8.0] vs 20.1 [95% CI, 18.1-22.1] per 100 patient-years and 3.7 [95% CI, 2.0-5.3] vs 8.9 [95% CI, 7.8-10.0] per 100 patient-years, respectively; P?<?.001). Even after adjusting for demographic and clinical factors, the telemedicine cohort had a lower risk of hospital encounters (emergency department visits and admissions) with an adjusted incidence rate ratio of 0.57 (95% CI, 0.38-0.88) for all-cause encounters and an adjusted incidence rate ratio of 0.60 (95% CI, 0.36-0.99) for neurologic encounters. After matching on travel time to the neurology clinic, the adjusted incidence rate ratio was 0.19 (95% CI, 0.04-0.83) for all-cause admissions and 0.14 (95% CI, 0.02-0.82) for neurologic admissions.Conclusions and relevancePediatric neurology care through real-time, audiovisual telemedicine consultations was associated with lower hospital utilization compared with in-person consultations, suggesting that high-cost hospital encounters can be prevented by improving subspecialty access.

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Certified Examination Assistants in the Age of Telemedicine: A Blueprint Through Neurology.

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